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.     

Mental health services utilization in a children's mental health managed care demonstration

Service delivery under two systems of care--a traditional Civilian Health and Medical Program of the Uniformed Services (CHAMPUS) reimbursement system and an innovative continuum of care--was examined along six dimensions: access, type, mix, volume, timing, and continuity of services received by children and adolescents. It was found that the Demonstration served over three times as many children as the Comparison. In addition to serving more children, the Demonstration also provided more and different types of services to each child treated. Finally, the Demonstration appears to have delivered services in a more timely fashion and made a considerable effort to match children's and families' needs with services.     

Mental health care for young people: early intervention in psychosis

During the last 15 years, much progress in early interventions (Els) focusing on psychosis in the young people has been made, and new revelations about psychotic disorder including schizophrenia have come out. Furthermore, findings from clinical epidemiology in the general population and clinical genetics of psychiatric diseases have revealed the "trajectories" before the onset of psychosis. Current state and challenge of Els in the first-episode psychosis (FEP) and high risk state (HRS) (putatively prodromal state) for psychosis will be selectively overviewed in this article. Although Els in FEP shorten the duration of untreated psychosis and improve the short-term outcome, it would be required to sustain the EL effects for a long time. Els in HRS also prove fruitful, but predictor of transition to psychosis must be established for the clinical practice. Furthermore, Els in the earlier HRS targeting at the cognitive dysfunction and negative rather than positive symptoms under ethical consideration will improve psychosocial impairments. Clinical staging concept using in general medicine for the serious physical diseases might enable an individualized medicine in psychiatric EIs.     

Mental health benefit limits and cost sharing under managed care: a national survey of employers

Mental health services experts suggest that managed care diminishes the need for arbitrary benefit limits and consumer cost-sharing. Data from 577 health plans were used to test the hypotheses that health maintenance organizations (HMOs) and carve-out plans are less likely to use benefit limits or service exclusions, have more generous limits, and have lower cost-sharing requirements than non-HMOs and non-carve-out plans. The results show that HMOs were more likely to use service exclusions and did not make less use of benefit limits. Carve-outs were less likely to use some coverage exclusions. Comparisons of the stringency of limits and cost-sharing provisions did not show consistent differences.     

Mental health in young people

Summary The aim of this study is the investigation of psychological discomforts in workers considered to be exposed to mental health risks. The subjects chosen were all young males, aged between twenty and twenty-nine, resident in the same geographical area for at least ten years and still living with their original family. Through a random process of selection four groups were sampled: metalworkers exposed to mental health occupational risks, metalworkers not exposed to mental health occupational risks, full-time students, and persons unemployed or seeking their first job. The subjects from each group completed the questionnaire to determine the index of psychological discomforts (IDP). Significantly higher frequencies and averages were found in the group of metalworkers exposed to mental health risks, while no statistically significant results were noted in the other groups, including the group of unemployed.     

Mental health center adaptation in a changing environment

The shift in policy and funding authority from the federal to the state level of government has caused local mental health centers to reconsider some of their operations. Actions aimed at altering center relations with the external environment are not undergoing radical changes, and executive directors are not significantly increasing their contacts with state authorities, community groups, or local service agencies. Relations with state mental health authorities were described as positive or improving, as was the influence of statewide associations of center directors. The implications of this lack of increased attention to external relations for long-term center viability are discussed.Jeanette M. Jerrell is Associate Research Scientist and Judith K. Larsen is Senior Research Scientist at COGNOS Associates. This research was supported by NIMH grant #5-R01-MH38069-02, Division of Biometry and Epidemiology. Requests for reprints should be sent to Dr. Jerrell at 111 Main St., Suite 5, Los Altos, CA 94022.     

Mental health and use of health care services in opioid-exposed school-aged children compared to foster children

Given the concerns raised regarding the effects of prenatal exposure to methadone and buprenorphine on the developmental outcomes of the children, this study assessed mental health and use of services in a national sample of school-aged children (N = 78) born to women enrolled in opioid maintenance treatment during pregnancy, compared with a group of foster children (N = 140). The majority of the opioid-exposed children lived with their birth parent(s) at the time of assessment (N = 62), while 16 lived in foster homes. Caregivers completed the Strengths and Difficulties Questionnaire (SDQ) and the Reactive Attachment Disorder scale. Teachers completed the SDQ. Three kinds of services were included in measuring service use: school-based education services, child mental health services, and hospital-based habilitation services. The main finding of the study is that children prenatally exposed to methadone or buprenorphine living with their family of origin had significantly better mental health status than their foster-placed counterparts and that of the comparison group of foster children. In addition, the exposed children living at home had less child welfare involvement, and only half of them were using any of the three services measured. The odds for using services increased significantly in accordance with increasing mental health problems, independent of group affiliation, indicating a need-based access to services. In line with other studies, we found that the odds for using one or more services was 2.3 times greater for boys than for girls. Our results contribute to a more-nuanced understanding of the developmental outcomes of prenatal exposure to methadone and buprenorphine, and factors associated with increased service use in groups of at-risk children.

     

Quality assessment in a Medicaid managed mental health care plan: an Iowa case study.

Clinical quality was assessed in a statewide Medicaid managed mental health care program. Because of the limited quantity and scope of the available clinical data, the quality of clinical care could not be adequately assessed. The implications of this finding for the evaluation and oversight of quality in public sector managed care plans is discussed.     

A collaborative approach to the development of psychiatric rehabilitation services in a public behavioral health managed care environment

This article summarizes the collaborative effort that took place between providers, managed care administrators, and state and county officials in Pennsylvania to create a fluid system in the development of psychiatric rehabilitation services. The stakeholders involved solved the numerous logistical problems that are inherent in the start-up of new services and were able to cooperatively create procedures for service delivery, service coordination, and reimbursement across systems and funding mechanisms. The article reviews that process and highlights the services of Welcome House, a psychiatric rehabilitation program exemplifying the products of their collaboration.     

Psychotherapy in the managed care health market

The author considers the future of psychotherapy in the managed care health market. He focuses on two interrelated questions. How can the efficacy of psychotherapy be scientifically demonstrated? Can psychotherapy meet the standards of cost-effectiveness set by health plans? He notes that efficacy is not enough in the managed care market, in which health plans also focus on the rational allocation of resources and economies of scale. The author then turns to the question of whether the doctor-patient relationship, which was central to American medicine throughout much of the 20th century, can survive in the current healthcare climate. He reviews the literature on the efficacy of psychotherapy and discusses the criteria for empirically validated treatments proposed by the American Psychological Association. He concludes that there is considerable support for the premise that the personal qualities of the individual therapist that contribute to the formation of the therapeutic alliance are at least as important, if not more important, than the specific method of psychotherapy used. The author concludes that medicine and psychiatry may be neglecting an important and uniquely curative element-the doctor-patient relationship, the human encounter that is the foundation of the art and science of medicine.     

Mental health care in Fiji

Fiji is one of the largest island nations in the South Pacific. It is multicultural and has an economy based on tourism and sugar production. Like many developing countries Fiji faces the double burden of communicable and non‐communicable diseases as well as a third emerging burden of accidents and injuries. Fiji lacks data on the national prevalence and burden of disease of mental disorders. Using World Health Organization estimates there is over a 90% treatment gap for mental disorders. Contributing to this treatment gap are the misconceptions and stigma surrounding mental illness leading people to seek alternative treatments. Fiji's mental health services were established in 1884, comprising a single ward to care for mentally ill expatriates. Services have since expanded to include a 136‐bed inpatient facility (St. Giles Hospital), which provides outpatient, psychosocial rehabilitative and community psychiatric services. Mental health services remain centralized at St. Giles, with follow‐up in the community supported by a well‐established public health hierarchy and by medical personnel at the divisional hospitals. St. Giles is also responsible for conducting mental health awareness and training for health workers and the public and provides input at a national level for mental health policy, plans and legislation. Psychiatric training is available at the undergraduate nursing and medical levels. The Fiji School of Medicine is in the process of developing a postgraduate psychiatric program. With its limited resources Fiji needs to integrate mental health services into the general and public health systems to achieve a comprehensive and integrated mental health system.     

Mental health care in Germany

Germany turned towards community-based mental health care in the mid seventies, during a general climate of social and political reform. The continuing deinstitutionalisation process and the implementation of community mental health services was considerably affected by the reunification of East and West Germany in 1990, which required dramatic changes in the structure and quality of the mental health care system of the former German Democratic Republic (GDR). Overall, German mental health care is organised as a subsidiary system, where planning and regulating mental health care is the responsibility of the 16 federal states. So German mental health care provision is spread among many sectors and characterised by considerable regional differences. A key characteristic is the particularly wide gap between inpatient and outpatient services, which are funded separately and staffed by different teams. In 2003 the total number of psychiatric beds was a mere two thirds of the overall bed capacity in 1991, the first year as a re-unified Germany, when psychiatric beds in East and West Germany totalled 80,275. From 1970 onwards the number of psychiatric beds was cut by roughly half. So the momentum of the reform has been strong enough to assimilate the completely different mental health care system of the former German Democratic Republic and, in the course of a decade, to re-structure mental health services for an additional 17–18 million new inhabitants. In an ongoing struggle to adapt to changing administrative set-ups, legal frameworks, and financial constraints, psychiatry in Germany in currently facing specific problems and is seriously challenged to defend to considerable achievements of the past. A major obstacle to achieving this aim lies in the fragmented system of mental health care provision and mental health care funding.     

Understanding managed behavioral health care.

Managed care can be understood from an historical perspective as a reaction to perceived abuses by providers or an extension of earlier efforts to manage care in the public sector. It can be viewed as a young and emerging force--a fourth party to the health care transaction--that is rapidly progressing through a series of generations that redefine the approach to organizing and delivering services. And finally, because managed care emerges with so many faces, consumers and providers can perhaps best understand its implementation in a specific state or community by examining the multiple dimensions, such as those outlined herein, on which these initiatives vary. Until the forms and functions are more uniform, no simple definition of managed care will exist.     

Pragmatics of tracking mental health outcomes in a managed care setting

Accountability, cost effectiveness, and continuous quality improvement are essential features of all managed health care systems. However, application of these principles to mental health treatments has lagged behind other health care services. In this article, administrative, practice, and technical issues are addressed through a joint effort between academically based researchers and administrators from two large managed health care organizations. Principles related to the measurement of outcome, instrument selection, and obstacles to the implementation of an ongoing program to assess mental health treatment outcomes are identified. Finally, principles for successfully changing mental health provider behavior toward outcome assessment and the implications of such for mental health delivery systems are discussed.     

Overview of Medicaid managed behavioral health care

The Oregon Health Plan is being implemented at a time when many states are revising their Medicaid mental health programs. A national overview places this state's efforts into context.     

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.