Community mental health centers and the “Seed Money” concept: Effects of terminating federal funds

What happens to community mental health centers when federal funding ends? Analysis of the funding patterns of a cohort of “graduate” community mental health centers indicates that these centers remained fiscally viable subsequent to termination of basic federal grants. However, further analysis revealed two distinct funding patterns within the cohort. One group relied primarily on increased third-party reimbursements to offset the end of basic federal grants. The other sought more state funds and additional federal grants available through the Community Mental Health Center Amendments of 1975. As more centers “graduate”, federal “floor funding” may be necessary to insure the survival of some of them.     

Federally funded CMHCs: The effects of period of initial funding and hospital affiliation

Previous research on federally funded community mental health centers has largely failed to recognize fundamental differences among different types of centers. Here we show that such basic factors as the arrangement for providing inpatient services and the period of initial federal funding have large effects on the development and organization of a center. Although the centers joining the federal program from 1965–1970 are the largest, those facilities funded between 1971–1975 are generally smaller than those funded later. The arrangement for providing inpatient services has an important effect on staffing. This work suggests the national norms may not be the most useful data for evaluating past performance or planning the future of a specific center.Rosalyn D. Bass is with the Division of Biometry and Epidemiology, National Institute of Mental Health.An earlier version of this paper was presented at the Eastern Evaluation Research Society Meeting, held in Philadelphia, Pennsylvania, April 1984. Research on this project was supported in part by grants MH15783 and MH37864 from the National Institute of Mental Health.     

Geriatric services: Community mental health center boon or bane?

The fragmented and uncoordinated development of federal and state mental health policy for the aged, the lifting of federal mandates for CMHC service emphases on the aged, and the underutilization of CMHC services by the aged all raise the issue of the implications of CMHCs emphasis on services to elderly clients. We hypothesized that CMHCs with increases in aged clientele would fare worse in terms of budgets, services, and staffing than those that did not report increases in elderly clientele. The findings are more complex in that, compared to centers with no change in aged clientele, CMHCs fared better when they either had decreases in aged clientele (as expected) or increases in such clientele (in contradiction to the hypothesis,), although the former relationship was stronger. These findings are interpreted in terms of the need for CMHCs to specialize either on the aged or on other client populations. Such specialization, and the stronger effect for de-emphasis on the aged, suggest greater barriers to access of the aged to community mental health care.This research was supported by grants from the Pew Memorial Trust, the Robert Wood Johnson Foundation and the Fred Meyer Charitable Trust. The interpretations and conclusions are those of the authors and do not necessarily reflect the position of the funding sources.     

Community mental health center staffing patterns

A survey of funded applications for federal staffing grants from 80 community mental health centers reveals that of 3,830 full-time positions projected by the centers, 1,613 or 42% were listed as nonprofessional mental health personnel. The study was conducted to help the planners of new centers benefit from the projected staffing patterns of existing centers, and to gather information about the use of manpower and the types of personnel employed in the centers variety of services. In many respects, each center is unique because it serves a distinct community. However, all share many features in common, including the use of a variety of personnel. Staffing needs for each of the five basic services and specialized services are analyzed by categories of centers and communities served.     

Behavioral Health Services in Separate CHIP Programs on the Eve of Parity

The Children’s Health Insurance Program (CHIP) plays a vital role in financing behavioral health services for low-income children. This study examines behavioral health benefit design and management in separate CHIP programs on the eve of federal requirements for behavioral health parity. Even before parity implementation, many state CHIP programs did not impose service limits or cost sharing for behavioral health benefits. However, a substantial share of states imposed limits or cost sharing that might hinder access to care. The majority of states use managed care to administer behavioral health benefits. It is important to monitor how states adapt their programs to comply with parity.     

The status of community mental health centers ten years into Block Grant financing

This study tracks the 761 community mental health centers which received federal grants as of 1981 and assesses their status 10 years after the shift to Block Grant financing. Contrary to what had been predicted (Biegel, 1982), the vast majority of centers remained open (88.3%), a small proportion were involved in mergers (8.5%) and an even smaller percentage closed (3.3%). No pattern was evident as to which centers closed or merged by type of initial funding, although some states showed a concentration of mergers and closures. Data from the 1988 Inventory of Mental Health Organizations are used to characterize the centers still in operation by facility type, ownership, service mix and revenue mix. In 1988, federally funded CMHCs accounted for 34% of the total patient episodes treated and 22.7% of the total revenues reported by specialty mental health providers in the United States.     

Policy shifts and organizational adaptation: A review of current developments

Changes in the operations and structure of local mental health centers are occurring in response to policy and funding shifts at the state and federal levels. Clinical and administrative staffing changes reflect both cutbacks in funding for traditional outpatient and inpatient services, as well as increases in partial care, community, residential and case management services. Centers are diversifying their funding sources, especially through increased revenues from Medicare-Medicaid sources. Governing boards remain active in center policy making, with few changes in their composition. Current adaptation strategies focus mainly on enhancing efficiency, reviewing service costs, expanding services to more viable markets, and improving business practices. These actions and strategies are compared to findings from previous studies, and their implications are discussed.the authors extend their thanks to Terrence Curley and Anthony Broskowski for their helpful comments on earlier drafts of this paper.     

The contrasting careers of two structural types of CMHCs

Changes in funding, clientele, and services from 1971 to 1980 were examined cross sectionally and with cohorts for two types of CMHCs that differ in their structure for providing inpatient service. Inpatient provider CMHCs grew in revenues and shifted from reliance on federal funds to revenues from services and states. Inpatient-affiliated CMHCs fell in revenues (in constant dollars) and changed little in their proportional reliance on federal dollars. Inpatient provider CMHCs averaged more additions and episodes of care than inpatient-affiliated CMHCs. Inpatient-affiliated CMHCs grew more from 1971 to 1976, but from 1976 to 1980 inpatient provider CMHCs grew, while inpatient-affiliated CMHCs dropped or grew less. The relatively poor final showing of inpatient-affiliated CMHCs parallels findings with total revenues.The views expressed are those of the authors and do not necessarily represent the views of the National Institute of Mental Health. The authors are indebted to Ronald Manderscheid, Ph.D., and James Thompson, M.D., for suggestions.     

Taking the center to market

Community mental health centers have seldom been involved in marketing their services. Marketing is defined as responding sensitively to human needs, not hucksterism, and is an appropriate activity for centers. Centers are vulnerable because of declining federal funding and in order to serve the poor, must also service other populations with greater ability to pay for services or face retrenchment. Over the past twenty years, locally controlled centers have broadened their missions to serve many types of personal and family problems, not just the chronically ill. Centers should omit mental health for their names because of the stigma. Guidelines for creation of a positive image including name and logo selection, color, open houses, and ad campaigns are given using Madison Center (formerly the Mental Health Center of St. Joseph County) as a case study. Reactions of other providers, creative delivery of services through consultation and education, market segmentation and message levels of advertising are also discussed.Both authors were affiliated with Madison Center at the time this paper was prepared.     

How community mental health centers are coping

Many community mental health centers have had to operate with less funding in the past several years, especially since the advent of block grant funding. Evidence is now accumulating that some centers have had to decrease their overall level of services and staffing. Others have attempted to adjust by increasing their clinician caseloads, closing their satellite facilities, and de-emphasizing services that fail to generate adequate fees and third-party reimbursements, such as consultation and education, partial hospitalization, and programs for children and the elderly. In contrast, and partly as a result of the increased authority of the states over the community mental health centers program, services for the severely and chronically mentally ill appear to be receiving higher priority. This development will require that centers improve their access to the general health care sector, maintain and improve their relationships with academic institutions, and increase the number, responsibilities, and rewards of the psychiatrists they employ.     

An assessment of after-hours visits to a community mental health center.

Walk-in clinics, originally established in community mental health centers to provide primary and secondary prevention through around-the-clock emergency services, may be serving many people other than those in crisis. The authors conducted an 11-week study of utilization patterns at one center's after-hours walk-in clinc and found that most of the patients were already enrolled in psychotherapy sessions at the center. Some might have been acting out resistance in therapy, the authors theorize. Few patients seen for the first time at the clinic later enrolled in psychotherapy, and few inpatient admissions were made. Although the authors assert that walk-in clinics provide a valuable service, they question whether their original purpose has been distorted and whether the services they provide are always therapeutic.     

Community mental health centers in transition: Report on a national conference

The following is a report on a National Conference on Graduate Community Mental Health Centers held April 14–17, 1980, in South Carolina. Sponsored by the National Institute of Mental Health, the conference was intended to gather information on the status of community mental health centers (CMHC's) that had completed their federal grants, and to solicit recommendations to help assure the survival of centers after cessation of federal grants. This paper (1) describes the conference, (2) summarizes the findings, and (3) presents the conferees' recommendations for the future.J. Richard Woy, Ph.D., was formerly Acting Chief of the Program Analysis and Evaluation Branch, Office of Program Development and Analysis, NIMH; Dr. Woy is currently Director of Research at the South Shore Mental Health Center, 77 Parkingway, Quincy, MA 02169. Noel A. Mazade, Ph.D., is Director of The Advanced Training Program in Community Mental Health Administration at The Staff College, NIMH. Reprint requests and copies of the entire conference report may be addressed to Dr. Woy at the above address. The authors wish to acknowledge the contribution of the group facilitators whose reports provide the basis of the conference findings: Mr. John Sheets and Drs. Joseph Aponte, Laurel Files, Robert Moroney, Joseph Morrissey, and Richard Surles.This conference was co-sponsored by three components of the NIMH, including the Division of Mental Health Service Programs, the Office of Program Development and Analysis, and The Staff College. Core planning staff included Risa Weiner-Pomerantz, NIMH Division of Mental Health Service Programs; Enid Light, Office of Program Development and Analysis; and the authors. Advice as to the conference purposes, participants, and format was received from a variety of staff within the NIMH, the National Council of Community Mental Health Program Directors, and elsewhere.Views expressed are solely those of the authors and do not necessarily reflect the policies of the National Institute of Mental Health.     

Crossing state lines of chronic mental illness

A federal law passed in 1986 required states to develop service plans incorporating each state's own definition of chronic mental illness. This study considered whether the state definitions can be used to identify comparable populations of chronic mentally ill patients and to obtain a meaningful national estimate of the number of such patients. The study applied definitions of chronic mental illness used in ten states to a representative sample of patients receiving public mental health services in West Philadelphia over a two-year period. The prevalence estimates of patients defined as chronically mentally ill ranged from 38 percent using the Hawaii definition to 72 percent using the Ohio definition. The National Institute of Mental Health definition, used as a reference point, produced a prevalence estimate of 55 percent. The authors conclude that the considerable variance among the states in prevalence estimates renders the sum of state counts of chronic mentally ill patients of limited use.     

Monitoring and Enforcing Cultural Competence in Medicaid Managed Behavioral Health Care

In recent years cultural competence has expanded beyond language provisions to include understanding and factoring into services provision the cultural perspectives clients may have that are different from the majority culture. The federal government requires state Medicaid programs to offer culturally competent services, but little is known about how states implement such mandates and monitor and enforce them. We reviewed the origins and implications of cultural competence mandates and conducted a brief case study of 5 states to learn about the implementation of cultural competence provisions in behavioral managed care contracts. We found that states and managed behavioral health organizations (MBHOs) vary in their definitions and implementation of standards to ensure mental health care access for vulnerable populations. Although states had a variety of oversight mechanisms, varying contractual requirements ranging from optional to required, vague contract language, no existing standardized indicators or definitions, and scant data on the cultural characteristics of the populations enrolled in Medicaid managed care hamper monitoring and enforcement of cultural competence by states. Implications for MBHOs, states, and the federal government, as well as services researchers, follow.     

A proposal for future funding of chronic and episodic mental illness

The estimated 1.7 to 2.4 million Americans who suffer from chronic mental illness are poorly served by the current nonsystem of services. No agency at any level is responsible for coordination of funding, treatment, and care. Since the mid-1950s funding has become increasingly fragmented as state mental hospitals have been depopulated, community services have been developed, and federal entitlement programs such as Medicaid, Medicare, and Social Security Disability Insurance have been introduced. To overcome the problems of fragmented funding and uncoordinated services, the authors propose establishment of a new federal entitlement program for the chronic mentally ill that would pool all existing funds regardless of the source. States would be empowered to develop a single administrative agency with responsibility for coordinating a comprehensive program of services.     

Cost-efficiency and staffing in mental health services

While mental health center inpatient services will probably remain largely unaffected by diminishing federal grants, this loss of financial support will affect outpatient care. This paper examines how staffing patterns and workload levels affect the ability to generate fee-for-service income from outpatient services while holding down costs.Louis Wynne is Assistant Professor of Psychiatry in the University of New Mexico School of Medicine and Coordinator of Program Review & Analysis at the Bernalillo County Mental Health/Mental Retardation Center, Albuquerque, New Mexico.     

The effects of state intergovernmental transfers on local public mental health services

The provision of public mental health services is shifting increasingly from states to local areas. Yet state governments continue to bear financial responsibility for the majority of these services. One implication of this trend is that the success of state policies become dependent on a state's ability to influence the behavior of local areas. This paper discusses the different options states have in designing intergovernmental grant contracts with local areas, and describes likely impacts of the different strategies. These propositions are then tested using data from the Ohio state mental health system from 1989–1993. This study finds that the design of grants affects public expenditures, local revenue generation, and the mix of services provided at the local level.     

An estimation of the impact of OBRA-87 on nursing home care in the United States.

The Omnibus Budget Reconciliation Act of 1987 (OBRA-87) established criteria for Medicare- or Medicaid-certified nursing homes to use in admitting or retaining mentally ill patients. In effect, the law created five dispositional categories for residents or potential residents of nursing homes. Using data from the 1985 National Nursing Home Survey conducted by the National Center for Health Statistics, the authors estimate what proportion of nursing home residents would fall into each of the categories. They suggest that the initial impact of the law will be to shift costs from federal programs to the states. Nursing homes will be expected to provide more mental health services. In the absence of other services, the regulations have a high potential for creating homelessness and continuing a pattern of failure to adequately serve patients with serious mental illness.     

Eligibility, Assessment, and Educational Placement Issues for Students Classified with Emotional Disturbance: Federal and State-Level Analyses

The purpose of this paper is to contribute to an understanding of how state education authorities conceptualize and utilize the construct of emotional disturbance (ED) within the special education system. Specifically, this study examined variability across state definitions of ED and the extent to which such differences in definition are associated with ED identification and educational placement rates. Relevant literature and publicly disseminated documentation at the federal and state levels were reviewed. Results indicated that most state definitions of ED did not differ from the federal definition, although 20% of states broadened the federal ED definition to make it more inclusive. States with broader definitions did classify more students with ED, relative to states using either the federal or a more narrow definition, although rates of restrictive and mainstream placements did not differ as a function of definition. Results also suggest that use of a “social maladjustment” exclusion criterion contributes to variation not only in state-level definitions of ED, but also in students’ access to mental health and special education services. Recommendations for future research are provided.     

The impact of federally funded CMHCs on local mental health service systems. Community Mental Health Centers

To measure how much federally funded community mental health centers increased the quantity and range of mental health services, 63 catchment areas in which CMHCs began to receive federal funding in 1974-75 were matched individually with catchment areas that never received federal CMHC funding. The two groups of catchment areas were compared to determine average increases from 1973 to 1980 in amounts of services, mental health staff, expenditures, and accessibility and availability of services. Results showed that establishment of local CMHCs had a clear impact on the quantity and the availability and accessibility of services in the catchment area. The effect sizes resulting merely from the passage of time and from CMHC funding were compared.