Work and social support: a comparison of consumers who have achieved stability in ACT and clubhouse programs.

A current debate in the field is whether consumers, who have achieved stability in Assertive Community Treatment programs, can be transferred to less intensive services. To bring some data to bear on this question, this study compared consumers and members, who have achieved stability, in either an Assertive Community Treatment (ACT) or a clubhouse program, on domains of vocational activity, social relationships/loneliness and community integration. The 51 stable clients from the two programs who were interviewed, reported similar vocational activity, similar experiences with social relationships and social networks, and similar community integration. Clients in both groups were less lonely than previously reported in the literature. Study results indicate, that for those clients who have achieved stability, there are sufficient similarities between consumers in the two programs, to suggest a potential for movement from more to less intensive programs with less disruption than previously assumed possible.

Mental health expenditures for services for people with severe mental illnesses.

OBJECTIVE: To provide comprehensive information on expenditures for mental health and substance abuse services for a large number of people with severe mental illnesses, this study examined use of major types of clinical-medical mental health and psychiatric rehabilitation services over a one-year period. METHODS: Data were obtained for 1,890 clients in ten public county-based nonmetropolitan mental health systems in Wisconsin. Expenditures were for services provided with public funding, including local sources of funding, Medicaid, and Medicare. Data about services and expenditures were obtained from county records and unduplicated Medicaid claims for 12 months in 1989 and 1990. RESULTS: Expenditures per client averaged $10,995 for one year ($13,992 in 1994 dollars), with a maximum of $95,093. Expenditures for community-based outpatient services, including residential care and vocational services, represented 53.5 percent of all expenditures; residential care accounted for 12.4 percent and vocational services for 5.7 percent. Overall, 46.5 percent was spent for institutional care, with inpatient hospital care accounting for 12.6 percent. Approximately 40.6 percent of total expenditures were for services not typically covered under managed care plans. CONCLUSIONS: Expenditures for community-based care accounted for more than half of total expenditures. Expenditure patterns revealed the important role of social and rehabilitation services, a role that must be continued in managed care arrangements if they are to provide adequate services for people with severe mental illnesses.

Services for clients of community support programs in rural Wisconsin.

To improve understanding of services provided or coordinated by rural community support programs (CSPs) for people with severe mental illness, this article identifies services most used by clients and the amounts of services used. Data on publicly funded services for more than 900 clients in 13 rural CSPs in a midwestern state have been analyzed. Virtually all clients were Caucasian. Information about types and amounts of client services for 12 consecutive months was obtained from county information systems, local records, and Medicaid claims. Most CSP clients use case management, community support, medication checks, counseling, and medication counseling services. Much smaller percentages use other outpatient, residential, vocational, and inpatient services. Significant amounts of only two services, case management and community support, are reported. The findings emphasize the ability of rural mental health providers to supply general services, but some limitation in provision of specialized services and facilities.

Use of Medicaid for mental health care by clients of community support programs.

The use of Medicaid for mental health services by the severely mentally ill is examined using paid Medicaid claims for clients of Community Support Programs in Wisconsin. The extent to which clients participate in Medicaid, the types and amounts of mental health services, and the costs of services are discussed. A narrow majority of CSP clients use Medicaid, which provides a substantial amount of case management service for program participants. Psychotropic medications are also used by a large percentage of clients. Other relatively common services covered by Medicaid are medication checks and psychotherapy. Average annual Medicaid payments for mental health services (including medications) are $2438.

Staffing patterns in rural community support programs.

OBJECTIVE AND METHODS: Rural mental health programs are thought to have difficulty recruiting and retaining qualified staff and to have excessively large caseloads per staff member. The authors surveyed 12 community support programs in small cities and rural areas of Wisconsin to determine staff size and characteristics, staff-to-client ratios, and the relative use of paraprofessional staff and professional staff, excluding psychiatrists. RESULTS: The programs surveyed had an average of 5.6 full-time-equivalent caregiving staff and an average caregiver-to-client ratio of 1 to 13. Caregiving staff were predominantly female, had been in the mental health field a mean of 8.8 years, and received an average salary of $20,732. Although program directors indicated that about one-fifth of staff left in the previous year, they reported little difficulty recruiting staff. Thirty-eight percent of all caregivers were paraprofessionals; in several programs, more than half the caregivers were paraprofessionals. Use of paraprofessionals is more common in rural programs; thus caregivers in those programs are likely to have lower levels of salary and experience. CONCLUSIONS: The community support programs in the sample employed experienced caregivers and had staff-to-client ratios that were close to the ratio recommended for such programs by Wisconsin legislation. The survey findings suggest that claims of acute staffing problems in rural community support programs need to be examined more closely, with attention to the relationship between staff characteristics and client outcomes.

Falling through the cracks: care of the chronically mentally ill in the United States, Germany, and the United Kingdom.

In comparing the development and strength of community-based services for the chronically mentally ill in the United States, Germany, and the United Kingdom, I analyze how the structure of each country's general medical system has influenced services for the chronically mentally ill and the extent to which more universal medical care systems are associated with stronger community-based systems for the mentally ill. Community-based services are frail and inadequate in all three countries, in each country for different reasons. The specifics of organization of the health care system seem less important in shaping these outcomes than the status of mental health care as a national priority.

Differences between voluntary and public organizations: the behavior of hospitals in England and Wales.

This study confronts the following questions: what are the conditions under which a society decides to do things in the public and voluntary nonprofit sectors, and in what ways do organizations behave differently, depending on whether they are in the public or the voluntary nonprofit sector? To address these questions, the study focuses on English and Welsh hospitals during the twentieth century but prior to the National Health Service. The study argues that as long as the sources of funding for public and voluntary organizations diverge, their behavior will diverge. Because English and Welsh voluntary hospitals prior to the National Health Service were heavily dependent on the voluntary sector for funding and the public hospitals were primarily dependent on the public sector for their funding, the data set is especially valuable for observing how divergent sources of funding influence the behavior of organizations.