The evaluation of statewide mental health programs: A systems approach

This paper attempts to outline a model for the evaluation of a statewide mental health program drawn from general systems theory. The derived model is partially stated and illustrative applications discussed. Inferential procedures as applied to evaluation research are discussed and experimental inference is stated to be inapplicable to most evaluation problems. Evaluative technique is applied not only to the attainment of ultimate objectives but to the attainment of intermediate objectives as well. In this latter connection, there is a brief discussion of program budgeting and its relation to evaluation studies.This paper was presented in a symposium entitled Conceptual and Methodological Issues in the Evaluation of Community Mental Health Programs at the 74th annual meeting of the American Psychological Association, September 2, 1966.     

Justifying inpatient admissions at a community mental health center

A model for screening and reviewing inpatient psychiatric admissions at a community mental health center is presented in which the process, including the use of both a diagnostic criteria set and a functional criteria scale, is described. Results of a time-limited experimental program indicated that the diagnostic criteria set could be applied in approximately three fourths of the admissions, while the scale of function could be utilized in all cases. Also, a statistically high rate of concordance was found both when the two methods were used by the same evaluator, and when two independent evaluators were employing the same method. At the conclusion of the final review, 6 of 273 admissions or 2.2 per cent were unjustified. The pilot program demonstrated that 90 per cent of the admissions could be screened adequately by nonphysicians. The average time expended by in-house staff including screeners, reviewers, and supportive staff was estimated to be 58.4 minutes per admission with an average direct cost per case of $6.68. Had the review been performed by physicians in local practice, the average cost per case was estimated to be $8.93. The six unjustified admissions represented an average reviewing cost of about $240 per case.     

County mental health directors' evaluation of a statewide intensive case management program: the New York State experience

Case management is increasingly recommended as part of an overall strategy for serving individuals with severe mental illness. The New York State Office of Mental Health developed such a program in 1988, with county mental health directors the key players in its development and operationalization. This article reports the results of a statewide survey administered by the authors to these directors 3 1/2 years after the program's implementation to determine its degree of success. Overall, the program was viewed as effective for individual clients, particularly those most in need of services. However, with respect to overall systems change, there was more variability in results. In general, a combination of strategies to reduce fragmentation within the mental health system and increase collaboration between service providers should be considered by state mental health authorities.     

Prevalence and clinical correlates of self-harm and suicidality during admission of children in a mental health inpatient unit

BackgroundSelf-harm and suicidality are common presentations in children and adolescents requiring a mental health inpatient admission. Although there are several studies on adolescents, there is relatively limited research into childhood self-harm and suicidality during such admissions.MethodsA retrospective electronic file review was conducted on all children discharged from a national mental health inpatient children’s unit over a 6-year period. Several independent variables were compared between self-harm/suicidal and non-self-harm/non-suicidal children. Separate analyses investigated changes in self-harm/suicidality, functional outcomes, and risk assessment ratings between admission and discharge.ResultsA total of 105 children were included in this study. During admission, 65.7% of them reported self-harm thoughts, 61% engaged in self-harm, 50.5% expressed suicidal thoughts, and 14.3% engaged in suicidal behavior. Thoughts and acts of self-harm were associated with previous self-harm, longer admissions, and Attention Deficit Hyperactivity Disorder. Suicidality overlapped with self-harm and was strongly predicted by previous self-harm. The prevalence of self-harm and suicidal thoughts and acts significantly decreased during admission. Children in the non-self-harm group had marginally better functional outcomes upon discharge compared to those in the self-harm group. Children and parents/caregivers were similarly satisfied with treatment, irrespective of children’s self-harm/suicidality.ConclusionsSelf-harm and suicidality were widespread among children admitted to hospital. Better understanding of the mechanisms and factors related to self-harm and suicidality in this age group could help mitigate associated risks and improve existing safety strategies.     

Staff-patient ratio and type of interaction on a child psychiatry inpatient unit

Eight children from a child psychiatry inpatient unit were observed during mealtimes to examine the effects of varying staff-patient ratios on their behavior. The frequency of negative behavior was lowest during the moderate ratio periods for most subjects. Type of staff attention, rather than number of staff, appeared to be related to acting-out behavior in the children.Richard J. Pines and Mario Natta are former milieu therapists, Mary Jo Kupst is a Research Psychologist, and Jereme L. Schulman is a Psychiatrist and head of the Department of Child Psychiatry, Children's Memorial Hospital, Chicago, Illinois.     

Outcome predictors of intermediate-term treatments in inpatient child and adolescent psychiatry

Purpose of this study is to identify predictors of the length of stay (LOS) in child and adolescent psychiatry (CAP) and the success of inpatient treatment. All child and adolescent inpatients that had been dismissed over a year's time from a non-university hospital after a medium-length-treatment were rated by their therapists (crisis interventions for < 2 weeks excluded). The group featured a low drop-out-rate (9.8%) and a high percentage of "problematic patients". The ICD-10 diagnoses were irrelevant for the prediction of LOS and success of treatment. The Global Assessment of Function scale (axis VI) correlated significantly with LOS, and functioning in all areas improved with a longer LOS. By the degree of initial psychopathology therapeutic success as well as LOS could be predicted fairly well. Concerning adolescents, motivation for treatment and the degree of cooperation both correlated with LOS and improvement, which implies the importance of their participation. For children under 12, cumulated psychosocial adversities (axis V) predicted a less positive outcome, cooperation of parents and patients raised the chance of success. Shortened lengths of stay will not lead to comparable success. As a system like DRGs for reimbursement of hospitalization in CAP will not prove to be efficient, other variables deserve more attention in future health economy planning. More intervening variables, such as psychosocial adversities, motivation, and cooperation have to be considered.     

Nursing staff satisfaction on a mental health unit

The present study set out to assess the level of nurses' job satisfaction in an acute in-patient mental health setting. All but one (n = 22) of the full-time nursing staff employed on the unit took part in the study. Unlike many previous studies where the level of job satisfaction was assessed using predetermined questionnaire items but without providing an understanding for workers' choices, the present study sought an estimation of what job characteristics nurses saw as important, an estimation regarding their current satisfaction with each characteristic and, importantly, the reasons behind their choices.     

Patterns and prevalence of arrest in a statewide cohort of mental health care consumers

OBJECTIVE: Although criminal justice involvement among persons with severe mental illness is a much discussed topic, few large-scale studies systematically describe the patterns and prevalence of arrest in this population. This study examined rates, patterns, offenses, and sociodemographic correlates of arrest in a large cohort of mental health service recipients. METHODS: The arrest records of 13,816 individuals receiving services from the Massachusetts Department of Mental Health from 1991 to 1992 were examined over roughly a ten-year period. Bivariate relationships between sociodemographic factors and arrest were also examined. RESULTS: About 28 percent of the cohort experienced at least one arrest. The most common charges were crimes against public order followed by serious violent offenses and minor property crime. The number of arrests per individual ranged from one to 71. Five percent of arrestees (roughly 1.5 percent of the cohort) accounted for roughly 17 percent of arrests. The proportion of men arrested was double that of women. Persons 18 to 25 years of age had a 50 percent chance of at least one arrest. This rate declined with age but did so unevenly across offense types. CONCLUSIONS: The likelihood of arrest appeared substantial among persons with severe mental illness, but the bulk of offending appeared concentrated in a small group of persons and among persons with sociodemographic features similar to those of offenders in the general population. Data such as these could provide a platform for designing jail diversion and other services to reduce both initial and repeat offending among persons with serious mental illness.     

The successful marketing of a child and adolescent inpatient unit in a community hospital.

This article presents the development and implementation of a marketing plan designed for a 24-bed child and adolescent inpatient psychiatric unit in a 500+ bed community hospital. It includes questions raised while developing the marketing strategy and goals. Methods of implementation for specific target groups such as psychiatrists, pediatricians, school counselors, and clergy, are outlined. Assessment and consequent adjustments to the marketing plan based upon ongoing evaluation are discussed.     

Monitoring inpatient length of stay in a community mental health center.

The authors assess their experience with reviewing the length of stay of inpatients in a mental health facility. The study yielded data that refine the review process and suggest a rationale for selection of cases for review that may have educational value both to the admitting staff and physician-reviewers. The authors urge experimentation with length of stay norms which reflect specified treatment protocols related to diagnosis, rather than reliance on diagnosis alone.     

Use of a state inpatient forensic system under managed mental health care

OBJECTIVES: One of the goals of managed mental health care has been to lower the use of inpatient psychiatric treatment. In the past, interventions that have limited hospitalization for persons with severe mental illness have led to greater involvement of these individuals with the criminal justice and forensic mental health systems. The authors examined associations between Medicaid managed mental health care in Massachusetts and rates of admission to the inpatient forensic mental health service maintained by the state's mental health department. METHODS: A total of 7,996 persons who were receiving services from the department before and after the introduction of managed care were studied. A logistic regression model based on generalized estimating equations was used to identify associations between Medicaid beneficiary status and forensic hospitalization before and after the introduction of managed care. RESULTS: The overall rate of forensic hospitalization declined in the study cohort in both periods. However, no significant decline was observed in the risk of forensic hospitalization among Medicaid beneficiaries whose care had become managed. CONCLUSIONS: Although the results of this study warrant further exploration, the risk of forensic hospitalization among Medicaid beneficiaries should be considered by policy makers in the design of mental health system interventions.