Integrating Service Delivery Systems for Persons with Severe Mental Illness

1. Integrating Service Delivery Systems for Persons with Severe Mental Illness Horwitz & Scheid, Ch. 24

2. Overview • Past 50 years has seen shift from centralized, institutional model of care (large state psychiatric hospitals) to decentralized, community-based system involving large number of private and public providers • Thousands of long-stay patients discharged to community settings (including nursing homes, board and care, etc.) • Community mental health centers attracted large numbers of formerly unserved patients.

3. Result of changes • Severely mentally ill (SMI) have been disadvantaged, according to some researchers • SMI have multiple needs, not just mental health needs • Psychosocial rehabilitation • Income maintenance • Housing • Health care • Employment • Social supports • Substance abuse counseling

4. Need for service integration • Given the multiple needs of SMI clients, many clients “fall between the cracks” of various service delivery systems • Thus arose the need for “service integration” to develop linkages between sectors and enhance effectiveness and efficiency of services

5. Four major innovations in service integration in past decades • Community Mental Health Centers (CMHC’s) • Community Support Program (CSP) and Child and Adolescent Service System Program (CASSP) • Program on Chronic Mental Illness (PCMI)—co-sponsored by Robert Wood Johnson Foundation and US Department of Housing and Urban Development • Managed mental health care

6. Roots of services integration • During 1960’s, the New Frontier and Great Society (Kennedy and Johnson presidencies) • Neighborhood service centers • Community action • Community mental health centers • Model Cities • Head Start • Older Americans Act • War on Poverty • By early 1970’s service coordination was a buzzword in Department of Health, Education, and Welfare

7. Services integration strategies for persons with severe mental illness

8. Community Mental Health Centers • Initiated in mid-1960’s • Goals • Develop comprehensive community-based services (emergency, inpatient, outpatient, partial hospitalization, consultation and education) • Responsible for catchment area • Promote early treatment, continuity of care, prevention, rehabilitation

9. Community Mental Health Centers • Began to serve “worried well” instead of SMI • Only in late 1970’s did they begin to serve SMI population • As federal funding disappeared, states took over funding and regulation of centers, put priority on SMI population

10. Community Support Program • Created by National Institute of Mental Health to improve services for severely and persistently mentally ill (SPMI) • Services to include psychosocial rehabilitation, medical and mental health care, case management, supportive living and working arrangements, crisis intervention to prevent hospitalization • In early 1980’s began to include children and adolescents (CASSP)

11. Local mental health authorities • Program on Chronic Mental Illness (PCMI) • A unique public-private partnership (Robert Wood Johnson Foundation and US HUD) • Mostly a demonstration project that occurred in 9 cities • Research did not support broad expansion of these programs

12. Managed Care • Covers broad range of financing arrangements, different types of organizations, regulatory mechanisms • Goals • Control access to care • Control types of care delivered • Control costs of care • Mental health is frequently “carved out” and managed separately from other forms of health care • Concerns—managed care is really all about saving money, not about providing care needed by SPMI

13. Effectiveness?? • Research has demonstrated that services can be successfully integrated • However, research has been unable to demonstrate that there is a significant difference in outcomes for clients who are served under “service integration” • Further research is needed

14. How are decisions usually made? • Research findings? NO • Interest group politics YES