State mental health policy: Overview and goals of the Mississippi Youth Programs Around the Clock (MYPAC)

This column briefly outlines the Mississippi Youth Programs Around the Clock (MYPAC) Demonstration Project. MYPAC is a federally funded effort to examine community-based alternatives to residential placement for youths with severe emotional disturbance. The project is one of ten similarly structured grants awarded nationally and is among the first to reach implementation. Because such a large amount of funding has been dedicated to such a substantial cross-section of national public mental health services ($66,000,000 in Mississippi alone), it is important to make the field aware of developments in these projects as they occur.     

State planning for community mental health programs: Implications for psychologists

Official planning bodies in every state are engaged in an intensive two-year analysis of public and voluntary mental health programs. This planning is an integral part of the national effort to provide community mental health services to regions of 75,000 to 200,000 persons. Experiences in establishing and operating the Massachusetts Planning Project are described. Particular attention is paid to the manner in which broad citizen and professional participation has been obtained. Implications for the future functioning of mental health professionals are highlighted. Specific reference is made to the profound crises confronting psychologists and their professional organizations.A brief version of this paper was read at the September, 1964 meeting of the American Psychological Association in Los Angeles.     

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.     

The impact of closing a state psychiatric hospital on the county mental health system and its clients.

OBJECTIVE: This three-year study examined the impact of closing a state psychiatric hospital in 1991 on service utilization patterns and related costs for clients with and without serious mental illness. METHODS: The cohort consisted of all individuals discharged from state hospitals and those diverted from inpatient to community services and enrolled in the unified systems project, a state-county initiative to build up the service capacity of the community system. The size of the cohort grew from 1,533 enrollees to 2,240 over the three years. Information on the types, amounts, and cost of all services received by each enrollee was compiled from multiple administrative databases, beginning two years before enrollment and for up to three years after. The data were analyzed to reveal patterns of and changes in service utilization and related costs. RESULTS: Replacement of most inpatient services with residential and ambulatory services resulted in significant cost reduction. For project enrollees, a 94 percent reduction in state hospital services resulted in cost savings of more than $45 million during the three-year evaluation period. These savings more than offset the funds used to expand community services. Overall, the net savings to the system for mental health services for this group was $3.4 million over three years. CONCLUSIONS: The hospital closure and infusion of funds into community services produced desired growth of those services. The project reduced reliance on state psychiatric hospitalization and demonstrated that persons with serious mental illness can be effectively treated and maintained in the community.     

Refining the Costs Analyses of the Fort Bragg Evaluation: The Impact of Cost Offset and Cost Shifting

A key aim of the evaluation of the Fort Bragg Demonstration was to determine whether delivering services through a continuum of care lowered expenditures on mental health services. The evaluation clearly showed that expenditures were actually higher in the Demonstration. Critics of the evaluation claimed that the evaluation's perspective on costs was too narrow—in particular, that the Demonstration produced cost shifting and cost offset that were not captured by the evaluation. New data allow us to include a broader array of costs: mental health services received outside the catchment areas, general medical services for the children themselves, and mental health services used by family members. Results showed that reductions in other costs do partially offset higher expenditures on mental health services for children at the Fort Bragg Demonstration. However, even when broader costs are included, total family expenditures are still substantially higher at the Demonstration.     

“Program” deinstitutionalization

Summary Due to the petroleum recession, Oklahoma's mental health system, when new prisoner programs are subtracted, suffered a $15 million reduction since 1981. With careful shifting of funds, personnel, and patients, progress was accomplished in deinstitutionalization. State hospital mentally, ill populations were reduced by over 50% and community patient load quadrupled.     

The costs of mental health services under the Fort Bragg Demonstration

This article examines the costs of treatment under the Fort Bragg Demonstration. It focuses on the direct costs of mental health services and suggests that expenditures on those services were much higher at the Demonstration. Increased access and greater "doses" of services provided at the Demonstration are identified as the proximal causes of the system-level cost difference. Consideration is given to whether these differences in costs and in service use can be attributed to the continuum of care per se or to differences in the financial arrangements under which care was provided. Supplemental analyses suggest that these expenditures were not offset by cost savings elsewhere. Implications for mental health policy are discussed.     

The Fort Bragg Continuum of care Demonstration Project: The population served was unique and the outcomes are questionable

Examination of the evaluation sample and the outcome data from the Fort Bragg Demonstration Project suggests that the children served were mildly disturbed, were atypical of those served in most public mental health clinics, spent less than optimal time in the new services developed, and were judged as making considerable progress with minimal treatment regardless of age or level of judged psychopathology. The use of normative outcome measures in a pre-post design was considered a major reason for failure to find any significant differences between differently treated children.     

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.     

An Economic Comparison of Risperidone and Olanzapine Use within an Integrated Managed Mental Health Program

This study assessed differences in total mental health care costs for 1 year following initiation of risperidone or olanzapine in individuals within NorthSTAR, an integrated managed mental health pilot project. A retrospective database analysis of individuals with schizophrenia or schizoaffective disorder and newly started on either agent was conducted. Antipsychotic medication costs were significantly lower for individuals prescribed risperidone than olanzapine ($1763 versus $2582; p<0.001). Individuals prescribed risperidone had lower (but not significant) expenditures for mental health services ($4714 versus $5077; p=0.792), as well as total mental health care costs ($7407 versus $9011; p=0.255).     

Analysis of the Association of Clubhouse Membership with Overall Costs of Care for Mental Health Treatment

We examined whether frequency of attendance at the B’More Clubhouse was associated with lower mental health care costs in the Medicaid database, and whether members in the B’More Clubhouse (n?=?30) would have lower mental health care costs compared with a set of matched controls from the same claims database (n?=?150). Participants who attended the Clubhouse 3 days or more per week had mean 1-year mental health care costs of US $5697, compared to $14,765 for those who attended less often. B’More Clubhouse members had significantly lower annual total mental health care costs than the matched comparison group ($10,391 vs. $15,511; p?<?0.0001). Membership in the B’More Clubhouse is associated with a substantial beneficial influence on health care costs.     

Expenditures and revenues of state mental health agencies, 1981-1985

Data compiled by the National Association of State Mental Health Program Directors were used to compare expenditures and revenues of state mental health agencies in fiscal years 1981, 1983, and 1985. The agencies had direct control of funds totaling $8.3 billion in 1985, compared with $7.1 billion in 1983 and $6.1 billion in 1981, but spending in the three years varied by less than 1 percent in inflation-adjusted dollars. Spending for state mental hospitals declined by 5 percent, while spending for community-based programs grew by 10 percent. The great majority of the agencies' funds, 78 percent in 1985, were provided by state governments. Information about the budgets of state mental health agencies can help fill the financial information gap that confronts policymakers in the federal, state, and local mental health service delivery systems.     

The 'anatomy' of research funding of mental illness and addictive disorders.

To assess the level and sources of research funding for mental illness and substance abuse fields, we undertook a systematic survey of public and private funding entities. Applying standard definitions, we found that research support in these fields totaled approximately $859 million in fiscal 1988. This level of research support for mental illness and substance abuse is extremely limited and disproportionate to the overall costs to society by these disorders. Mental disorders and substance abuse accounted for $66.8 billion in health care costs in 1988; in the same year, research on these disorders represented only 4.7% of all health research support nationwide. The three institutes of the Alcohol, Drug Abuse, and Mental Health Administration (ADAMHA) (namely, the National Institute of Mental Health [NIMH], the National Institute of Drug Abuse [NIDA], and the National Institute on Alcoholism and Alcohol Abuse [NIAAA]) support 64% of all mental illness and substance abuse research; other federal agencies add little more than 7.5%, with the Department of Veterans Affairs the largest at 2%. The pharmaceutical and hospital industries account for another 17% of all support; state funding is 8%, which is particularly surprising in light of the states responsibility for the chronically mentally ill. While there has been recent significant growth in the research budgets of the NIMH, the NIDA, and the NIAAA, other sectors have not grown commensurately, leaving the field vulnerable to the funding vicissitudes of these institutes. Greater coalition building and advocacy are necessary to expand the breadth and depth of research resources for the field.(ABSTRACT TRUNCATED AT 250 WORDS)     

Cost of care for Medicaid recipients with serious mental illness and HIV infection or AIDS

OBJECTIVE: To assist in developing public policy about the feasibility of HIV prevention in community mental health settings, the cost of care was estimated for four groups of adults who were eligible to receive Medicaid: persons with serious mental illness and HIV infection or AIDS, persons with serious mental illness only, persons with HIV infection or AIDS only, and a control group without serious mental illness, HIV infection, or AIDS. METHODS: Claims records for adult participants in Medicaid fee-for-service systems in Philadelphia during 1996 (N=60,503) were used to identify diagnostic groups and to construct estimates of reimbursement costs by type of service for the year. The estimates included all outpatient and inpatient treatment costs per year per person and excluded pharmacy costs and the cost of nursing home care. Persons with severe mental illness, HIV infection, or AIDS had received those diagnoses between 1985 and 1996. RESULTS: Persons with comorbid serious mental illness and HIV infection or AIDS had the highest annual medical and behavioral health treatment expenditures (about $13,800 per person), followed by persons with HIV infection or AIDS only (annual expenditures of about $7,400 per person). Annual expenditures for persons with serious mental illness only were about $5,800 per person. The control group without serious mental illness, HIV infection, or AIDS had annual expenditures of about $1,800 per person. CONCLUSIONS: Given the high cost of treating persons with comorbid serious mental illness and HIV infection or AIDS, the integration of HIV prevention into ongoing case management for persons with serious mental illness who are at risk of infection may prove to be a cost-effective intervention strategy.     

The Louisiana Mental Health Client-Outcome Evaluation Project: An initial progress report

The Louisiana Mental Health Client-Outcome Evaluation Project is assessing the effectiveness of the Schainblatt-Hatry system of client-oriented outcome monitoring as applied to Louisiana CMHC outpatient settings. This system involves incorporating a self-administered mental health questionnaire into the routine center intake procedures and use of a combination mail-out and telephone follow-up data collection method. Follow-up procedures can be operated by a small evaluation staff through the State central office. This initial progress report provides an overview of the instruments and procedures being utilized and discusses results of the project obtained thus far.     

Health service delivery and research outcomes of a common departmental structure for psychiatric consultation-liaison and social work services at a university hospital

Convincing evidence exists that psychosocial factors have a major impact on both outcome and costs in the medical/surgical services in general hospitals. This paper describes the Human Services Department's impact on social work and consultation-liaison psychiatry, using a data-based management system across five specialties: 1) social work; 2) consultation-liaison psychiatry; 3) supportive care (hospice); 4) home care (home health discharge planning); and 5) pastoral care, which offers opportunities for research and quality assurance monitoring. Time spent in service delivery was used to estimate the cost per hour: 1) pastoral care $96; 2) social work $36; 3) consultation-liaison psychiatry $59; 4) home care $49. Referral to social work was preferred for a range of family and discharge planning services. Consultation-liaison services were preferred for depression, paranoid behavior, and management problems. Referral overlap was noted for "coping with diagnosis" for social work and consultation-liaison psychiatry. Using a computerized data base format for documenting the referral process, work accomplished, and time spent among those services providing mental health care in the general hospital permits the observation of redundancy of services delivered and their costs.     

Supporting Mental Health and Wellness among Private School Students: A Survey of Catholic Elementary and Secondary Schools

Little systematic inquiry has focused on school-based mental health services in the Catholic education sector, which educates more than two million children annually in the United States. More than 400 Catholic elementary and secondary schools were surveyed to inform a baseline environmental scan measuring how Catholic schools nationally are serving children's mental health needs. The article sheds light on patterns of mental health staffing and resource provision, student psychosocial and mental health issues, mental health service provision, and barriers to and challenges of mental health service provision. The findings are contextualized by comparison with estimates of public school mental health service provision, consideration of funding issues pertinent to the private school sector, and the continuing need for strategic assessment and action planning to support student mental health.     

Cost and cost-effectiveness of hospital vs residential crisis care for patients who have serious mental illness

BACKGROUND: This study evaluates the cost and cost-effectiveness of a residential crisis program compared with treatment received in a general hospital psychiatric unit for patients who have serious mental illness in need of hospital-level care and who are willing to accept voluntary treatment. METHODS: Patients in the Montgomery County, Maryland, public mental health system (N = 119) willing to accept voluntary acute care were randomized to the psychiatric ward of a general hospital or a residential crisis program. Unit costs and service utilization data were used to estimate episode and 6-month treatment costs from the perspective of government payors. Episodic symptom reduction and days residing in the community over the 6 months after the episode were chosen to represent effectiveness. RESULTS: Mean (SD) acute treatment episode costs was $3046 ($2124) in the residential crisis program, 44% lower than the $5549 ($3668) episode cost for the general hospital. Total 6-month treatment costs for patients assigned to the 2 programs were $19,941 ($19,282) and $25,737 ($21,835), respectively. Treatment groups did not differ significantly in symptom improvement or community days achieved. Incremental cost-effectiveness ratios indicate that in most cases, the residential crisis program provides near-equivalent effectiveness for significantly less cost. CONCLUSIONS: Residential crisis programs may be a cost-effective approach to providing acute care to patients who have serious mental illness and who are willing to accept voluntary treatment. Where resources are scarce, access to needed acute care might be extended using a mix of hospital, community-based residential crisis, and community support services.