Organizational Development Strategies for Integrating Mental Health Services

The recent debates about health care reform have focused attention on the need to develop organized systems of care capable of delivering comprehensive services which are coordinated or integrated. Achieving service integration has emerged as a central and pressing objective in most mental health systems in response to existing difficulties with fragmentation of care. However, attempts at service integration often fail at the implementation stage as provider agencies zealously guard their organizational boundaries and struggle with each other for power and control. In this article, the authors formulate an organizational development approach to service integration that focuses on reducing the rigid maintenance of agency boundaries by developing informal networks among staff of local provider agencies. Eight strategies, drawn from the research literature on services integration and recently implemented by a local mental health authority, are described as potential tools for use by systems managers in accomplishing these goals.     

What’s in a Name? Terms Preferred by Service Recipients

In a large (n = 1,827) multi-site study examining effectiveness of consumer operated service programs as an adjunct to traditional mental health services, we examined individuals’ preferred term describing their status as service recipients, and we applied logistic regression to examine whether preference varied by gender, race or diagnosis. Preferred terms were client (39%), patient (22%), consumer (16%), survivor (11%), other (11%) and ex-patient (1%), varying by site. Controlling for site, preferences did not vary by gender, race, or diagnosis. The lack of consensus suggests clinicians, researchers, program administrators, and policymakers should be sensitive to individuals’ preferences.     

The Eye of the Beholder: Youths and Parents Differ on What Matters in Mental Health Services

The goal of this study was to examine the degree to which youths and caregivers attend to different factors in evaluating their experiences with mental health programs. Youth (n = 251) receiving mental health services at community agencies and their caregivers (n = 275) were asked open-ended questions regarding the positive and negative aspects of the services. Qualitative analyses revealed some agreement but also divergence between youth and caregivers regarding the criteria by which services were evaluated and aspects of services that were valued most highly. Youths’ positive comments primarily focused on treatment outcomes while caregivers focused more on characteristics of the program and provider. Youths’ negative comments reflected dissatisfaction with the program, provider, and types of services offered while caregivers expressed dissatisfaction mainly with program characteristics. Results support the importance of assessing both youth and caregivers in attempts to understand the factors used by consumers to evaluate youth mental health services.     

A mental health consultation-education program with group service agencies in a disadvantaged community

The consultation-education program described here worked with about 20 community-based group service agencies in a severely deprived urban area. The agencies included: (a) traditional neighborhood houses, (b) recreational and character-building centers, (c) church-sponsored group programs, and (d) neighborhood service centers. The program involved: (a) a planning body of administrators of group service agencies, (b) a consultation service on problems of individuals or groups, and (c) training workshops for agency staff. The program was geared to both institutional changevia enhanced integration of services and promotion of new skills, and to attitude changeof individual psychosocial caretakers.The authors wish to acknowledge the help of Dr. Melvin S. Roman, Mr. Emanuel Hallowitz, and Mrs. Joan Margolis in the development of this program.     

Client-level Measures of Services Integration Among Chronically Homeless Adults

Introduction  While several major studies have examined services integration at the system or interagency level, there has been far less effort to measure the integration of services at the client-level and its correlates. Methods  This study presents three client-level measures of services integration, two objective measures, representing the proportion of needed services received and the number of outpatient services received by each client, and one subjective measure, a five-item scale measuring perceived coordination of care among clients’ service providers. Data from the evaluation of the collaborative initiative to help end chronic homelessness (CICH) are used to examine bivariate and multivariate relationships of these three client-level measures to two system-level measures of services integration, one addressing interagency services coordination/planning and the other interagency trust/respect as well as to baseline client characteristics among 734 chronically homeless adults in 11 cities. Results  Client-level measures of service integration were not strongly associated to each other or to the system-level measures, except for weak associations (r = 0.10) between one objective client measure and the system-level measure of service coordination and planning, and another between client-level use of outpatient mental health services and system-level trust and respect. Multivariate analysis showed that clients who received a greater array of needed services received more service overall and were more likely to have a diagnosis of PTSD and more medical problems, but less serious alcohol problems. Clients who reported more outpatient mental health and substance abuse visits were significantly more likely to be married, to be veterans, to have more serious drug problems, and to be dually diagnosed. Clients with more serious drug problems reported poorer coordination among their service providers on the subjective measure of client-level service integration. Conclusion  Three client-level measures of services integration were, at best, weakly associated with measures of system-level integration. Positive associations between client-level measures of integration and health status, outpatient service use and negative relationships with indicators of substance abuse suggest they may usefully represent the experiences of chronically homeless clients, even though they are not strongly related to system-level measures.     

A comprehensive service delivery model for preschoolers with special educational needs: Its characteristics and effectiveness

BackgroundThe compartmentalization between early intervention services and early childhood special education programs is a worldwide phenomenon, which results in the fragmentation of services for preschoolers with special educational needs (SEN).AimsTo address this fragmentation of services, an intervention program in Hong Kong adopted a comprehensive service delivery model with six characteristics: 1) multidisciplinary approach, 2) integration of services across different contexts, 3) multimodal intervention with direct and indirect services, 4) capacity building for systems, 5) inclusive environment, and 6) high program intensity.MethodsThe program evaluation was a quasi-experiment with a control group (n = 60) matched to the experimental group (n = 60).ResultsAt the end of the school year, the experimental group made significant improvement in most measures including cognitive skills, receptive language skills, expressive language skills, gross-motor skills, fine-motor skills, and self-direction skills. School heads in the experimental group also agreed that the program had empowered their teachers and reinforced their school systems.ConclusionDespite its exploratory nature, the study has shed light on the future directions of services for preschoolers with SEN. The comprehensive service delivery model offers a response to the fragmentation of services and reveals the importance of integration of services across different contexts with multidisciplinary approach.     

Availability of mental health services for older adults: a cross-cultural comparison of the United States and Turkey

Researchers conducted a cross-cultural study using qualitative methods (based on a phenomenological approach) to explore the availability of mental health services (MHS) for older adults in the United States and Turkey. Using purposive sampling, semi-structured in-depth interviews were conducted with administrators (n=24) from a wide-range of sites (nursing homes, hospice, senior centers) in a rural area of North Central Florida, United States and Ankara, Turkey. Interview questions focused on types of staff employed; integration of MHS with other services provided; community promotion of services; coordination, cooperation and communication with other service providers; and administrators' perceptions of barriers in the provision of MHS for older adults. Interestingly, employing on-site mental health staff was a much more popular practice in Turkey compared to the United States with three times as many Turkish sites having on-site mental health professionals. As anticipated, administrators in both countries cited inadequate funding as the most common barrier to MHS provision. Potential solutions to MHS barriers in both countries are discussed.     

Transferring psychiatric specialist services to local authorities—Characteristics of the patients involved

Background: To obtain more co-ordinated services, better co-operation between the services and more efficient use of resources, a pilot project for transferring some district psychiatric centres (DPCs) to large municipalities is planned by the Norwegian government. Systematic knowledge about the patients involved is needed when clinical needs and standards, funding, and political agendas are discussed. This study identifies the clinical, socio-demographic, and behavioural characteristics of patients who need services from both the municipality and the DPC.

Method: A national mapping of patients in specialist mental health services was conducted in 2012/2013, including 65% of all inpatients (n?=?2358) and 60% of all outpatients (n?=?23?124). The need for services was assessed by each patient’s clinician.

Results: It was found that 74% of inpatients and 43% of outpatients needed one or more services from the municipality, usually involving housing, mental health treatment/therapy, or economic support according to their clinicians. These were typically patients with severe mental illness, young inpatients, older outpatients and persons with low education and weak social networks. Only small differences in the need for municipal services were found between patients in hospitals and DPCs.

Conclusions: Many of the patients in specialist mental health services, especially the inpatients, needed services from municipal social and health services. Because these patients had the most severe mental illnesses and were the most socially deprived, a stronger integration of service levels would potentially benefit these patients most. The pilot project should be evaluated to identify the consequences for patients, staff, quality of services, and costs of transferring services to a lower system level.     

Quality Indicators for Family Support Services and Their Relationship to Organizational Social Context

Quality measurement is an important component of healthcare reform. The relationship of quality indicators (QIs) for parent-delivered family support services to organizational social contexts known to improve quality is unexamined. This study employs data collected from 21 child mental health programs that deliver team-based family support services. Performance on two levels of QIs—those targeting the program and staff—were significantly associated with organizational social context profiles and dimensions. High quality program policies are associated with positive organizational cultures and engaging climates. Inappropriate staff practices are associated with resistant cultures. Implications for organizational strategies to improve service quality are discussed.     

Outcomes post‐discharge from an early intervention in psychosis service

Aim: To investigate the effectiveness of an early intervention in psychosis (EIP) service on engagement and hospital bed usage, post‐discharge. A secondary aim was to identify if there was a subgroup of patients with ‘poor outcomes’. Method: A naturalistic study comparing engagement and hospital bed day usage of individuals who received treatment from an EIP service (n = 75) with those who presented before the service was established (n = 113). Results: The EIP service demonstrated better engagement with service users in year 5 (P = 0.001). No significant differences were observed on hospital bed day usage. When ‘poor outcome’ cases were removed, a trend towards lower bed usage in EIP services emerged (P = 0.139). Conclusion: EIP services improve engagement with service users. There was not a significant reduction in hospital bed usage. However, advantages could be masked by a relatively small number of individuals with ‘poor outcomes’.     

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.     

Factors associated with staff support and resident lifestyle in services for people with multiple disabilities: a path analytic approach

The quality and costs of residential services for 40 adults with severe learning disabilities and sensory impairments across four different service models were evaluated. A path analytic approach was used to calculate factors associated with four indicators of service quality: (1) assistance received by residents from staff; (2) positive contact received by residents from staff; (3) resident engagement in constructive activity; and (4) the level of physical integration of residents. The path analyses accounted for between 50 and 77% of the variance in the indicators. Factors found to be commonly associated with all four indicators included a community location, a specialized service orientation, the cognitive abilities of residents and a high level of scheduled activity. Service resources in the form of costs or staff ratios were not associated with any indicator of service quality. The findings strongly suggest an inverse system of care in that residents with greater skills receive more staff support. The implications of these and other findings for further research and service practice are discussed.     

A descriptive study of 'non-cases' and referral rates to an early intervention for psychosis service

Aim: Despite there being approximately 200 early intervention services for psychosis worldwide, little is known about the referral rates to these services, the diagnoses and needs of individuals found not to have a first episode of psychosis (FEP). Firstly, we aimed to describe the diagnoses for individuals who were found not to have a FEP (non‐cases) following an assessment using the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders IV (SCID). We then aimed to examine the referral rates of cases and non‐cases to an early intervention service. Methods: All individuals referred to the early intervention service underwent a clinical assessment using the SCID. Results: In a 4‐year period, there were 632 referrals to the early intervention service for psychosis, and of these, 53% (n = 338) were found to have a FEP, 5% (n = 34) were found to have an at‐risk mental state for psychosis and 41% (n = 260) were found to be ‘non‐cases’. This represents a ratio of 1.9:1 of referrals to cases, or approximately 2:1. Of the non‐cases, 27% (n = 62) satisfied criteria for a mood disorder, with major depressive disorder the commonest diagnosis. A further 18% (n = 42) of non‐cases satisfied criteria for an anxiety disorder and nearly half of these were diagnosed with social phobia. The ratio of referrals to cases was not consistent over time and rose from 1.3:1 in the first year to 2:1 in the fourth year. Conclusion: A large proportion of individuals referred to an early intervention for psychosis service were found not to have psychotic disorder, however they still have significant needs regarding their mental health.     

First-time primary caregivers' experience accessing first-episode psychosis services

Aim: Easy access to first‐episode psychosis (FEP) services is critical in reducing the duration of untreated illness. However, primary caregivers can encounter difficulties accessing services on behalf of young people with FEP. This qualitative study describes the lived experience of first‐time primary caregivers of young adults with FEP, with a focus on examining how they access specialist FEP services. Methods: A qualitative study was undertaken using semi‐structured, in‐depth interviews with 20 caregivers in Melbourne. Results: Most carers were women (85%, n = 17) and parents (85%, n = 17). Nearly all lived in the same households as the young people with FEP (90%, n = 18). The mean duration of their involvement with the FEP service was 14.5 months (standard deviation = 8.9). Three competing themes were identified in the data, reflecting caregivers' polarized experiences accessing FEP services. First, general practitioners were regarded as either a resourceful or an unresourceful means of access to FEP services. Second, caregivers often encountered service‐focused and carer‐focused barriers when initially accessing services. Third, a combination of acquired knowledge, experience with services and caregiver assertiveness enhanced access on subsequent occasions. Conclusion: This study highlights the important contribution and experience of first‐time primary caregivers and the difficulties they face accessing services. The findings suggest access should be influenced more by clinical need and less by caregivers' perseverance. The findings also underline the importance of providing clinical training that acknowledges the needs and contributions of caregivers, as well as interventions that meet the unique challenges faced by first‐time caregivers accessing services after the onset of FEP.     

Expanding service delivery: does it improve relationships among agencies serving homeless people with mental illness?

Enhancing interagency services integration for homeless people has been advocated as an approach for improving service delivery to this population. In contrast to system-level top-down interventions, this study examines the association of expanded funding of client-level homeless services, a bottom-up approach, with strengthening of interorganizational relationships. We compared Veterans Affairs/non-Veterans Affairs interagency relationships at VA facilities supporting community-oriented programs (N=72), at VA facilities supporting on-site internally focused homeless programs (N=10), and at facilities with no specialized homeless programs (N=47). VA facilities that supported community-oriented homeless programs enjoyed stronger VA-community agency relationships than the other two VA facility types. The study identifies an effective bottom-up resource-based approach to services integration.     

Examining the Use of Restrictive Interventions in Respite Services in an Australian Jurisdiction

Very little is known about the use of restrictive interventions on children and young people with disabilities and challenging behaviours who receive respite. This study examines the use of restrictive interventions in an Australian jurisdiction where there is mandatory reporting of these practices in government-funded services. The characteristics of those subject to restrictive interventions and the types of restraint and seclusion used in respite are compared with those in people who do not receive respite. Approximately 28% (n = 578) of the total number of people with disabilities subjected to restrictive interventions were from respite services. They were generally male, younger (average age 21 years old) and reported to have a diagnosis of autism. The majority were subject to chemical restraint. The use of restrictive interventions in respite services requires further investigation and monitoring. There are policy and practice implications for respite service delivery.     

Strategies for improving services for the chronic mentally ill

A central goal of policies aimed at improving care of the chronic mentally ill is better service coordination and integration. The author examines four current policy strategies--continuous care teams, local mental health authorities, integrated entitlement programs, and capitation payment systems--and discusses their incorporation in four model programs of integrated services. The programs differ in the degree to which they attempt to direct service coordination at the patient level, but all four programs have created local mental health authorities to oversee services. The success of any of the policy strategies depends on a system's capacity not only to regulate services but to ensure that presumed incentives to deliver cost-effective services filter down to well-trained and motivated front-line staff.     

Attitudes toward mental health services: Age-group differences in Korean American adults

The present study examined the attitudes toward mental health services held by younger (aged 20–45, n = 209) and older (aged 60 and older, n = 462) groups of Korean Americans. Following Andersen's (1968; A behavioral model of families’ use of health service, Center for Health Administration Studies) behavioral health model, predisposing (age, gender, marital status and education), need (anxiety and depressive symptoms) and enabling (acculturation, health insurance coverage and personal experience and beliefs) variables were considered. In the mean-level assessment, younger and older adults were found to hold a similar level of positive attitudes toward mental health services. In the multivariate analysis, culture-influenced beliefs were shown to have a substantial contribution to the model of attitudes toward mental health services in both age groups. The belief that depression is a medical condition was found to be a common predictor of positive attitudes across the groups. In the older adult sample, more negative attitudes were observed among those who believed that depression is a sign of personal weakness and that having a mentally ill family member brings shame to the whole family. Our findings show that older adults are not only more subject to cultural misconceptions and stigma related to mental disorders, but also their attitudes toward service use are negatively influenced by the cultural stigma. The findings provide important implications for interventions targeted to improve access to mental health care among minority populations. Based on the similarities and differences found between young and old, both general and age-specific strategies need to be developed in order to increase effectiveness of these programs.     

Factors Associated with Mental Health Service Need and Utilization among Unaccompanied Refugee Adolescents

This study is the first to address the need for mental health Care (MHC) and the patterns of utilization of MHC services among Unaccompanied Refugee Minors (URM). Information concerning the well being, mental health need, and utilization of services of URM was collected from three informants, the minors themselves (n = 920), their legal guardians (n = 557), and their teachers (n = 496). The well-being, need and utilization of MHC services of URM was compared with those of a representative Dutch adolescent sample (n = 1059). The findings of this study indicated that URM that report a mental health care need (57.8%) also report higher levels of emotional distress than Dutch adolescents who report a similar need for MHC (8.2%). In addition, guardians and teachers detect emotional distress and mental health care needs in only a small percentage (30%) of URM. The referral of URM to mental health care services does not appear to be driven by the reported needs of the URM, but by the need and emotional distress as observed and perceived by guardians. This resulted in the fact that 48.7% of the URM total sample reported that their need for mental health care was unmet.     

Providing Post-treatment Support in an Outpatient Alcohol and other Drug Treatment Context: A Survey of Client Opinion

This paper examines the post-treatment support practices, attitudes and preferences of outpatient alcohol and other drug (AOD) treatment staff as well as perceived barriers to implementing a post-treatment support service in an outpatient AOD treatment context. Data were collected via semi-structured interview and group discussion (n = 23). Findings suggest that post-treatment support was rarely provided by participating AOD treatment staff or their respective services. However, there was widespread support for implementing such services, and it was generally believed that implementation would be most successful if: multiple post-treatment support options were made available; if one or more of these options were based on the maintenance of an established client/clinician relationship; and if one of the options involved proactive (service-led) telephone support. A number of barriers to possible implementation were identified, although none were considered insurmountable.