The Role of Conflict Identification and Management in Sustaining Community Collaboration: Report on a Four-Year Exploratory Study.

Community collaboration has become increasingly common in behavioral health services. Conflict is likely to occur in any community coalition bringing together organizations with differing mandates, missions, and histories. However, research on how coalitions identify and handle conflict, and on the impact of conflict on sustainability is scarce. An exploratory study examined conflict in two federally funded children's "systems of care" using site visits and concept mapping to describe differences in how sites conceptualize and respond to conflict. Results suggest that unacknowledged and unaddressed conflict can negatively affect the development and sustainability of sites, and that focusing on cooperation may, paradoxically, make it more difficult to acknowledge conflict and to implement conflict transformation processes. Implications for behavioral health administrators are discussed, including potential interventions that could address these issues.

An Exploratory Study of Conflict and Its Management in Systems of Care for Children with Mental, Emotional, or Behavioral Problems and Their Families.

Since 1993, the Substance Abuse and Mental Health Services Administration has invested more than $1 billion establishing systems of care (SOC) in over 173 local communities to provide services to children with mental, emotional, and behavioral problems and their families. The SOC model requires that effective partnerships be developed between parents and professionals and also among different service sectors and agencies. To date, there has been no systematic examination of these interagency partnerships associated with the presence of conflict and its management. This paper reports the findings from a survey of the members of the governing boards of currently funded and graduated SOC sites related to interorganizational conflict. The results indicated that conflict was common in SOC regardless of the stage of the system's development. The most common types of conflict included incompatible goals, interpersonal relationships, and overlapping authority. When conflict occurred, a number of management efforts were used including analyzing the conflict and developing a strategy to deal with it and dealing with the conflict behind the scenes. Suggestions are provided for identifying and managing conflict.

Should herbs take all the blame? Causality assessment of a serious thrombocytopenia event.

BACKGROUND: With the increasing use of herbal medicines, the causality assessment of adverse drug-related reactions becomes more complicated because of the concomitant use of herbs and conventional medications. Epidemiological causal inference can be a central feature of such judgment but may be insufficient. Other scientific considerations include study design, bias, confounding, and measurement issues. The approach of this study is to establish an active safety surveillance system for finished herbal products (FHPs) and to review each adverse event regularly. METHOD: A single case of serious thrombocytopenia was found in 136 subjects taking FHPs on a clinical trial for 12 weeks, for which the cause was sought. RESULTS: Because at the end of the first month the patient's platelet counts were normal and the thrombocytopenia developed after the co-medication with conventional drugs, it was suspected that the thrombocytopenia might not be attributed to the use of FHP. CONCLUSIONS: This report summarizes the criteria of causality assessment under mixed use of herbs and conventional medicine and recommends a feasible process for careful evaluation of adverse drug reactions related to all herbal medicine.

Is Duhuo Jisheng Tang containing Xixin safe? A four-week safety study.

BACKGROUND: Though the nephrotoxicity and carcinogenicity of aristolochic acid (AA) are known, its safety in clinical usage is not clear. This study aims to evaluate the safety of Duhuo Jisheng Tang (DJT) in a four-week study to treat osteoarthritis (OA) of the knee. METHODS: A qualitative and quantitative investigations on DJT were conducted. A list of adverse events (AEs), complete blood counts, and liver and kidney function tests were measured for participants with knee OA at their scheduled hospital visits. Each detected AEs was independently assessed for severity and causality by site investigators (Chinese medical doctors) and study nurses. RESULTS: A total of 71 eligible subjects were included in the clinical study where 287 AEs were reported. DJT did not contain detectable aristolochic acid (AA) under thin-layer chromatography (TLC) analysis and gas chromatography coupled with mass spectrometry (GC-MS). There were no significant changes in liver or kidney functions. CONCLUSION: In four-week use of DJT, no renal tubular damage, no severe incidences of AEs and adverse drug reactions (ADRs) were observed. The present study obtained safety data from active surveillance of DJT.

The psychometric properties of the Colorado Symptom Index.

The Colorado Symptom Index (CSI: Shern et al. 1994, Milbank Quart 72:123-148) is widely used in research as a self-report measure of psychiatric symptomatology, yet little information exists regarding the scale's psychometric properties. Additionally, the CSI has no cut-off score denoting the need for further psychiatric assessment. This study examined the CSI's psychometric properties and established a cut-off score. Analyses were based on 3,874 adult Florida Medicaid respondents. The CSI had excellent internal consistency (.92) and test-retest reliability (.71). Evidence of the CSI's validity was strong; CSI scores distinguished among individuals with and without mental health services needs and were significantly correlated with functioning. Results using a contrasting groups approach indicate that 30 is a reasonable "clinical" cut-off score. At this score, the CSI had respectable sensitivity (.76) and specificity (.68) and a ROC curve analysis suggests that the CSI is "fair to good" discriminator of individuals with psychiatric disabilities.

Medicaid managed care and the distribution of societal costs for persons with severe mental illness.

OBJECTIVE: Managed care financing strategies that involve financial risk to insurers can reduce budgeted health expenditures. However, resource substitution may occur and negate apparent savings in budgeted expenditures. These substitutions may be important for individuals with disabling illnesses. The distribution of societal costs for adults with mental illnesses enrolled in plans that differ in their financial risk is examined to evaluate the degree to which risk-based financing strategies result in net savings or in the differential distribution of costs across public or private payers. METHOD: Six hundred twenty-eight adults with severe mental illnesses enrolled in three Medicaid plans that differ in financial risk arrangements were followed for 1 year to determine the distribution of resource use across Medicaid and other payers. Self-reported service use was obtained through interviews. Cost data were derived from self-reported expenditure, administrative, or agency data. Statistical procedures were used to control for preexisting group differences. RESULTS: Managed care was associated with a tendency toward reduced overall costs to Medicaid. However, private expenditures for managed care enrollees offset decreased Medicaid expenditures, resulting in no net difference in societal costs associated with managed care. CONCLUSIONS: Understanding the distribution of societal costs is essential in evaluating health care financing strategies. For adults with mental illnesses, efforts to manage Medicaid expenditures may result in substituting individual and family resources for Medicaid services. Government must focus on the distribution of societal costs since risk-based financing strategies may redistribute costs across the fragmented human services sector and result in unintended system inefficiencies.

Predictors of enrollees' satisfaction with a county-sponsored indigent health care plan.

This article summarizes the findings from a study examining the predictors of satisfaction among individuals enrolled in a county-sponsored indigent health care plan. Mail survey procedures were used to obtain information from enrollees regarding their satisfaction with the health care plan, as well as enrollees' demographics, health care status, and trust in their providers. Results of a stepwise regression model developed using a random half of the respondents revealed enrollees' trust in health care providers was the strongest predictor of general satisfaction, followed by perception of change in health status, and age. The model explained 49% of the variance and demonstrated little shrinkage when cross-validated on the remaining half of the respondents. Trust in health care providers, followed by perception of change in health status also emerged as the strongest predictors of enrollees' satisfaction with freedom of choice.

Development of active safety surveillance system for traditional Chinese medicine: an empirical study in treating climacteric women.

PURPOSE: Traditional Chinese medicines (TCM) prescribed by doctors are regularly reimbursed by the National Health Insurance (NHI) in Taiwan. The safety of TCM should undergo the same scrutiny that most western medicines do. This study was to monitor adverse events (AEs) associated with a new mixture of TCM, TMN-1, used to treat climacteric symptoms. METHODS: For this multi-center, prospective observational study, we recruited 134 women with climacteric symptoms. During this 12-week study, the subjects made nine visits, took TMN-1 three times a day, and received routine hematologic tests, biochemical tests, and tests for gynecologically relevant hormones at baseline and after 4 and 12 weeks of beginning medication. At every visit, the subjects were asked by questionnaire about any AEs. All AEs were examined through a process of causality assessment (CA) by a research team. RESULTS: In total, we recorded 203 AEs, in order of decreasing incidences--cough, pharyngitis, rhinitis, abdominal pain, abdominal fullness, diarrhea, and pruritus with incidence rates of 2.57, 2.47, 1.88, 1.78, 1.68, 1.58, and 1.58 per 10(3) person-days, respectively. Most AEs were tolerable. Five of the AEs were judged to be "probable" adverse drug reactions (ADRs): Two events of diarrhea and one event each of nausea, abdominal pain, and abdominal fullness. CONCLUSION: This study demonstrates the effectiveness using active safety surveillance to document safety of TCMs. This surveillance system could probably be useful to document the safety of other alternative or complementary medicines.

Examination of the effects of financial risk on the formal treatment costs for a Medicaid population with psychiatric disabilities.

OBJECTIVES: We examined the effects of differing financial risk arrangements for mental health, physical health, and pharmacy services on the overall costs of these services with particular attention to cost containment and cost shifting. METHODS: Comprehensive service utilization information was obtained from a sample of 458 adults with severe mental illnesses during a 12-month period. Rate information was used to calculate costs for health, mental health and pharmacy. A 2-part model was employed to test for differences among financial risk conditions. RESULTS: Total treatment costs, both those financed by Medicaid and those paid by other sources, were lower in plans that had a broader array of services for which they were at risk. Pharmacy costs were principally responsible for these differences. CONCLUSIONS: Treatment costs for adults with severe mental illnesses can be contained by placing providers at financial risk. However, risk arrangements may also increase treatment costs borne by other payers including charity services and self-pay. Evaluating the impact of at-risk financing mechanisms from a public health perspective requires assessing cost shifting, particularly for pharmaceuticals.

Mental illness and principal physical diagnoses among Asian American and Pacific Islander users of emergency services.

The stigma of mental illness is one of the factors that prevents Asian Americans/Pacific Islanders (APIs) from seeking formal mental health services. A somatic complaint is more acceptable in expressing psychiatric/emotional distress. Admission diagnoses in API emergency service users with secondary psychiatric diagnoses were identified from the 2001 National Inpatient Sample (NIS) of the Healthcare Cost and Utilization Project (HCUP). The sample consisted of 10,623 adult APIs. The study examined the differences in the six leading principal physical admission diagnoses between API emergency service users with psychiatric diagnoses and those without psychiatric diagnoses. Several of the study findings create concern (e.g., the higher percentage of APIs with psychiatric diagnosis who were discharged against medical advice, the high percentage admitted with medication intoxication). Further study is needed to provide guidance for clinical practice.