Abstract
BackgroundSince deinstitutionalization in the 1950s–1970s, public mental health care has changed its focus from asylums to general hospitals, outpatient clinics and specialized community-based programs addressing both clinical and social determinants of mental health. Analysis of the place of community-based programs within a comprehensive health system such as the Veterans Health Administration (VHA) may illuminate the role of social forces in shaping contemporary public mental health systems.MethodsNational VHA administrative data were used to compare veterans who exclusively received outpatient clinic care to those receiving four types of specialized community-based services, addressing: 1) functional disabilities from severe mental illness (SMI), 2) justice system involvement, 3) homelessness, and 4) vocational rehabilitation. Bivariate comparisons and multinomial logistic regression analyses compared groups on demographics, diagnoses, service use, and psychiatric prescription fills.ResultsAn hierarchical classification of 1,386,487 Veterans who received specialty mental health services from VHA in Fiscal Year 2012, showed 1,134,977 (81.8%) were seen exclusively in outpatient clinics; 27,931 (2.0%) received intensive SMI-related services; 42,985 (3.1%) criminal justice services; 160,273 (11.6%) specialized homelessness services; and 20,921 (1.5%) vocational services. Compared to those seen only in clinics, veterans in the four community treatment groups were more likely to be black, diagnosed with HIV and hepatitis, had more numerous substance use diagnoses and made far more extensive use of mental health outpatient and inpatient care.ConclusionsAlmost one-fifth of VHA mental health patients receive community-based services prominently addressing major social determinants of health and multimorbid substance use disorders.
Highlights
Since deinstitutionalization in the 1950s–1970s, public mental health care has changed its focus from asylums to general hospitals, outpatient clinics and specialized community-based programs addressing both clinical and social determinants of mental health
The result has been a non-institutional system composed of two broad components: a standard clinic-based component backed by a limited hospital capacity, that serves the majority of patients, providing medications and behavioral therapies; and a second, outwardly facing, community focused component providing more resource intensive services to patients most impacted by “social determinants” and in need of specialized in vivo care
Bivariate analysis showed that veterans treated in criminal justice, homeless and vocational programs were substantially younger than those seen exclusively in outpatient mental health clinics
Summary
Sample Using national VHA data from FY 2012, a total of 1,386, 487 veterans were identified who had used specialty mental health care. These veterans were classified into groups by the types of services they received. Community based services include those predominantly delivered outside the offices of the health care system to directly address social risks to health such as homelessness, incarceration, poor social functioning, poverty, and lack of employment skills. Analysis Bivariate analyses were used to compare veterans treated only in mental health clinics to those who received services from each of the four hierarchically classified types of intensive community based services.
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