Carers and community mental health services

Background There is a growing appreciation of the role and needs of carers for people with mental health problems. Carers are a diverse group, including partners, relatives and friends who are seen as such by service users. Methods Sixty-four carers of people with severe mental health problems served by four different mental health care providers were interviewed using the Experiences of Care-giving Inventory. The districts were selected to differentiate services that are targeted at more severely impaired users from those that include a wider spectrum, and to contrast services that have greater integration between health and social care providers with those whose health and social care agencies operate relatively discretely. Results In the two districts where service users had more severe mental health problems, carers worried more about negative symptoms and thought less about good aspects of the caring relationship. In the two districts where health and social services worked more closely together, carers worried significantly less about the need to back up services. Conclusions These findings suggest that service organisation can affect carers, in particular that integration between health and social care for people with mental health problems may benefit carers in ways that were hitherto unproven. They highlight the needs of carers for younger people. They show that the ECI is a useful instrument in measuring the impact of caring for people with severe mental health problems. Accepted: 19 September 2001     

Promoting Healthy Organizational Partnerships and Collaboration Between Consumer-run and Community Mental Health Agencies

Community mental health agencies (CMHAs) and consumer-run agencies (CRAs) both provide critically important services to persons with severe psychiatric disabilities. Emerging research has begun to support the effectiveness of the CRA approach, a newer service delivery mechanism. However, collaboration between the two service systems, when it occurs, is often problematic. This article briefly identifies the core features of CRAs, discusses their potential for collaboration with CMHAs, and suggests ways to promote healthy organizational partnerships between the two based upon the model proposed by Gidron and Hasenfeld [(1994) Nonprofit Management & Leadership, 5(2), 159–172]. Salient collaboration theories are reviewed and barriers to collaboration are discussed. Finally, implications for mental health practice and future research directions are identified.John Q. Hodges, Ph.D., is assistant professor of social work at the University of Missouri, Columbia. His research interests include mental health consumer-run services, consumer perspectives on the mental health service system, homelessness, and severe mental illness.Eric R. Hardiman is assistant professor of social welfare at the University at Albany, State University of New York. His research interests include mental health service utilization, consumer-operated services, peer support, and psychiatric recovery.     

Children in foster care: Mental health, service use and costs

Abstract Objective To assess the prevalence of mental health problems in children in foster care, their families’ use of services and the associated costs. Methods Information on mental health problems, service use and costs was collected, by postal questionnaires and home interviews, on 182 children, their foster carers and teachers from 17 local authorities in Central Scotland. Results Over 90% of the children had previously been abused or neglected and 60 % had evidence of mental health problems including conduct problems, emotional problems, hyperactivity and problems with peer relations. When compared with 251 children from local schools, the children in foster care had significantly higher symptom scores for Reactive Attachment Disorder. Those children with highest scores for mental health problems were attracting a high level of service support from a wide range of agencies, except Child and Adolescent Mental Health Services (CAMHS). Costs were associated with learning disability, mental health problems, and a history of residential care. Conclusions Children in “mainstream” foster care are at greater risk of mental health problems, and are attracting greatest costs, but CAMHS are not successfully targeting these problems. CAMHS may need to develop new models of service delivery.     

Building mental health promotion capacity in health care: results from Phase I of a workforce development project

The development of mental-health-promoting health care systems is dependent on having a skilled and informed workforce to effectively integrate mental health promotion (MHP) into programme and service delivery. This paper describes Phase I (September 2009-July 2010) of Health Compass, an innovative, multi-phased project that aims to transform health care practice and shift organizational culture by enhancing the capacity of health care providers to further promote patient, client and family mental well-being. Phase I of Health Compass examined the current state of MHP within British Columbia's Provincial Health Service Authority health care services. The findings, based on group discussions and key informant interviews, examined health care providers' current understanding and knowledge of MHP; identified existing strategies, facilitators and barriers that help or hinder the incorporation of MHP into health care practice and services; and identified preferred learning modalities for development and piloting of future MHP resources in Phases II and III.     

Transforming mental health and substance abuse data systems in the United States

State efforts to improve mental health and substance abuse service systems cannot overlook the fragmented data systems that reinforce the historical separateness of systems of care. These separate systems have discrete approaches to treatment, and there are distinct funding streams for state mental health, substance abuse, and Medicaid agencies. Transforming mental health and substance abuse services in the United States depends on resolving issues that underlie separate treatment systems--access barriers, uneven quality, disjointed coordination, and information silos across agencies and providers. This article discusses one aspect of transformation--the need for interoperable information systems. It describes current federal and state initiatives for improving data interoperability and the special issue of confidentiality associated with mental health and substance abuse treatment data. Some achievable steps for states to consider in reforming their behavioral health data systems are outlined. The steps include collecting encounter-level data; using coding that is compliant with the Health Insurance Portability and Accountability Act, including national provider identifiers; forging linkages with other state data systems and developing unique client identifiers among systems; investing in flexible and adaptable data systems and business processes; and finding innovative solutions to the difficult confidentiality restrictions on use of behavioral health data. Changing data systems will not in itself transform the delivery of care; however, it will enable agencies to exchange information about shared clients, to understand coordination problems better, and to track successes and failures of policy decisions.     

Using strategy to promote knowledge utilization and change in community mental health systems.

The Washington community mental health system illustrates three examples of knowledge utilization: a long range strategy to improve the accountability of the service system and finances, the formulation and implementation of a strategy to expand minority services in provider agencies, and a process to expand the application of community support concepts for adults and children in local service systems. The management information system (MIS) implementation applies the Davis A VICTORY model.     

Improving medical care for persons with serious mental illness: challenges and solutions

A critical step in addressing excess medical morbidity and mortality in persons with serious mental illness is to better understand and seek to improve the medical care that they receive. Medical quality deficits for persons with serious mental illness include problems related to overuse of certain medical services, such as emergency room care; underuse of some evidence-based general medical services; and misuse, or medical error. The origins of poor quality care for persons with mental disorders are rooted in interrelated contributory factors from patients, providers, and the medical and mental health care systems. At a system level, at least 4 types of separation between mental and medical health care may exacerbate the problems for persons with serious mental illnesses: (1) geographic (lack of co-located medical and mental health services), (2) financial (separate funding streams for medical and mental health services), (3) organizational (difficulty in sharing information and expertise across these systems), and (4) cultural (providers' focus on particular symptoms or disorders, rather than on the patients with those problems). Research studies and demonstration programs for improving medical care in this population have spanned a continuum of medical provider involvement from psychiatrist and patient training to on-site consultation by medical staff, multidisciplinary collaborative care approaches, and facilitated linkages between community and mental health and medical providers. Ultimately, it will be important to develop, test, and implement a range of models for improving the medical care of persons with serious mental disorders that are tailored to patients' needs, mental health system capacities, and local community resources.     

Challenges and solutions to integrating mental and physical health care

A critical step in addressing excess medical morbidity and mortality in persons with serious mental illness is to better understand, and seek to improve, the medical care that they receive. Medical quality deficits for persons with serious mental illnesses include problems including overuse of certain medical services such as emergency room care; underuse of some evidence-based general medical services; and misuse, or medical error. The origins of poor quality care for persons with mental disorders are rooted in interrelated contributory factors from patients, providers, and the medical and mental health systems. At a system level, at least 4 types of separation between mental and medical health care may exacerbate the problems for persons with serious mental illnesses: 1) geographic (lack of co-located medical and mental health services), 2) financial (separate funding streams for medical and mental health services), 3) organizational (difficulty in sharing information and expertise across these systems), and 4) cultural (providers' focus on particular symptoms or disorders, rather than on the patients with those problems). Research studies and demonstration programs for improving medical care in this population have spanned a continuum of medical provider involvement from psychiatrist and patient training, to on-site consultation by medical staff, multidisciplinary collaborative care approaches, and facilitated linkages between community and mental health and medical providers. Ultimately, it will be important to develop, test, and implement a range of models for improving the medical care of persons with serious mental disorders tailored to patients' needs, mental health system capacities, and local community resources.     

Improving collaboration between primary care and mental health services

Abstract

Objective: Previous guidelines and planning documents have identified the key role primary care providers play in delivering mental health care, including the recommendation from the WHO that meeting the mental health needs of the population in many low and middle income countries will only be achieved through greater integration of mental health services within general medical settings. This position paper aims to build upon this work and present a global framework for enhancing mental health care delivered within primary care.

Methods: This paper synthesizes previous guidelines, empirical data from the literature and experiences of the authors in varied clinical settings to identify core principles and the key elements of successful collaboration, and organizes these into practical guidelines that can be adapted to any setting.

Results: The paper proposes a three-step approach. The first is mental health services that any primary care provider can deliver with or without the presence of a mental health professional. Second is practical ways that effective collaboration can enhance this care. The third looks at wider system changes required to support these new roles and how better collaboration can lead to new responses to respond to challenges facing all mental health systems.

Conclusions: This simple framework can be applied in any jurisdiction or country to enhance the detection, treatment, and prevention of mental health problems, reinforcing the role of the primary care provider in delivering care and showing how collaborative care can lead to better outcomes for people with mental health and addiction problems.     

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.     

Limitations of System Integration in Providing Employment Services for Persons with Mental Illness

This study assessed the influence of service systems integration on employment outcomes for persons with mental illness. A survey was sent to all 125 key program staff that worked for community mental health treatment agencies or vocational rehabilitation agencies. The survey found that referral and employment rates were low; but that these rates were related to characteristics of the interagency systems integration. Community mental health staff referred 448 individuals for employment services. Staff from vocational rehabilitation agencies accepted only 26% of these referrals and found work for just 11%; 7% were employed six months later. Also, 39% of respondents reported that the linkage agreement between their agencies was never established. This study suggests the need for more effective strategies for integrating mental health treatment and vocational rehabilitation systems.A version of this paper was presented at the Academy/Health annual conference in San Diego, June 8, 2004.     

Managed Care and Service Capacity Development in a Public Mental Health System

Developing a continuum of care is considered to be one of the first steps in the process of implementing managed care strategies. This study summarizes the results of a final survey that focused on the ability of Colorado community mental health centers (CMHCs) to build service capacity and create new programs as a result of Medicaid capitation financing. Capitated agencies, compared to those that remained fee-for- service during the study period, reported a much greater ability to develop services as a result of capitation. Decreases in services were minimal for all agencies. Some differences in managed care organizational models were noted, as were differences in the speed of implementation. Gaps in some services still remain. These findings point to important program implementation issues for publicly funded managed care.     

Integrated local networks as a model for organizing mental health services

Organizing services in an integrated network as a model for transforming healthcare systems is often presented as a potential remedy for service fragmentation that should enhance system efficiency. In the mental health sector, integration is also part of a diversified response to the multiple needs of the clients, particularly people with serious mental health disorders. The authors describe how the notion of integrated service networks came to serve as a model for transforming the mental health system in Québec, and they propose a frame of reference for this notion. They also address the challenges and issues raised by this mode of service organization in the mental health sector and more generally in a context of transforming healthcare systems.     

Service costs of caring for adolescents with mental illness in a rural community, 1993-2000

OBJECTIVE: Costs of treating child psychiatric disorders fall on educational, primary care, juvenile justice, and social service agencies as well as on psychiatric services. The authors estimated multiagency mental health costs by integrating service unit costs with utilization rates in an 11-county area. Using psychiatric diagnoses made independently of service use records, the authors calculated costs across agencies as well as the extent of unmet need for psychiatric care. METHOD: Annual parent and child reports were used to measure mental health care needs and units of service across 21 types of settings for the population-based Great Smoky Mountain Study sample of 1,420 adolescents from ages 13 to 16. Unit costs for services were generated from information from service providers and records. The authors calculated costs overall, costs by type of service, and costs by diagnosis. RESULTS: Average annual costs per adolescent treated were $3,146. Juvenile justice and inpatient/residential facilities accounted for well over half of the total costs. Costs for youths with two or more diagnoses were twice as much as costs of those with a single disorder. Among adolescents with service needs, 66.9% received no services. Public health insurance was associated with higher rates of specialty mental health care than either private insurance or no insurance. CONCLUSIONS: Annual costs across all services were three to four times greater than recent health insurance estimates alone. Many costs for adolescents with mental health problems were borne by agencies not designed primarily to provide psychiatric or psychological services. Only one in three adolescents needing psychiatric care received any mental health services.     

Integration of service systems for homeless persons with serious mental illness through the ACCESS program. Access to Community Care and Effective Services and Supports

OBJECTIVE: The aim of this study was to evaluate the first of the two core questions around which the ACCESS (Access to Community Care and Effective Services and Supports) evaluation was designed: Does implementation of system-change strategies lead to better integration of service systems? METHODS: The study was part of the five-year federal ACCESS service demonstration program, which sought to enhance integration of service delivery systems for homeless persons with serious mental illness. Data were gathered from nine randomly selected experimental sites and nine comparison sites in 15 of the nation's largest cities on the degree to which each site implemented a set of systems integration strategies and the degree of systems integration that ensued among community agencies across five service sectors: mental health, substance abuse, primary care, housing, and social welfare and entitlement services. Integration was measured across all interorganizational relationships in the local service networks (overall systems integration) and across relationships involving only the primary ACCESS grantee organization (project-centered integration). RESULTS: Contrary to expectations, the nine experimental sites did not demonstrate significantly greater overall systems integration than the nine comparison sites. However, the experimental sites demonstrated better project-centered integration than the comparison sites. Moreover, more extensive implementation of strategies for system change was associated with higher levels of overall systems integration as well as project-centered integration at both the experimental sites and the comparison sites. CONCLUSIONS: The ACCESS demonstration was successful in terms of project-centered integration but not overall system integration.     

Association Between Employment and Mental Health Service Use Among Justice-Involved Individuals

Using a nationally representative sample of justice-involved persons (N?=?1525), the present study examined the extent to which employment status was associated with mental health service use by various service providers. The findings indicate that the rate of mental health service use by general health care providers among the unemployed was higher than that of the employed. Factors associated with mental health service use varied by type of provider. Our findings suggest that employment may be critical for justice-involved people in enhancing their mental health status, which could result in their successful community integration.     

The administration of school-based mental health services.

Challenges and proposed solutions in the administration of school-based mental health services have been addressed. Differences depend on whether the services are provided by the mental health component of an SBHC or by an ISBMHP. Seven common elements relevant in developing and administering school-based mental health services, whether in an SBHC or ISBMHP, have been identified: funding, assessment and resources, program structure, staffing and training, partnership and collaboration, quality assurance, and evaluation. How these elements are addressed varies from school district to indivdual school to individual principal to agencies providing services to specific clinicians. One of the most important lessons learned is that the ecosystem of each school is different; one size does not fit all. When external agencies enter a school, they are in the best case guests, in the worst case foreigners or invaders. Agencies and their clinicians must be respectful, adaptable, flexible, and competent professionals. With such attributes, the chance for an effective collaboration is enhanced. Contributions of school-based mental health services to the child and adolescent mental health delivery system include (1) access to services for disadvantaged and underserved youth, (2) system-wide collaboration, (3) prevention of acute psychiatric intervention, (4) gate-keeper role for more acute or specialized care, (5) systematic program evaluation in a "naturalistic" setting, (6) professional training in working with a range of systems and cultures, and (7) outreach and community-based care. With the emphasis on partnership and collaboration, school-based programs have the potential to benefit the children and families, schools, communities, and managed care organizations. The provision of access and early intervention is cost effective in the long run, and findings indicate that school-based mental health service is as effective as that of a central clinic. With the emphasis on collaboration, partnership, and bridging systems and cultures, the provision of school-based mental health care may be able to offer tools and experience to create integrated systems of care. This is a reciprocal process and an ongoing dialectic, however. Providers and planners of a school-based mental health programs, schools, and managed-care leaders can learn from one another, and all have major contributions to make to the overall delivery system. Schools and mental health service providers contribute knowledge and skills in working with this population; managed care organizations bring administrative and fiscal expertise and a focus on and mandate for quality and cost-effective care. For-profit and not-for-profit agencies must enter into a dialogue to educate and understand each other so that they may become collaborators in the underutilized service for children and youth.     

Child and youth telepsychiatry in rural and remote primary care

Young people with psychological or psychiatric problems are managed largely by primary care practitioners, many of whom feel inadequately trained, ill equipped, and uncomfortable with this responsibility. Accessing specialist pediatric and psychological services, often located in and near large urban centers, is a particular challenge for rural and remote communities. Live interactive videoconferencing technology (telepsychiatry) presents innovative opportunities to bridge these service gaps. The TeleLink Mental Health Program at The Hospital for Sick Children in Toronto offers a comprehensive, collaborative model of enhancing local community systems of care in rural and remote Ontario using videoconferencing. With a focus on clinical consultation, collaborative care, education and training, evaluation, and research, ready access to pediatric psychiatrists and other specialist mental health service providers can effectively extend the boundaries of the medical home. Medical trainees in urban teaching centers are also expanding their knowledge of and comfort level with rural mental health issues, various complementary service models, and the potentials of videoconferencing in providing psychiatric and psychological services. Committed and enthusiastic champions, a positive attitude, creativity, and flexibility are a few of the necessary attributes ensuring viability and integration of telemental health programs.     

Mental Health Provider Attitudes Toward Adoption of Evidence-Based Practice: The Evidence-Based Practice Attitude Scale (EBPAS)

Mental health provider attitudes toward organizational change have not been well studied. Dissemination and implementation of evidence-based practices (EBPs) into real-world settings represent organizational change that may be limited or facilitated by provider attitudes toward adoption of new treatments, interventions, and practices. A brief measure of mental health provider attitudes toward adoption of EBPs was developed and attitudes were examined in relation to a set of provider individual difference and organizational characteristics. METHODS: Participants were 322 public sector clinical service workers from 51 programs providing mental health services to children and adolescents and their families. RESULTS: Four dimensions of attitudes toward adoption of EBPs were identified: (1) intuitive Appeal of EBP, (2) likelihood of adopting EBP given Requirements to do so, (3) Openness to new practices, and (4) perceived Divergence of usual practice with research-based/academically developed interventions. Provider attitudes varied by education level, level of experience, and organizational context. CONCLUSIONS: Attitudes toward adoption of EBPs can be reliably measured and vary in relation to individual differences and service context. EBP implementation plans should include consideration of mental health service provider attitudes as a potential aid to improve the process and effectiveness of dissemination efforts.     

Issues in Medicaid policy and system transformation: recommendations from the President's Commission

Efforts to ensure that people with disabilities participate fully in their communities have raised awareness of current Medicaid policies that impede provision of best-practice mental health services. The author summarizes issues that were examined by the Medicaid Subcommittee of the President's New Freedom Commission and its recommendations in four areas: access, service delivery, service coordination, and quality. Because of Medicaid's substantial role as a payer for mental health services, more creative and flexible program policies can promote system transformation. Current eligibility rules and time-consuming procedures can inhibit timely access to Medicaid coverage for people with mental illness. Medicaid benefit plans may create financial incentives for maintaining more traditional but less effective models of care. Some policies impede states' ability to coordinate Medicaid funding with other sources of funding to create systems of community-based care. Medicaid does not provide specific requirements to ensure that individuals with depression are identified and offered informed choices about treatment through primary or specialty care providers. Action steps to address these and other issues include use of presumptive eligibility and parity, retention of coverage as enrollees enter the workplace, guidance to states on evidence-based practices and service coordination with other agencies, more flexible financing mechanisms, improved data collection and reporting, and enhanced integration of primary and mental health care.