Restructuring public mental health and substance abuse service systems

The authors originally circulated the concepts in this proposal during May 1995. The purpose was to support an open, public dialogue regarding the restructuring of the mental health and substance abuse services in Illinois in anticipation of Medicaid funding changes. Restructuring mental health and substance abuse service systems should follow certain key principles. These principles are applicable to other states, particularly those large in territory and population. The authors propose the temporary use of multiple managed care companies serving as administrative services only (ASO) organizations, each of whom would have responsibility for a given geographic portion of a state. The role of the ASOs would be to organize providers into networks on a regional basis and transfer managed care expertise in financing and clinical management to the relevant state departments and provider groups. Changes in the service delivery system would be phased in over time with reorganization of key components of the system during each phase. Where the provision of mental health, substance abuse, and social services is split among multiple state agencies, these agencies would be merged to achieve unified funding and administrative efficiency. Patients and advocacy organizations would play a key role in overseeing and shaping system restructuring at all levels, including a governmental board reporting to the governor, overseeing ASO organizations' operations and assuring quality and access at the provider level. The authors propose funding of public behavioral health services through use of a tiered, integrated funding model.     

Rural telepsychiatry

Telepsychiatry is the use of telecommunications technology to connect patients and health care providers, permitting effective diagnosis, education, treatment, consultation, transfer of medical data, research, and other health care activities. Telepsychiatry has been used as a partial solution to the problem of limited psychiatric services for clinics and hospitals in remote areas of areas underserved by psychiatrists and other mental health care specialists. In the United States, eastern Oregon's RodeoNet telepsychiatry program and the telemedicine program of the Kansas University Medical Center, which has a psychiatric component, are excellent models. Telepsychiatric applications can be cost-effective, but careful evaluation is needed.     

Managed care, school health programs, and adolescent health services: opportunities for health promotion

The rapid expansion of managed care creates opportunities and dilemmas for those involved in school health and adolescent health promotion. Managed care organizations (MCOs), public health agencies, and school and adolescent health providers share certain common goals and priorities including an emphasis on prevention, cost-effectiveness, and quality of care--and a willingness to explore innovative approaches to health promotion and disease prevention. However, MCOs often face conflicting challenges, balancing the goals of cost containment and investment in prevention. In considering support for school health programs, MCOs will be interested in evidence about the effectiveness of services in improving health and/or reducing medical expenditures. Mechanisms for improving prevention efforts within MCOs include quality assurance systems to monitor the performance of health plans, practice guidelines from professional organizations, and the contracting process between payers and health care providers. Development of partnerships between MCOs and schools will be a challenge given competing priorities, variation in managed care arrangements, structural differences between MCOs and schools, and variability in services provided by school health programs.     

Managed care strategy for mental health services

In the UK, managed care is beginning to be recognized as a cost effective, quality-driven system which can be used to structure patient care. This article examines the potential use of managed care pathways in mental health services, focusing on clients with schizophrenia. The strengths of managed care include the effective coordination of healthcare resources, the clear accountable audit of mental health practice and the re-engineering of mental health practice to improve patient outcomes. Problems in designing representative care pathways and encouraging healthcare providers to implement care pathways are some of the disadvantages of this system.     

Pursuing an evidence-based culture through contextualized feedback: Aligning youth outcomes and practices.

How can contextualized feedback on therapy practices and youth outcomes promote an evidence-based culture for adolescent mental health? Relative to other quality improvement tools, feedback and progress monitoring systems are generally underutilized. This article describes a feedback system collaboratively developed by the Hawai'i Department of Health Child and Adolescent Mental Health Division and private agency staff contracted to provide mental health services to youth. Feedback reports allow providers to monitor progress of their youth clients, compare their progress with youth receiving similar services, examine the extent they are using practices derived from evidence-based protocols, and compare these practice profiles to what other youth are receiving. Providers gather to discuss reports, share success stories, and offer suggestions to improve practices and outcomes based on data from the reports. The provider feedback system in Hawai'i has emphasized youth outcomes and has promoted an “evidence-based culture.” This article encourages direct providers and supervisors to consider how such a system might fit in their current practice and whether contextualized feedback might be one way to enhance services and outcomes for youth with mental health needs. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

Experienced anesthetists show better reaction to central gas supply dropout--an anesthesia simulator study

The reform process underway within the Italian National Health System is aimed at making decision makers responsible for appropriate and efficient resource utilisation and at ensuring quality of care, eliminating conflict between fairness, quality and cost control. The risk for the quality of the services provided entailed by resource rationalisation is avoidable and controllable. This article explains how the Italian NHS has managed the reform process assuring quality improvement, and describes the policy and the tools adopted. As well as involving all players and the system as a whole in constant improvement, the Italian NHS's policy in pursuing quality of care is based on the adoption of a wide range of measures: measurement of health care and of clinical outcomes, systematic data collection, team work and protocols. The tools adopted, currently under implementation, to support quality control are: an integrated system of indicators for measuring efficiency and quality of NHS structures (demand and accessibility indicators, resource related indicators, activity indicators and result indicators); compulsory accreditation as a prerequisite for health care providers; a system to monitor and control the effects of the new prospective payment system; clinical guidelines (each related to a specific clinical problem); a menu of services (Carta dei Servizi) released by all NHS accredited service providers with full information and warranties regarding the services provided and their quality.     

Why do states privatize mental health services? Six state experiences. The MEDSTAT Group

State governments fund more than one-half of public mental health service system costs through mental health departments, other state agencies, and the Medicaid program. They use some of these resources to finance community-based mental health services through purchase-of-service contracts. I explored the reasons why states privatize mental health services and focused on political, economic, and organizational theories as possible frameworks for contracting. I gathered data during site visits to Massachusetts, Michigan, New York, Oregon, Tennessee, and Texas, where I interviewed more than one hundred individual stakeholders about mental health purchase-of-service contracting. I also examined relevant documents about contracting practices for mental health services in each state. My results suggest that state policy makers can use mental health contracting to effect multiple goals. Contracting helps states achieve political, economic, and organizational objectives, such as avoiding the influence of interest groups and leveraging state resources, while avoiding conflict. With contracting, state policy makers can also continue the ongoing mental health policy paradigm shift begun during deinstitutionalization, in which persons with serious and persistent mental illnesses receive services from community-based providers rather than in state hospitals. Finally, my results suggest that contracting will continue to be an important state policy tool in further development of state-supported mental health systems.     

Developing community capacity to treat post-deployment mental health problems: A public health initiative.

Meeting the mental health needs of Veterans returning from recent deployment requires the coordinated effort of partnerships across Department of Defense (DoD), Department of Veterans Affairs (VA), and state and local communities. Although the proportion of Veterans of Iraq and Afghanistan who have accessed VA health care has grown, the majority of these new combat Veterans have yet to present for VA care. The stigma associated with reporting a deployment-related mental health problem may be one factor in this, but access to treatment may also be an important concern among the one third of American Veterans who live in rural or highly rural areas. As these Veterans are more likely to present to a primary care, faith-based or mental health provider in their own community, partnerships between community providers, DoD, and VA are of critical importance in ensuring appropriate care, regardless of treatment setting. In an effort to improve services and access to services, especially to rural Veterans, an educational public health initiative was created to educate community providers about military culture, deployment-related mental health issues, VA resources, and evidence-based treatments. We describe the development, dissemination and evaluation of this initiative, as well as lessons learned for future similar endeavors. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

Patient satisfaction. The survey says...

Health care organizations and providers compete in a marketplace where loyal consumers are essential to a successful business. Contemporary consumers have health care knowledge and power. As employers negotiate benefits with providers, most will consider input from employees receiving care. Negative feedback from dissatisfied recipients of care can affect employers' selection of facilities and providers. This is significant leverage that health care organizations should consider when providing services to customers. Information obtained through patient satisfaction programs has proven to be a valuable source for quality improvement marketing, risk management, strategic planning, and finance initiatives. In this article, the authors describe variables associated with a patient satisfaction survey, identify key elements of a patient satisfaction survey program, and offer workable solutions to maximize patient satisfaction programs.     

The Consumer Reports mental health survey.

Provides an overview of the 1995 Consumer Reports survey of the effectiveness of psychotherapy. Specific issues addressed include the study's goals; the findings for mental health professionals, family doctors, and self-help groups; and methodological strengths and weaknesses related to external validity, sampling, controls, self-reports, and time frame. The data show that, free of the artificial constraints of controlled studies in the real world, a population of consumers can often benefit from psychological intervention services. Real relief can be found at the hands of professional mental health providers. M. Kotkin et al reaffirm their independence from M. E. P. Seligman (see record 1996-13324-001) regarding the interpretation of the data. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Improving Mental Health Service Utilization for Children and Adolescents.

Approximately 10% of children and adolescents have mental health problems necessitating intervention, but well below 50% of these children receive needed services, and far fewer receive the quality of care required to effectively reduce their impairments. Although system reform is needed to improve service utilization and quality of care for all children, preschoolers, girls, individuals of minority status, and the uninsured are most at risk for being underserved. Factors contributing to poor service utilization can be classified into two broad sets: sociopolitical factors referring to issues related to funding and access, and cultural/familial factors including beliefs about mental health services, providers, and treatments. This article describes the help-seeking process and focuses on cultural and familial factors that contribute to movement through these stages, with a particular focus on variables that are amenable to change by practitioners in the school and community, including school psychologists. Guidelines for understanding and changing the help-seeking behavior of families, including suggestions for creating service options, providing family education, and offering individualized family services, are described. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

Characterization of acellular dermal matrices (ADMs) prepared by two different methods

This paper describes a program in Hamilton-Wentworth, Ontario, Canada, that brings mental health counselors and psychiatrists into the offices of 87 local family physicians, working in 35 practices serving 170,000 people. It outlines the organization of the mental health teams in the family physician's office and the way in which these teams are coordinated and discusses how this "shared care" approach can overcome many of the problems that traditionally bedevil the relationship between psychiatric services and family practices. It summarizes the benefits of this approach for patients providers and the health care system and looks at its implications for learners and for new approaches to continuing education. This model can be adapted to most communities.     

Quality of services and demand for health care in Nigeria: a multinomial probit estimation

This study attempts to empirically answer three important policy questions for a population sample from Ogun State, Nigeria: 1. Would price (fee) increases for health care lead to large reductions of care usage or to shifts across types of care used? 2. Would price increases lead to net increases in revenues for the health system? 3. Would the price increases have larger impacts (in the form of reductions in health care usage) on lower income members of the population? Household data are combined with data on prices and quality of care, collected directly from facilities, to estimate the demand for outpatient health care. Many of the statistical problems of demand estimation with micro level data are avoided by an innovation--the first use of the multinomial probit estimation method for health demand. A separate but related problem, that the price data used in such studies are usually endogenous (in fact usually are expenditures, which are to a great degree determined by the actual care choice) is avoided by the collection of a specific exogenous price variable directly from the health providers. Because the health care 'good'--outpatient health care--can vary to such a degree across providers, quality of care must be controlled in order that the coefficients on prices and other variables will not be biased. A strong circumstantial case can be made that past estimation efforts probably underestimated the impact of prices of care on provider choices, because those providers charging higher prices also tend to provide higher quality care and those charging lower prices to provide care of lower quality. Because of this fear of bias on the extremely important price coefficient, effective control of the quality of the care available at the alternative accessible care providers is almost certainly at this time the most important marginal innovation to demand estimation. Most past researchers simply have not had available to them exogenous quality of care information collected via a facility (provider) survey. This study tried several health care provider quality variables and finally used three distinct variables which were statistically significant: (a) expenditure per person in population served; (b) percentage of times drugs are available; and (c) interviewers evaluation of the physical condition of the facility. Price of a visit to the facility is also included, and also is an exogenous variable collected directly from the alternative available providers. For the variables of most interest for this study, price and quality of care, the results are quite reasonable and much as expected.(ABSTRACT TRUNCATED AT 250 WORDS)     

Development of enzyme-linked immunosorbent assays using recombinant borrelial antigens for serodiagnosis of Borrelia burgdorferi infection

The basic tenet of continuous quality improvement is that there is always room for additional improvement in the clinical care provided to patients. The opportunities for this improvement come from the analysis of information collected during the ongoing monitoring of important elements of care. The provision of clinical psychiatric care is seen as a complex process that is dependent on the effective functioning of all of the health and mental health care organization. The concept of continuous quality improvement is the most recent stage in a long process of defining and redefining the basic goals and tenants of medical and psychiatric quality assurance. The determination of the actual improvement of psychiatric and mental health care due to quality assurance is a substantial and important technical problem. The determination of the value of this improvement in mental health care is an even greater ethical and social problem.     

The Colorado Medicare study: Perspective of the peer review committee.

In 1977, the Social Security Administration sponsored a study to determine whether including psychologists as independent providers and increasing the dollar limit of Medicare's mental health benefits would have an impact on the availability of mental health care to Medicare recipients, the quality of care provided, and the cost and utilization of the program. The present study discusses peer review issues that emerged from the study: (1) the peer review criteria for quality of care provided, (2) the range of covered services and covered diagnoses under Medicare, (3) the unique patient population aspects, (4) patient participation in the treatment plans and outcome forms used for peer review, (5) the issue of confidentiality of the peer review forms, (6) and findings regarding medical consultation on cases treated by psychologists. The review committee concluded that within the limits of the study, the review system was successful and the quality of services delivered was high. (1 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Cultural and contextual influences in mental health help seeking: A focus on ethnic minority youth.

In this article, a mental health help-seeking model is offered as a framework for understanding cultural and contextual factors that affect ethnic minority adolescents' pathways into mental health services. The effects of culture and context are profound across the entire help-seeking pathway, from problem identification to choice of treatment providers. The authors argue that an understanding of these help-seeking pathways provides insights into ethnic group differences in mental health care utilization and that further research in this area is needed, (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The problem-oriented research laboratories of the Military Medical Academy

1. Extending cultural care beyond language enhances the use of mental health services and fosters a mutually agreed-on plan of care. 2. Understanding cultural characteristics facilitates an understanding of behavior, family and social dynamics, and adaptation patterns to stress that can empower clients to work toward their goals and validate the impact of emotions and behaviors on others. 3. Culturally appropriate mental health care reflects a synthesis among communication, space, social organization, time, environmental control, and biological variables.     

Psychology and HMOs: New partnership or new adversary?

Discusses the provision of psychological services in health maintenance organizations (HMOs) with regard to the level of the legal recognition of the autonomous functioning of psychologists. Professional concerns over the role of psychologists in HMOs and over incentives to provide quality mental health care in such organizations are also discussed. The need is stressed for psychologists to be recognized as autonomous providers under the basic federal health programs. (17 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Community mental health service use by older adults with dementia.

We considered the role of community-based public mental health services in providing care to older persons with Alzheimer's disease and other forms of dementia, and examined service outcomes within California's county-based public mental health system over a 3-year period. Treated prevalence rates, repeat service use rates, and service mix patterns were regressed onto individual, market, and contextual variables across 25 counties over 12 observation periods. The number of older adults with dementia who used community mental health services increased slightly over the observation periods, and service use was associated with age and Medicaid status. Service outcomes also were affected by complementary mental health and aging service systems within each county, as well as the poverty rate and location of the county. Future research is needed to clarify how administrative policies and service management practices contribute to increasing community mental health service use by persons with dementia. In the meantime, these findings can help program administrators and service providers understand the role of community-based mental health services in providing care to persons with dementia. (PsycINFO Database Record (c) 2010 APA, all rights reserved)