Community Mental Health System Research Articles

The impact of state administrative practices on community mental health

State mental health authorities have progressively upgraded their planning capabilities during the 1980s. The extent these authorities use rational planning methods was found to be positively associated with the rated quality of their community mental health system, particularly in states with greater deinstitutionalization and privatization of community mental health services.

Mental Health Care Delivery: Innovations, Impediments and Implementation.

Preface Norman Sarorius Introduction I. M. Marks and R. A. Scott Part I. Innovations: 1. Community care for patients with psychotic disorders 2. Theoretical and research bases of community care programs M.-A. Test 3. Maintenance (management) of people with long term psychotic illness J. Leff 4. Dissemination in New South Wales of the Madison model J. Hoult Primary Care 5. Implications for care delivery of mental illness in primary care W. Katon 6. Innovations in mental health care in the primary care system E. Paykel Emergency services 7. Innovative approaches to delivery of emergency services in Europe H. Katschnig and T. Konieczna 8. Emergency care for the acute and severely mentally ill S. Segal Part II. Impediments: Sociopolitical 9. Sociopolitical influences on mental health care policy in the UK J. Carrier 10. The political and economic context of mental health care in the US K. S. Gill 11. Mental health care in continental Europe: medley or mosaic? N. Sartorius Administrative 12. Administrative barriers to implementation and diffusion of innovative approaches to mental health care in the UK H. Yellowlees 13. Administrative obstacles to innovations in the US at the federal level G. Klerman 14. The demise of a major innovation: Carter's 1980 Community Mental Health Systems Act in Reagan's hands H. Pardes Economic and professional 15. Economic barriers to innovation in mental health care: community care in the UK M. Knapp 16. Economic barriers to implementing innovative mental health care in the US J. Rubin 17. Professional obstacles to implementation and diffusion of innovative approaches to mental health care J. Cooper Note on chapter 17 M.-A. Test 18. Implementation and overview I. M. Marks and R. A. Scott.

Mental health crisis in California.

Over the last 30 years, California dejure (legislated) mental health policy has been based on deinstitutionalization and outpatient care through community mental health systems. But by the end of the 1970s, there was a growing concern over whether deinstitutionalization had successfully occurred, whether community mental health systems had failed and whether mental health systems had ever been adequately funded. In a national study released in 1990, California was named one of four states where mental health delivery has regressed in the past two years. A review of current California mental health policies indicates dejure and defacto policies are not the same. Most mental health dollars are going to state hospitals and community acute inpatient facilities. Budgets for community mental health have been steadily eroded, and the current mental health system is in crisis. Implementation of mental health policy is dependent on intergovernmental financing, and each level of government tries to avoid costs. Definitions of which clients are to be served remain unclear while pressures for more social control mount. Mental health remains segregated from physical health policy-making and continues to operate at a political disadvantage in general fund budget battles.

Rehabilitation services in day treatment programs

This case study illustrates a planning and design model for rehabilitation services in the day treatment programs of a large community mental health system. The process is a data-driven, logico-deductive methodology. Application to other service delivery systems appears feasible. Suggestions are made to assist in the customization of this process in a variety of settings.

Psychotherapy and community support: Community mental health systems in transition

AbstractThe practice of psychotherapy must change in order to remain relevant to public mental health systems of the 1990s.

The Performance of State Community Mental Health Systems: A Path Model

The study develops and tests a path model of the performance of state community mental health systems. It reports a secondary analysis of data from several recently completed studies. The final model, which accounts for over half of the variation in rated performance, replicates earlier findings, which reveal a minimal role for spending, and identifies centralization in state human service agencies as having major importance in determining performance.

How treatment resistance influences community mental health system operations

How treatment resistance influences community mental health system operations

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.

Incompetency and insanity: feasibility of community evaluation and treatment.

In order to examine the feasibility of doing more sanity and competency evaluations and treatment on an outpatient basis rather than at a state hospital, we gave a feasibility questionnaire to 288 CMHC and state hospital administrators and treatment staff members. The respondents indicated that, given enhanced community evaluation and treatment programs for forensic clients, (a) 41 percent of the sanity evaluations and 45 percent of the competency evaluations done at the hospital could be done in local communities, (b) 35 percent to 38 percent of the clients found incompetent could be treated in local communities, and (c) 39 percent to 50 percent of the clients found insane could be released to outpatient treatment six months earlier than presently. Other findings indicated several specific improvements needed in the community mental health system before it can properly handle more forensic clients.

Community mental health systems generate new chronics: The study of a pure case

This study indicates that while a well-integrated comprehensive community mental health system (CMHS) can dramatically reduce the utilization of long-stay inpatient beds compared to more traditional care systems, it does not banish the appearance of “new chronic” patients from a catchment area. South Beach Psychiatric Center, the CMHS which is the focus of this study, is a state-operated program with a New York City location that provides all long-stay hospital beds and the major proportion of acute inpatient and community care for the 1.36 million people in its service delivery region. Compared to the patient population of traditional care systems, CMHS new chronic patients are younger, composed of more males, have a higher percentage of schizophrenia diagnoses, and show fewer signs of institutionalization. In addition, CMHS patients frequently exhibit dangerous behaviors. Major elements of CMHS operations contributing to these findings, particularly the small number of available long-stay beds, are reviewed. Recommendations are made for community-oriented system design.

Detecting "cracks" in mental health service systems: application of network analytic techniques.

This paper argued that problems of coordination and integration of community mental health systems are best approached from a network perspective in which all linkages between agencies are considered simultaneously. Structural coordination and integration can be assessed through the analysis of these linkages. The utility of this approach was demonstrated by deriving a typology of system "cracks" from network analytic constructs. A network analysis of a community mental health service network was then generated to illustrate how these cracks can be empirically identified. It is suggested that mental health planners will find both the network analytic approach and the typology of cracks useful for addressing problems of coordination and integration.

Psychiatric manpower and services in a community mental health system.

Executive directors of Oregon's 36 community mental health programs were surveyed in the fall of 1983 to determine the nature of psychiatric services offered and the roles played by psychiatrists. The study showed that a total of 18.2 full-time-equivalent psychiatrists were working in the community system, a mean of .5 per program, considerably below the national average. None of the responding directors were psychiatrists, and only six employed psychiatrists as medical directors. The directors valued psychiatrists most highly for their skills in educating, supervising, and consulting with staff; for their unique clinical skills; and for medication management. They considered the biggest disadvantage of employing psychiatrists to be the expense. The authors discuss factors that contribute to psychiatrists' satisfaction with work in community mental health programs and strategies for recruiting and retaining psychiatrists in the programs.

Use of manpower data in an integrated database for program efficiency analysis: an example from a statewide community mental health system.

This article describes a method for systematically utilizing manpower data to analyze program efficiency of community mental health services. Examples of how analyses of performance data can be substantially enhanced by integrating manpower staffing data with other key financial, client, and service volume variables are provided.

Bucking the Community Mental Health System

Bucking the Community Mental Health System

Manpower information and the community mental health system.

The lack of knowledge about basic manpower issues in the community mental health system led the authors to devise five questions that address manpower issues of general interest to community mental health system managers. The questions concern the ratio of staff to population, the types of professionals on staff and their demographic characteristics, the amount of time staff spend on various activities, the cost of the work force, and the outcomes of services. The authors discuss how these questions have been considered in the literature, and they illustrate with analyses of data from a survey of staff of New Jersey's mental health agencies how the issues of number, type, and cost of staff can be explored. The authors believe that basic manpower information can contribute directly to the decisions of managers of mental health service systems.

Medical services in community mental health programs.

Considerable attention has focused on the recent decline in the numben of psychiatrists working in community mental health centers (1) and the fact that the role of psychiatrists in many CMHCs has changed from one of leadership to one of little authority (2). It has been reported that psychiatrists are very dissatisfied with their roles in CMHCs, partly because of their inability to provide adequate medical care for their patients (3). In addition, the impact of deinstitutionalization on the severely and chronically mentally ill has generated increasing concern about how to meet the major medical and psychiatric needs of patients in the community (4). Despite this concern, there are only a few reports of how individual CMHCs have attempted to meet the medical needs of their patients or have related to primary health care delivery systems (5-7). To the best of our knowledge, the nature of medical services within an entire community mental health system has not been described.

A comprehensive treatment program for schizophrenia and chronic mental illness.

The failure of deinstitutionalization and the community mental health movement to improve the treatment of chronic psychiatric patients, particularly schizophrenics, is described. Problems with the current treatment paradigm include unrealistic expectations concerning the rehabilitative effects of antipsychotic medications, inadequate funding of the community mental health system, and the predominance of the "infectious disease model," rather than the more appropriate "chronic disease model" of mental illness. A model for the comprehensive treatment of chronic mental illness is proposed that includes: treatment, rehabilitation, social services, and continuity of care. The need for an integrated community approach to rehabilitating chronic psychiatric patients is stressed, and some of the specific ingredients essential to such a program are identified.

Design and Implementation of Decision Support Systems in the Public Sector

This article examines the implications of utilizing decision support systems (DSS) in the public sector based on a DSS developed and implemented for a community mental health system. The DSS includes a multiple objective (goal programming) allocation model and encompasses a multiple party decision process. The experiences and insights acquired during the development and implementation of this DSS are relevant to public sector decision support in general. The importance of a DSS as a process-support aid rather than a product-oriented aid (i.e., simply providing answers) and the interaction of system architecture and the chosen design strategy are key insights. In particular, the distinction between model-oriented and data-oriented DSS does not appear to be appropriate. The public sector decision maker's concern with issues of equity requires the ability to operate in a higher dimensional framework than the typical spreadsheet model and there is a critical need for communication support.

Leaderstyle and community involvement.

Mental health executives are faced with implementing policy mandates that require the participation of a variety of constituency representatives in a community mental health system. This study examines the extent of community involvement in community mental health centers and utilization of a transactional leadership orientation as the foundation for compliance with community involvement demands.

Measuring case management activity.

A method is presented for measuring the activities of case management in the care of the severely mentally disabled in catchmented public community mental health systems. Two variants of the method were compared, interviewing case managers and record abstracting. The methods were tested in two community mental health center (CMHC) sites, and appear to yield comparable results. The record abstract method seems workable for retrospective examination of case management in a CMHC system, and for the comparison of case management in different systems.