Behavioral Health Service Delivery Research Articles

Using Decision Support to Address Racial Disparities in Mental Health Service Utilization

SUMMARY Unfortunately, racial disparities are well documented in the delivery of behavioral health services. This study examines the effects of implementing a decision support process, integrating clinical information into the administration of mental health services, on racial disparities in psychiatric hospital admissions for children in state custody. Differences in a hospitalization prediction model and the proportion of low-risk admissions in Caucasian, African American, and Hispanic youth from 1998 to 2002 were assessed in a statewide sample of 7,653 screenings. Differences in low-risk admissions were assessed after the 1999 initiation of the decision support process. Following the initiation of feedback to clinicians and the use of the Childhood Severity of Psychiatric Illness (CSPI), a decision support tool, the hospitalization prediction model improved significantly. The proportions of low-risk Caucasian and Hispanic youth hospitalized decreased from 1998 to 1999; the proportions of low-risk African American youth hospitalized during this period significantly decreased. In addition to traditional methods of addressing racial disparities in behavioral health care, such as increasing cultural competence in service delivery, providing feedback to service providers to improve the consistency of decision-making may have significant secondary impacts on other system problems— in this case, racial disparity.

Managed Behavioral Health Care Carve-Outs: Past Performance and Future Prospects

As the managed behavioral health care market has matured, behavioral health carve-outs have solved many problems facing the delivery of behavioral health services; at the same time, they have exacerbated existing difficulties or created new problems. Carve-outs developed to address rising inpatient behavioral health costs and limited insurance coverage. They are based on the economic principles of economies of specialization, economies of scale, price negotiation, and selection. Literature shows that carve-outs have been successful in lowering costs and maintaining or improving access, but results on their impact on quality of care are mixed. In recent years, carve-outs have evolved to take on new roles within the health system, such as coordinating mental and physical health, addressing fragmented public financing systems, and using market power to implement quality improvement. Although not perfect, carve-outs have been instrumental in addressing long-standing challenges in utilization, access, and cost of behavioral health care.

Adolescent and Therapist Perception of Barriers to Outpatient Substance Abuse Treatment

Attrition is one of the most vexing problems for the effective delivery of behavioral health services. Most prior studies focus on patient demographics and psychopathology factors predicting dropout. We examined patient and therapist post-treatment reports of barriers to attending treatment. Six hundred adolescents and their therapists completed the Perceived Barriers to Treatment scale (PBT) at discharge from a brief substance abuse intervention. After adjusting for covariates, results suggest that perceived barriers, in particular, practical obstacles, lack of treatment readiness, relevance, and compatibility, are related to sessions attended. Shifting to a more patient-centered approach for understanding treatment retention is discussed.

The impact of withdrawals by Medicaid managed care plans on behavioral health services.

The impact of withdrawals by Medicaid managed care plans on behavioral health services.

In the echoes of gunfire: Practicing psychologists' responses to school violence.

The recent rash of school shootings has thrust practicing psychologists into the role of assisting communities prevent such high profile incidents of juvenile violence. Although many psychologists are involved in assessing and treating children at risk for violent behavior, their efforts are rarely linked with other organized prevention efforts. This article describes how practicing psychologists represent a critical resource to school districts in developing and implementing a comprehensive violence prevention strategy. The authors outline a model school and mental health clinic collaborative program that can be replicated in various practice settings and discuss the benefits and essential steps for building such a collaboration. Psychologists have increasingly found themselves engaged in a series of similar conversations over the past year regarding the issue of youth violence. While reflecting on the catastrophes in Littleton, Colorado; Paducah, Kentucky; Jonesboro, Arkansas; and Conyers, Georgia, parents, teachers, friends, and family repeatedly ask the same questions: Why did they do that? Where are their parents? and Could this happen at my child's school? Clearly, these tragedies have focused the nation's attention on the issue of juvenile violence as never before. Many practicing psychologists are being asked to contribute to the community's understanding of the mental health issues related to these high profile incidents. Furthermore, as community leaders, politicians, school officials, clergy, parents, and other stakeholders struggle with this issue, they are increasingly asking whether psychologists can offer more to help prevent juvenile violence (both in and out of school) in the community. Given the dramatic nature of these incidents, it would seem easy for the public to become seduced into believing that school shootings represent the greatest danger to children. Actually, school homicide represents a low frequency but high impact expression of GARRET D. EVANS received his PsyD in clinical psychology from Indiana State University in 1995. He is an assistant professor in the Departments of Family, Youth, and Community Sciences and Clinical and Health Psychology at the University of Florida. His research interests include violence prevention, school-linked mental health services, and rural behavioral health service delivery. JANNETTE REY received her PhD in clinical psychology from Oklahoma State University. She was a postdoctoral resident in the Departments of Family, Youth, and Community Sciences and Clinical Health Psychology at the University of Florida at the time this article was written. She is now an educational consultant with the May Institute, and her research interests include violence prevention, assessment and intervention of early childhood behavior problems, and school consultation.

Criminal behavior and emotional disorder: comparing youth served by the mental health and juvenile justice systems.

This study explored whether youth involved in joint service systems differed from single-agency users in terms of types of crimes committed and clinical functioning. Data from 4,924 youth involved in one county's public mental health and juvenile justice service systems were examined. Twenty percent of those youth receiving mental health services had recent arrest records, and 30% of youth arrested received mental health services. Of all youth arrested in the county, mental health service users had more arrests than non-mental health service users. A subsample of 94 mental health service users with arrests was matched on demographics with 94 mental health service users without arrests. Youth with arrests had a higher frequency of conduct disorder, higher Child Behavior Checklist Externalizing and Total Problem Scale scores, and more functional impairment on the Child and Adolescent Functional Assessment Scale as compared to youth without arrests. Implications for behavioral health service delivery were discussed.

Community-level changes in behavioral health care following capitated contracting

As capitated managed care contracts are becoming more prevalent in the delivery of behavioral health services, it is important to review community experiences with these contracts. A survey of all community agencies in one area that provided or interacted with behavioral health services for children and adolescents was administered during the implementation of a clinically-managed demonstration and again four years later after the transition to a capitated managed care contract. The following changes were reported under the capitated contract: 1. a) problems in service delivery experienced by the target population increased; 2. b) quality of behavioral health and related services available decreased; 3. (c) service system performance decreased, 4. (d) the extent to which goals of an effective behavioral health service system were being attained was also rated as significantly decreased; and 5. (e) coordination of services for the target population and collaboration among providers declined.

The Impact of Managed Care on Mental Health Services for Children and Their Families

For more than a decade, the philosophy of community-based systems of care has guided the delivery of mental health services for children and adolescents served by publicly funded agencies. This philosophy supports system attributes that include a broad array of services; interagency collaboration; treatment in the least-restrictive setting; individualized services; family involvement; and services responsive to the needs of diverse ethnic and racial populations. The notion of systems of care emerged in an era when managed health care also was gaining popularity. However, the effect of managed care on the delivery of mental health and substance-abuse services--also known as behavioral health services--has not been widely studied. Preliminary results from the nationwide Health Care Reform Tracking Project (HCRTP) inform discussions about the impact of managed behavioral health care on services for children and adolescents enrolled in state Medicaid programs. Most states have used some type of "carve-out design" to finance the delivery of behavioral health services, and there is a trend toward contracting with private-sector, for-profit companies to administer these benefits. In general, managed care has resulted in greater access to basic behavioral health and community-based services for children and adolescents, though access to inpatient hospital care has been reduced. Under managed care, it also has been more difficult for youths with serious emotional disorders, as well as the uninsured, to obtain needed services. With managed care has come a trend toward briefer, more problem-oriented treatment approaches for behavioral health disorders. A number of problems related to the implementation of managed behavioral health care for children and adolescents were illuminated by the HCRTP. First, there is concern that ongoing efforts to develop systems of care for youths with serious emotional disorders are not being linked with managed care initiatives. The lack of investment in service-capacity development, the lack of coordination with other agencies serving children with behavioral health problems, and cumbersome preauthorization requirements that may restrict access to appropriate service delivery were other concerns raised by respondents about managed care. As the adoption of managed behavioral health care arrangements for Medicaid beneficiaries expands rapidly, the HCRTP will continue to analyze how this trend has affected children and adolescents with behavioral health problems and their families.

A new approach to managed care: the provider-run organization.

Behavioral managed care has been dominated by for-profit carve-out managed care organizations who deliver mental health and substance abuse services by reducing services and fees to the detriment of patients and providers. We offer a new model of managed care based on a provider-run, hospital-based approach in which provider groups contract directly with HMOs and eliminate the managed care organization intermediaries. This approach allows providers to maintain or regain control of the delivery of behavioral health services. A model is presented of an academically based organization which has achieved utilization patterns compatible with the demands of payors. Innovations in service delivery, network management and fiscal issues are reviewed.

Dilemmas in professional collaboration with consumers.

The unprecedented shifts in the delivery of behavioral health services have bad an impact on the practice of occupational therapy, as on all health professions. Occupational therapy practitioners with foresight about the exodus from hospital-based practice have been working in the cornmunity fbr many years. However, as the 2 1 st century approaches, all health care providers are required to make yet another paradigm shift directly related to the emerging societal emphasis on personal power, autonomy, seif-direction, and seW-responsibility (1). This ftx:us on autonomy, and the resulting changes in roles and boundaries, is especially seen in psychiatry. The patient is viewed as a competent mdividual and as his or her own agent of change; practitioners are asked to see the patient less as a patient or client and more as a colleague. This column will explore the challenges of the shift as occupational therapy practitioners have confronted them. The hope is that it will stimulate all health care providers to reflect on the need ftr thoughtful, well-reasoned responses to circumstances that may threaten traditional understandings of practice roles and relationships as well as on the meaning of autonomous function, stigma , and empathy.