Hispanic client-case manager matching: differences in outcomes and service use in a program for homeless persons with severe mental illness

Mental health professionals have responded to ethnic and racial disparities in mental health care by advocating increasing cultural relevancy in treatment. A central component of cultural relevancy is ethnic and racial pairing of clients and providers. This study examined the effects of client-case manager ethnic and racial matching among white and Hispanic clients who received assertive community treatment in the Access to Community Care and Effective Services and Supports Program. Twelve-month outcomes and service use were examined among 242 Hispanic and 2333 white clients seen in the first 3 years of the program. Analysis of covariance was used to evaluate the association of client-case manager ethnic and racial matching with changes in health status and service use from baseline to 12 months after program entry. At baseline, Hispanics had more serious problems than whites on several measures of psychiatric and substance abuse domains, and they also showed less improvement than whites over the next year on several measures of psychiatric status and service use. One significant association with ethnic matching was found: when treated by a Hispanic clinician, Hispanic clients showed less improvement in symptoms of psychosis. These results do not support the hypothesis that ethnic and racial matching improves outcomes or service use. Several explanations are offered for the results.     

Familiarization: A vital step in mental health consultation

In recent years, more effective utilization of limited mental health manpower has required mental health professionals to shift more from direct service to consultation with workers whose job roles, while important to good mental health, are outside of the mental health field. There are often serious barriers to effective consultation in marked differences in job functions, training and education, and social class identification between consultant and consultee. The consultant can overcome these by familiarizing himself as directly as possible with the consultee's job, client population, and background. Successful examples of this type of consultation are described. Dr. Nelson, formerly Director of Psychological Services at the center     

Lessons from the evaluation of the ACCESS program. Access to Community Care and Effective Services

The authors summarize the main findings of the ACCESS (Access to Community Care and Effective Services) program and offer lessons for policy makers. Data from studies at the site level and the client level, which were presented in the two previous articles in this issue of Psychiatric Services, are summarized and synthesized with the authors' collective experience with the ACCESS program. The results of the evaluation suggest that although service systems integration can be improved, targeted efforts to implement strategies for integration do not produce better client outcomes. Efforts to integrate service systems can be supported by their effects on some organizational relationships within the mental health service system but not by their widespread effects across human services or their direct effects on clients.     

Person-centred mental health care: the challenge of implementation

Within mental health care, 'person-centredness' has been generally interpreted to convey a holistic approach with an attitude of respect for the individual and his/her unique experience and needs. Although it has been possible to demonstrate that professionals can acquire such skills through training, the impact on clinical outcomes has been more difficult to demonstrate in randomized controlled trials. Indeed what is becoming increasingly apparent in the literature is the need to acknowledge and address the degree of complexity that exists within the health care system that militates against achieving satisfactory implementation and outcomes from person-centred mental health care. In addressing this, we must develop and work with more sophisticated and three-dimensional models of 'patient-centredness' that engage with not only what happens in the consulting room (the relationship between individual service users and healthcare professionals), but also addresses the problems involved in achieving person-centredness through modifying the way that services and organizations work, and finally by engaging families and communities in the delivery of health care. A truly meaningful concept of 'people-centredness' encompasses how the views of the population are taken into consideration not only in healthcare but also in health and social care policy, and wider society too.     

Learning Disability Liaison Nursing Services in south‐east Scotland: a mixed‐methods impact and outcome study

Background There have been significant concerns about the care and treatment of people with intellectual disabilities (ID) when attending general hospitals, which have led to inquiries that highlight service and systems failures. One response has been the development of Learning Disability Liaison Nursing (LDLN) Services across the UK that aim to ensure that additional, specialist support is available for patients, their carers and general healthcare professionals. Methods A mixed‐methods study to investigate the impact of LDLN Services across four Scottish NHS boards was undertaken. In total, 323 referrals made over 18 months were analysed along with qualitative data drawn from interviews and focus groups with a sample of 85 participants including patients with ID (n = 5), carers (n = 16), primary care healthcare professionals (n = 39) and general hospital professionals (n = 19) and learning disability liaison nurses (n = 6). Results The referral patterns to the four liaison nursing services closely matched the known health needs of adults with ID, with common admissions being due to neurological, respiratory and gastrointestinal issues. The LDLN role was seen to be complex and impacted on three key areas: (i) clinical patient care; (ii) education and practice development; and (iii) strategic organisational developments. Specific patient outcomes were linked to issues relating to capacity and consent to treatment, fostering person‐centred adjustments to care, augmenting communication and the liaison nurses acting as positive role models and ambassadors for people with ID. Conclusions The LDLN Services were valued by stakeholders by achieving person‐centred outcomes. With their expert knowledge and skills, the liaison nurses had an important role in developing effective systems and processes within general hospital settings. The outcomes highlight the importance of supporting and promoting LDLN Services and the challenges in delivering the multifaceted elements of the role. There is a need to take account of the complex and multidimensional nature of the LDLN role and the possible tensions between achieving clinical outcomes, education and practice developments and organisational strategic initiatives.     

Attitudes towards and organizational support for evidence-based practices: A comparison of education and allied health professionals in autism

BackgroundEvidence-based practices (EBPs) have been developed for clients on the autism spectrum across allied health and education. However, there remains a significant gap between research and practice. We explored the similarities and differences between educators and allied health professionals in two key factors that may link to uptake: individual attitudes and organizational culture support for EBP.MethodAllied health (n = 156) and education professionals (n = 95) completed measures of their individual attitudes and perceived organizational support for EBP.ResultsModerate levels of support for each were found within both groups. Educators however, showed more positive individual attitudes, whereas allied health professionals showed more positive organizational support toward EBP.ConclusionsThese results add to the scant literature comparing professions, highlighting discipline differences in attitudes and organizational support across professionals for EBP in autism. These findings highlight the need for targeted knowledge translation approaches as opposed to development of generic models across contexts and disciplines.     

Vocational rehabilitation service usage and outcomes for individuals with Autism Spectrum Disorder

BackgroundIn the pursuit of improving employment outcomes for individuals with Autism Spectrum Disorder (ASD), understanding how participants are using Vocational Rehabilitation (VR), and which services result in competitive integrated employment is of great interest to advocates, families, professionals, and policy makers. The primary objective of this study was to examine the relationships between participant characteristics, service delivery, and employment outcomes for individuals with ASD in state VR programs.MethodThe Rehabilitation Services Administration's Case Service Report (RSA-911) database for fiscal year 2013 was examined using a binary logistic regression analysis to explore ASD characteristics and service variables.ResultsResults indicate that ASD characteristics, defined as a source of impairment by VR, had predictive capacity for administrative VR services participants received (e.g. assessment and vocational rehabilitation counseling and guidance (VRCG)), but not for job-related services (e.g. job search, job placement, and on-the-job supports). In addition, job-related VR services were more likely to be associated with integrated employment at closure as compared to administrative VR services. In some cases, additional variables related to gender, race, and state system decreased the likelihood of a VR recipient receivingspecific services or achieving integrated employment.ConclusionDiscussion includes how awareness of service access and equity can assist in improving the quality and outcomes of VR services.     

Allied health care in Parkinson's disease: Referral,consultation, and professional expertise

There is evidence for the efficacy of allied health care in Parkinson's disease (PD). However, barriers exist that hamper implementation of evidence into daily practice. We conducted a survey to investigate: (1) to what extent PD patients currently utilize allied health care for relevant problems in the core areas of allied health care and (2) the level of PD‐specific expertise among allied health professionals. Questionnaires were sent to 260 patients and 297 allied health professionals. Referral rates were 63% for physical therapy, 9% for occupational therapy, and 14% for speech therapy. PD patients with problems that can potentially be alleviated by input from allied health professionals are often not being referred. Furthermore, most patients were treated by allied health professionals who lacked PD‐specific expertise. Current referral to and delivery of allied health care in PD are suboptimal. Evidence‐based guidelines for allied health care in PD and active implementation of these guidelines are needed. © 2008 Movement Disorder Society     

Health status, utilization patterns, and outcomes of persons with intellectual disabilities: review of the literature

A literature review was conducted to analyze existing data on health status, health care utilization, and medical outcomes of persons with intellectual disabilities. We found that barriers exist, but evidence indicates that (a) individuals with intellectual disability and medical needs are living in the community, (b) people with significant medical conditions can be maintained in community settings, and (c) medical supports can and are provided to people with intellectual disabilities and allied medical conditions to enable community living. However, some people had unmet medical needs, and the availability of and access to community-based services were problematic for others. These contradictory findings indicate that it is possible to provide services in the community, but the service delivery system needs improvement.     

Pitfalls and pratfalls in consultation-liaison psychiatry in a general hospital

As Consultation-Liaison Services continue to develop and expand in general hospitals, psychiatrists must be aware of pitfalls and pratfalls inherent in dealing with medical colleagues and other allied health professionals, as well as with the patients. Practical considerations in answering consultation requests are discussed with respect to "hidden agendas" of the consultee, role and expectations of the psychiatrist, and problem referrals. It is only through mutual respect and collaboration that Consultation-Liaison Services can truly be effective.     

Doctors’ perspectives regarding the changes in the delivery of health care to people with developmental disabilities

This paper reports the findings of a survey of doctors, working with people with a developmental disability, which was designed to assess their perspectives as to the changes to the delivery of health care as a consequence of the transfer of their services from the NSW Department of Health to the NSW Department of Family and Community Services. The study also investigated the influences that the Disabilities Services and Guardianship Act has had on the delivery of health care within this area. It found an alarmingly high attribution rate of not only doctors but other health care professionals within this area of service and noted the flagging morale and downgrading of career structure. The implementation of the Guardianship Act has served to augment this declining morale and to increase the work load of doctors who are already under pressure as a consequence of falling numbers.     

Time-limited assertive community treatment for homeless persons with severe mental illness.

BACKGROUND: The assertive community treatment (ACT) model for people with severe mental illness was originally designed to be provided continuously without termination. This study evaluated postdischarge changes in health status and service use associated with the time-limited provision of ACT to homeless people with severe mental illness. METHODS: Clients in the fourth annual cohort of the Access to Community Care and Effective Services and Supports (ACCESS) program (N = 1617) were assessed at entry into ACT and 3, 12, and 18 months later. Random effects models were used to compare outcomes and service use among clients who terminated ACT and clients who remained in ACT, controlling for potentially confounding factors. RESULTS: Altogether, of clients who participated in follow-up, 8.7% participated for less than 3 months; 40.6%, for 3 to 10 months; 15.3%, for 11-13 months; and 35.3%, for 14 months or more. Controlling for potentially confounding factors, mental health, substance abuse, and housing outcomes did not significantly differ between clients who had been discharged at the time of follow-up as compared with those who had not. Those who had been discharged had worked significantly more days than those who had not (t(1794) = 3.24, P<.001), and they reported significantly less outpatient health service use though there was no decline in hospital days or receipt of public support payments. CONCLUSION: Homeless clients who have severe mental illness can be selectively discharged or transferred from ACT to other services without subsequent loss of gains in mental health status, substance abuse, housing, or employment.     

Community-based treatment of psychiatric disorders in U.S.A. and Norway: insights for new service delivery systems.

This article reports on a successful community-based psychiatric treatment program in Philadelphia, Pennsylvania and describes subsequent experiences seeking approval of similar programs in Philadelphia and in Oslo, Norway. Previous studies have shown that the Philadelphia community-based program, which used patient social networks and indigenous community workers assisted by psychological and psychiatric professionals, provided better treatment outcomes than traditional hospital programs and socioenvironmental treatment programs. On the basis of these experiences a new service delivery system was proposed which integrates patient social networks, community workers, and lay community organizations with mental health center professionals. Examination of differences in official responses to the proposal shows the importance of several factors, including the mental health bureaucracy's perception of patient potential, their openness to social psychological therapy, and the power struggles within the bureaucracy and the professional community.     

Allied health care interventions and complementary therapies in Parkinson's disease

Allied health care and complementary therapies are used by many patients with Parkinson's disease (PD). For allied health care, supportive scientific evidence is gradually beginning to emerge, and interventions are increasingly integrated in the treatment programs for PD patients. To evaluate whether such multidisciplinary programs are justifiable, we review the literature of allied health care and complementary therapies in PD. According to the level of available evidence, we provide recommendations for clinical practice. Finally, we discuss the need for an improved organization of allied health care, and identify topics for future research to further underpin the pros and cons of allied health care and complementary therapies in PD.     

Negotiating the boundaries between clinical and non-clinical work within a supported housing program

Many contemporary mental health care programs rely on cross-agency models of service delivery. In these models, staff from different organizations provide care for the same clients, and this requires negotiation around role boundaries. In Australia, cross-agency programs have been developed to promote collaboration between government and not-for-profit community groups to meet the needs of those with serious mental health problems. Policy makers need to be aware of how staff in these roles conceptualize the boundaries and interconnection of their work with others to ensure that program goals are achieved. This study examined the division of labor that emerged between support workers (employed by the not-for-profit sector) and government health workers within a cross agency supported housing program for people with serious mental illness at risk of homelessness and self-neglect. Interviews were conducted with 40 government health workers and 37 staff from non-government agencies that shared clients in a supported housing program. Interviews were audio-recorded, transcribed verbatim, and analyzed using thematic analysis. While the division between clinical and non-clinical work was accepted and co-produced, tensions arose in defining the boundaries between them. These tensions resulted from poor communication on the part of both groups, perceived lack of clinical intervention by case managers, high caseloads of case managers, role ambiguity, and support workers feeling their input and feedback were not valued by government health workers. Divisions of labor in cross-agency programs need to be critically evaluated to assess whether they serve program goals. Tensions are inevitable when dividing the tasks involved in care of a single client between different organizations. Co-location of multidisciplinary teams that include health professionals, support workers and peer workers may lead to more effective recovery oriented care. The findings have implications for the future development of recovery oriented mental health services.     

The role of music therapy in paediatric rehabilitation

Meeting the needs of the child in rehabilitation requires an interdisciplinary approach, whereby a variety of health care professionals are called upon to work together in planning and coordinating each patient's programme. The Registered music therapist is one of the allied health professionals who plays an integral role in this team approach. Music therapy is a recognized allied health profession, which is becoming acknowledged in the expanding world of health care as a therapy able to meet the expansive needs of the patient in rehabilitation. This article will present a literature review which advocates the role of music therapy in rehabilitation, with particular focus on the needs of the paediatric patient. Case vignettes will be used as further evidence to support the role of music therapy in this context, together with considerations for future research.     

Capitation financing of public mental health services for the chronically mentally ill

In the 30 years since deinstitutionalization began the public mental health system has experimented with a variety of financing and management models in the delivery of care to the chronically mentally ill. Currently, capitation methods of payment for public mental health services to the chronically mentally ill are being tested as an alternative to fee-for-service reimbursement. Proponents suggest that capitation will increase service flexibility and produce a variety of better coordinated, more cost efficient services. Opponents believe that capitation will result in reduced care given the absence of treatment protocols and the financial incentives for cost containment. This paper discussed the impact of financing mechanisms and organizational structure on the delivery of mental health care for the chronically mentally ill, provides a review of the pertinent literature, and describes demonstration projects currently underway. Questions are raised as to the potential impact of capitation on the mental health system.This research was supported by a grant from the Pew Charitable Trusts to the University of Pennsylvania and The Community Council for Mental Health and Mental Retardation Inc., and was carried out jointly by the Policy Modeling Workshop of the Wharton School and the Section on Public Psychiatry and Mental Health Services Research of the School of Medicine.     

Mental health leadership and patient access to care: a public–private initiative in South Africa

Background

Mental health leadership is a critical component of patient access to care. More specifically, the ability of mental health professionals to articulate the needs of patients, formulate strategies and engage meaningfully at the appropriate level in pursuit of resources. This is not a skill set routinely taught to mental health professionals.

Methods

A public–private mental health leadership initiative, emanating from a patient access to care programme, was developed with the aim of building leadership capacity within the South African public mental health sector. The express aim was to equip health care professionals with the requisite skills to more effectively advocate for their patients. The initiative involved participants from various sites within South Africa. Inclusion was based on the proposal of an ongoing “project”, i.e. a clinician-initiated service development with a multidisciplinary focus. The projects were varied in nature but all involved identification of and a plan for addressing an aspect of the participants’ daily professional work which negatively impacted on patient care due to unmet needs. Six such projects were included and involved 15 participants, comprising personnel from psychiatry, psychology, occupational therapy and nursing. Each project group was formally mentored as part of the initiative, with mentors being senior professionals with expertise in psychiatry, public health and nursing. The programme design thus provided a unique practical dimension in which skills and learnings were applied to the projects with numerous and diverse outcomes.

Results

Benefits were noted by participants but extended beyond the individuals to the health institutions in which they worked and the patients that they served. Participants acquired both the skills and the confidence which enabled them to sustain the changes that they themselves had initiated in their institutions. The initiative gave impetus to the inclusion of public mental health as part of the curriculum for specialist training.

Conclusions

Despite the significant adverse social and economic costs of mental illness, psychiatric and related services receive a low level of priority within the health care system. Ensuring that mental health receives the recognition and the resources it deserves requires that mental health care professionals become effective advocates through mental health leadership.

     

Meaning and measurement of caregiver outcomes

The focus of dementia intervention research has broadened from a focus purely on the person with dementia to include the caregiver as well. Psychological, physical, social and health care utilization costs are well documented and effective caregiver interventions reported. Caregivers are crucial to many aspects of the path of dementia traveled by affected persons. They influence outcome and they are a secondary target in drug trials. Measurement of caregiver outcomes should be targeted to likely outcome, and key mediating variables should be measured too. A list of potential instruments and recommendations is provided.     

Service systems integration and outcomes for mentally ill homeless persons in the ACCESS program. Access to Community Care and Effective Services and Supports

OBJECTIVE: The authors evaluated the second of the two core questions around which the ACCESS (Access to Community Care and Effective Services and Supports) evaluation was designed: Does better integration of service systems improve the treatment outcomes of homeless persons with severe mental illness? METHODS: The ACCESS program provided technical support and about $250,000 a year for four years to nine sites to implement strategies to promote systems integration. These sites, along with nine comparison sites, also received funds to support outreach and assertive community treatment programs to assist 100 clients a year at each site. Outcome data were obtained at baseline and three and 12 months later from 7,055 clients across four annual cohorts at all sites. RESULTS: Clients at all sites demonstrated improvement in outcome measures. However, the clients at the experimental sites showed no greater improvement on measures of mental health or housing outcomes across the four cohorts than those at the comparison sites. More extensive implementation of systems integration strategies was unrelated to these outcomes. However, clients of sites that became more integrated, regardless of the degree of implementation or whether the sites were experimental sites or comparison sites, had progressively better housing outcomes. CONCLUSIONS: Interventions designed to increase the level of systems integration in the ACCESS demonstration did not result in better client outcomes.