The structural reform of mental health services

During past decades many countries have initiated extensive mental health care system reforms, and the main goal of these reforms has been the transfer of treatment of the mentally ill from psychiatric hospitals to the community. For example, assessment of the results of these reforms in Italy and Austria demonstrates considerable reduction in the number of psychiatric beds, higher quality and more available community services, and increased total expenditure for mental health services. However, because sufficient data is not yet available, many questions regarding how these reforms impact improvement in patient clinical parameters remain unanswered. Some of the answers to these questions can be gleaned from the results of research carried out in the United States and Canada in the 1980s. This research evaluated transfer of psychiatric treatment from a hospital setting to a community service setting. The results demonstrated that community treatment models were more effective than a hospital treatment model in reducing the number of hospitalizations and shortening length of stay. Patient monitoring also demonstrated good integration into the community. However, alongside the research supporting these reforms, there is some research that demonstrates a number of possible disadvantages: an increase in the number of homeless and in the mortality rate among psychiatric patients, and an increase in rehospitalization rates of chronically ill patients," referred to as the "Revolving Door Syndrome." To avoid the disadvantages that could possibly accompany the reform, particular attention needs to be given to planning and funding, so that development of community services and reduction in psychiatric hospital system correspond. Care must be taken to ensure that the number and the geographic location of these services meets the need of the population at risk, and that staff is available and well trained. A monitoring system should be set in place to monitor the patients according to the clinical standards agreed upon, and at the same time guidelines should be set up to evaluate the functioning of community services. The structural reform is progressing and should be completed at the end of 2005. However, development of community services is not progressing at the desired rate. In January 2003, the Israeli government made a decision to transfer the responsibility for medical insurance for the mentally ill from the government to the Sick Funds. However, an agreement between the Ministry of Health, the Ministry of the Treasury and the Sick Funds has yet to be signed and the government's decision has yet to be realized. This has caused development of community services to come to a halt, and neither the government nor the Sick Funds are investing in community development. We can only hope that the transfer of responsibility for health insurance for the mentally ill from the State to the Sick Funds will be completed soon and that development of community service for the mentally ill will then move forward quickly.     

Indigenizing mental health services: New Zealand experience

Mental health services in New Zealand have been significantly altered by Māori cultural values. Since 1980, a monocultural approach has given way to the incorporation of Māori language, Māori health perspectives, and Māori psychological frameworks in the assessment, treatment, and care of patients. Māori provider organizations, an expanded Māori health workforce, and Māori leadership have been crucial catalysts for the transformation. The shifts have paralleled similar changes in other sectors, reflecting a broader societal movement within which indigeneity has received greater acknowledgement. The author's bicultural background, psychiatric training, and inclusion in Māori networks were important for promoting the transformation.     

Implications of health care reform for rural mental health services

Efforts toward health care reform for people with mental illness in rural America must take into consideration the unique characteristics of these areas. Universal coverage, for example, would remove the barriers to accessing care for this population, but would not assure an expansion of services or providers in rural areas. Special incentives are necessary to address the needs of rural populations.This study was supported by NIMH Grant #MH 49173-02.     

The fate of mental health services in health care reform: II. Realistic solutions.

In the second part of a two-part paper, the three major proposals for U.S. health care reform--the government-sponsored model, the employment-based model, and the market reform model--are reviewed. Barriers to their success include the current economic crisis, the lack of a clear consensus, and the high costs of the proposals. Most proposals limit the extent of psychiatric coverage; some exclude such coverage from minimum benefit packages, an area of concern for clinicians. The author concludes that any substantial health care reform is unlikely in the near future. A thoughtful, realistic, and yet vigorous strategic plan is needed now to forestall the possible exclusion of significant mental health coverage. The basic elements of such a plan are reviewed.     

Defining best practices for specialty geriatric mental health outreach services: lessons for implementing mental health reform.

OBJECTIVE: This paper reviews fundamental areas that inform best practices for outreach services as they relate to shared care, education, and program and systems development and illustrates a framework for defining best practices. METHOD: We examined literature that addresses the needs and characteristics of older persons with mental illness, studies that investigate geriatric mental health outreach services, and relevant theoretical developments. In addition, we synthesized some of the health services field research that we conducted. RESULTS: This analysis provided a foundation for understanding the processes required to identify and implement best practices in specialty geriatric mental health outreach. Constructive insights for a comprehensive approach to the development, implementation, and evaluation of these services emerged. CONCLUSIONS: The needs of an aging population, the articulation of principal functions for specialty services within mental health reform, and the realities of individual communities converged to establish direction for service provision. The use of best practices across a range of health and social services, combined with an effective process that facilitates the exchange of knowledge between sectors, establishes an important mechanism by which shared care, education, and program and systems development can be achieved.     

The fate of mental health services in health care reform: I. A system in crisis.

The U.S. health care system is in the midst of a severe crisis. More than 50 million Americans are uninsured or underinsured. Medicare and Medicaid are not adequately serving populations in need. Analyses and reform proposals are often based on biased interpretations of data, resulting in confusion and heated debate. To avoid jeopardizing psychiatric care in a national health care reform movement, we must understand the causes of the national crisis. In the first part of a two-part paper, the author describes factors such as demographic trends and limitations in public health coverage that have contributed to the crisis. Outcomes of the current system include higher morbidity and mortality among the uninsured and a high prevalence of untreated illness. The author reviews direct and indirect costs of health care and concludes that in attempts to solve the difficult equation of access, cost, and quality, mental health services are in serious jeopardy.     

The impact of HMO development on mental health and chemical dependency services

The effects of the development of HMOs on the delivery of mental health and chemical dependency treatment services in Minneapolis-St. Paul were examined through structured interviews with representatives of HMOs and other provider groups. The structure and policies of five competing HMOs are described. Although all five HMOs have reduced their members' use of inpatient mental health and chemical dependency services, use of services by the non-HMO population remains substantially higher than national averages. HMO growth has stimulated the emergence of new types of mental health and chemical dependency treatment organizations to provide services to HMOs and has increased acceptance of goal-oriented, outpatient-based treatment strategies by providers.     

Measuring disability, need and outcome in Australian community mental health services

OBJECTIVE: This study trialled routine measurement of disability, need and outcome in mental health services within Sydney. METHOD: Fifteen community mental health clinicians with a combined caseload of 283 patients participated in the study. The Health of the Nation Outcome Scales (HoNOS) was used to assess disability and outcome and the patient and staff versions of the Camberwell Assessment of Need (CAN) were used to assess need. RESULTS: The HoNOS and CAN appear to be promising contenders for routine use. Patients receiving assertive case management were rated as having higher levels of disability and need than patients receiving standard case management. Significant change in outcome was demonstrated with the HoNOS. CONCLUSIONS: To ensure the continued measurement of consumer outcome, issues such as staff education, training, and the development of computerised information systems should be addressed.     

The effect of deinstitutionalization on the longitudinal continuity of mental health care in the Netherlands

Abstract.Background: Deinstitutionalization has been accompanied by a decreasing continuity of care in a number of countries. This study evaluates the effects of the Dutch model for deinstitutionalizing mental health care.Methods: Details of users and their use of community- and hospital-based services between 1990 and 1999 were retrieved from the Groningen case register. The time between discharge from the hospital and the first subsequent community-based contact was the primary indicator for changes in continuity of care.Results: The total proportion of discharges from hospital-based mental health care followed within 6 months by community-based care increased by 11% due to the improved availability of day treatment and home treatment. In terms of median survival time, aftercare in the years 1998/1999 was delivered more than twice as fast as in the years 1990/1991.Conclusions: Study results supported the hypothesis in Dutch deinstitutionalization policy that the continuity of mental health care would benefit as to its longitudinal dimension.     

Barriers to the delivery of mental health services: the New York City experience.

The author discusses some of the barriers encountered in attempting to transform New York City's fragmented mental health services into a comprehensive, nondiscriminatory, and accessible system. Among the barriers he identifies are the belief that more money alone will solve the problem; the uneven distribution of funds among the boroughs of the city and the resistance of existing agencies to redistribution; and the way in which reimbursement patterns shape the kinds of services provided. He believes the single most effective stimulus to the development of an integrated system of care would be a requirement that eligibility for reimbursement under Medicaid be based on a facility's participation in a comprehensive system of care. He emphasizes the need to remove social, rehabilitation, and other services from under the mental health umbrella and to obtain other sources of funding for them; the need for local governance of services; and the need to provide work opportunities for the more seriously disabled.     

Transformation of children's mental health services: the role of school mental health

The New Freedom Commission has called for a transformation in the delivery of mental health services in this country. The commission's report and recommendations have highlighted the role of school mental health services in transforming mental health care for children and adolescents. This article examines the intersection of school mental health programs and the commission's recommendations in order to highlight the role of school mental health in the transformation of the child and adolescent mental health system. Schools are uniquely positioned to play a central role in improving access to child mental health services and in supporting mental health and wellness as well as academic functioning of youths. The New Freedom Commission report articulated several goals related to school mental health: reducing stigma, preventing suicide, improving screening and treating co-occurring disorders, and expanding school mental health programs. The authors suggest strategies for change, including demonstrating relevance to schools, developing consensus among stakeholders, enhancing community mental health-school connections, building quality assessment and improvement, and considering the organizational context of schools.     

Health reform and the scope of benefits for mental health and substance use disorder services

The Patient Protection and Affordable Care Act will expand insurance coverage to millions of Americans with mental disorders. One particularly important implementation issue is the scope of mental health and substance abuse services under expanded health insurance coverage. This article examines current public and commercial insurance coverage of the range of services used by individuals with mental illnesses and substance use disorders and assesses the implications of newly mandated standards for benefit packages offered by public and private plans. The authors note that many services needed by individuals with mental or substance use disorders fall outside the scope of benefits currently covered by a typical private insurance plan. Compared with other insurers, Medicaid currently covers a broader range of behavioral health services; however, individuals moving into Medicaid under new eligibility pathways will receive "benchmark" or "benchmark-equivalent" coverage rather than full Medicaid benefits. If behavioral health benefits are set at those currently available in typical private plans or in benchmark coverage, some newly insured individuals with mental illnesses or substance use disorders who are covered by private plans or Medicaid expansions are still likely to face gaps in covered services. Policy makers have several options for addressing these likely gaps in coverage, including requiring states to maintain coverage of some support services, including certain behavioral health services in the "essential benefits package," and expanding eligibility for full Medicaid benefits.     

Psychiatric health needs and services before and after complete deinstitutionalization of people with intellectual disability

Before total deinstitutionalization in Norway, many believed that the ordinary health care system could give people with intellectual disability the same or even better health care than that which they received in institutions. It was said that institutions created psychiatric problems, and that these would diminish or even disappear with the closing of these establishments. The present study is a prospective cohort study without a control group. It examines the frequency of mental health problems and the psychiatric health services which 109 subjects aged between 16 and 65 years received before (1987) and after (1995) deinstitutionalization. Mental health problems were defined as behavioural disturbances, and psychiatric disorders and symptoms. Psychiatric disorders were identified with the Psychopathology Instruments for Mentally Retarded Adults (PIMRA), which were filled in by the carers. Behaviour disturbances were identified as having occurred or not during the previous year. Psychiatric problems remained frequent, and there was a significant increase in behavioural problems in spite of total deinstitutionalization and improved physical living conditions. Access to qualified help, such as psychologists and psychiatrists, had been substantially reduced. Most mental health problems among people with intellectual disability are not solved by reorganization or deinstitutionalization, and such measures are no substitution for professional assistance.     

The political development of "Program Realignment": California's 1991 mental health care reform

This article reviews the legislative process that resulted in the most significant reform of California's public mental health system in nearly 25 years. The reform, termed "Program Realignment," decentralized administrative and fiscal control of the mental health system from the state to the county level. The system prior to Program Realignment is discussed here to reveal an already diverse and decentralized county mental health system, fiscal distress, and general dissatisfaction with the system. From these conditions, the objectives of the relevant political actors arose. By tracing the policy development process of Program Realignment, several independent variables are revealed that help explain how and why this legislation came into being and allow generalization of this case to other states' experiences. These independent variables are an urgent need for action within a limited timeframe, a preexisting knowledge base and well-developed policy networks, a spirit of bipartisan cooperation, and the presence of strong leadership. Preliminary evidence suggests that consolidation of fiscal and programmatic authority at the local level has reduced fragmentation of services and increased fiscal flexibility. However, there is concern that the quality of care offered by the state's 59 local mental health programs will become increasingly disparate and that increased financial flexibility may not be used to improve services for clients but to save money for local governments. Lessons from California's experience can alert other states to the pros and cons of this policy approach to providing mental health services and inform policymakers in other states of the steps involved in bringing about such a policy change.     

Preparing for a public sector mental health reform in New Mexico: the experience of agencies serving adults with serious mental illness

In 2005, New Mexico began a comprehensive reform of state-funded mental health care. This paper reports on differences in characteristics, infrastructure, financial status, and services across mental health agencies. We administered a telephone survey to senior leadership to assess agency status prior to and during the first year of reform. Non-profit/public agencies were more likely than others to report reductions or no changes in administrative staff. CMHCs were more likely to report a decline in their financial situation. Findings demonstrated that CMHCs, non-profit/public agencies and rural agencies were more likely to offer critical services to adults with serious mental illness.     

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.