Subject(s)
Ambulatory Care/classification , Continuity of Patient Care/organization & administration , Managed Care Programs/trends , Mental Health Services/classification , Models, Organizational , Professional Practice , Ambulatory Care/organization & administration , Ambulatory Care/statistics & numerical data , Diagnosis-Related Groups/statistics & numerical data , Health Care Rationing/statistics & numerical data , Health Care Surveys , Humans , Mental Health Services/organization & administration , Mental Health Services/statistics & numerical data , Professional Practice/classification , Professional Practice/statistics & numerical data , Professional Practice/trends , United StatesABSTRACT
In July 1996, Tennessee initiated a managed mental health and substance abuse program called TennCare Partners. This publicly funded "carve-out" experiment started chaotically and soon deteriorated into a crisis. Many patients did not receive care or lost continuity of care, and the traditional "safety net" mental health system nearly disintegrated. This qualitative case study sought to ascertain the impact of the TennCare Partners program. It points out that the program's difficulties stemmed directly from a flawed design that spread funds previously earmarked for severely mentally ill patients across the entire Medicaid population. States contemplating similar reforms should strive to protect vulnerable patients by risk-adjusting capitation payments and by focusing resources on care for severely mentally ill persons. States should also minimize program complexity and ensure the accountability of managed care networks for their patients' behavioral health care needs.
Subject(s)
Managed Care Programs/organization & administration , Medicaid/organization & administration , Mental Health Services/organization & administration , State Health Plans/organization & administration , Adult , Aged , Capitation Fee , Case Management , Humans , Medical Indigency , Mental Disorders/therapy , Mental Health Services/economics , Middle Aged , Program Evaluation , Risk Management , Substance Abuse Treatment Centers/economics , Substance Abuse Treatment Centers/organization & administration , Substance-Related Disorders/therapy , Tennessee , United StatesABSTRACT
Traditional models of individual adaptation to stress increasingly are being supplemented with family-based conceptualizations of stress appraisal, coping, and resiliency. This article begins with a brief description of a theoretic framework for understanding how families evaluate stressors and their own coping resources and how this process guides their response to stress. Characteristics associated with successful family adaptation to stress then are outlined in relation to a number of both normative and unexpected stressors. Most families at some point experience stress in the context of normative transitions, such as changes in family composition through birth, maturation, or family break-up. Severe unexpected stressors that place significant strain on family functioning include serious illness, death, violence, and both natural and man-made disasters. Recommendations for therapeutic interventions with families are provided.
Subject(s)
Adaptation, Psychological , Family Therapy/methods , Family/psychology , Life Change Events , Stress, Psychological/therapy , Adolescent , Adult , Aged , Attitude to Death , Child , Child Abuse/psychology , Child, Preschool , Female , Grief , Humans , Infant , Infant, Newborn , Male , Middle Aged , Parent-Child Relations , Social AdjustmentABSTRACT
OBJECTIVE: One criticism of academicians is that they evaluate and disseminate outcome studies based more on the value and merit of the research design than on the utility of the findings for improving clinical practice. Increasing pressure on programs to evaluate the effectiveness of behavioral health care is transitioning outcome measurement from the exclusive domain of the researcher toward the clinical/organizational domain. To explore the multiple applications of such clinical outcome data, this article presents the results from a study of 114 patients completing treatment in two child and adolescent partial hospital programs. METHOD: Four areas define the scope of clinical outcome measurement pertinent to partial hospitalization: changes in the patient's clinical status, changes in the patient's level of daily functioning, impact on the utilization of behavioral health services after discharge, and patient/family satisfaction with treatment. Using these four domains, this study compares data assessed at admission and at 1 year postdischarge. RESULTS: Analyses used paired t tests primarily to measure change between admission and 1 year after discharge. Overall, the data show improvement in general functioning that remains evident up to 1 year postdischarge. CONCLUSIONS: Finding positive results in specific areas emphasized therapeutically--such as family functioning and use of community-based mental health resources after discharge, and the parent's attribution of improvement to experiences in treatment--provides justification for relating improvement to the treatment episode.
Subject(s)
Affective Symptoms/therapy , Child Behavior Disorders/therapy , Day Care, Medical , Personality Development , Activities of Daily Living/psychology , Adolescent , Affective Symptoms/psychology , Child , Child Behavior Disorders/psychology , Child, Preschool , Family/psychology , Female , Follow-Up Studies , Humans , Male , Patient Satisfaction , Social Adjustment , Treatment OutcomeABSTRACT
OBJECTIVE: In 1992, the American Association for Partial Hospitalization initiated a national survey of partial hospitalization providers to investigate their present status (programming, staffing, and pricing), to track market trends, and to improve advocacy for appropriate utilization and reimbursement. METHOD: Instrument development and field testing preceded widespread distribution of the survey. From survey data, a description of child and adolescent partial hospital services based on statistical averages is reported as are analyses of program differences by length of stay and for-profit/not-for-profit status. RESULTS: Of the 580 programs responding, 95 indicated that at least 50% of their patient population consisted of children and adolescents. Descriptive statistics on this subsample suggest continued variability in child and adolescent partial hospital programming. Program differences in referral and discharge patterns, population and programming, and utilization and funding patterns based on length of stay and profit status are presented. CONCLUSIONS: The pattern of significant program differences between acute-care and long-term child and adolescent partial hospital programs and for-profit/not-for-profit programs (along with the absence of for-profit programs treating children and adolescents in long-term programs) points to an evolving system of care.
Subject(s)
Child Welfare , Hospitalization/economics , Mental Disorders/rehabilitation , Mental Health Services/economics , Adolescent , Child , Child, Preschool , Data Collection , Health Care Reform , Humans , Length of Stay , Patient Discharge , Referral and Consultation , Reimbursement Mechanisms , United StatesABSTRACT
Partial hospitalization and other services along the continuum of ambulatory mental healthcare are rapidly gaining acceptance as attractive alternatives to inpatient treatment. To assure continued development of high caliber programs, leaders of the partial hospital field have been working to develop quality indicators and outcomes measures specifically tailored to the unique aspects of ambulatory care. The quality domains and indicators outlined below are based upon the principles of effectiveness, efficiency, satisfaction and viability that provide foundations for this treatment modality.
Subject(s)
Day Care, Medical/standards , Mental Health Services/standards , Quality of Health Care/standards , Day Care, Medical/organization & administration , Efficiency, Organizational , Mental Health Services/organization & administration , Patient Satisfaction , Program Evaluation , Treatment Outcome , United StatesABSTRACT
This study describes the reactions of children and adolescents to physical and/or sexual abuse, suggesting two distinct symptom pictures. Findings indicate that a majority (55%) of this clinical population develop symptoms characteristic of post-traumatic stress disorder, whereas abused children and adolescents who do not develop associated post-traumatic stress disorder symptoms exhibit more anxiety, depression, externalizing behaviors, and more problems overall. Significant differences were also found between children and adolescents reacting to single event abuse who display more behavior disorders and victims of ongoing abuse who appear significantly more disturbed, with symptoms ranging from depression to psychosis.
Subject(s)
Child Abuse, Sexual/psychology , Child Abuse/psychology , Personality Development , Stress Disorders, Post-Traumatic/psychology , Adolescent , Child , Child Abuse/diagnosis , Child Abuse, Sexual/diagnosis , Day Care, Medical , Diagnosis, Differential , Female , Humans , Male , Personality Inventory , Risk Factors , Stress Disorders, Post-Traumatic/diagnosisABSTRACT
Twenty treatment protocols in a day treatment program for children and adolescents have been developed by multidisciplinary groups based on a review of 200 patients. The protocols classify patients according to symptom clusters and provide standardized treatment plans for each classification. Each protocol contains a definition of the symptom cluster, a list of presenting problems, a list of other protocols to consider, admission guidelines, treatment options, and discharge criteria. The authors describe the developmental process for the protocols and present a clinical case example to illustrate their use. The application of treatment protocols in research, quality assurance, and teaching is briefly discussed.
Subject(s)
Clinical Protocols , Day Care, Medical/methods , Mental Disorders/classification , Patient Care Planning/standards , Adolescent , Child , Combined Modality Therapy , Day Care, Medical/psychology , Female , Humans , Male , Mental Disorders/psychology , Mental Disorders/therapyABSTRACT
How does a child and/or adolescent partial hospitalization program structure care for patients who are suicidal, assaultive, or combative or using drugs? Special treatment procedures designed for use in child and adolescent partial hospitalization programs must adequately address the issue of safety and involve the family and the community, while maintaining the patient in the least-restrictive environment. This paper deals with management of child and adolescent partial hospitalization patients whose behavior and level of impulsivity have escalated to the point where they require special programs. Special treatment procedures for dealing with patients displaying aggressive, acting-out behaviors, noncompliance with program rules, suicidal or runaway ideation, and drug usage are described.
Subject(s)
Adolescent, Hospitalized/psychology , Child Behavior Disorders/prevention & control , Child, Hospitalized/psychology , Day Care, Medical/standards , Risk Management/methods , Adolescent , Aggression , Child , Family/psychology , Humans , Models, Psychological , Patient Isolation , Restraint, Physical/methods , Runaway Behavior , Safety , Substance-Related Disorders/prevention & control , Systems Analysis , United States , Suicide PreventionABSTRACT
This article describes standards and guidelines for the treatment of children and/or adolescents in partial hospitalization programs. Developed through the Child and Adolescent Special Interest Group of the American Association of Partial Hospitalization, they are intended to aid in the establishment of quality treatment programs.
Subject(s)
Adolescent, Hospitalized/psychology , Child, Hospitalized/psychology , Day Care, Medical/standards , Mental Health Services/standards , Organizational Policy , Patient Admission , Societies , Adolescent , Child , Humans , Length of Stay , Patient Care Team , Patient Discharge , Therapeutic Community , United StatesABSTRACT
Partial-hospitalization services for children and adolescents continue to be an underutilized component of the mental health delivery system. With little treatment-effectiveness research available, there is limited incentive for shifts in reimbursement policies or for traditional referral sources to alter referral patterns. This paper provides an overview of published effectiveness research, a discussion of methodological difficulties, and an example of ongoing research for critique. Clearly, research in child and adolescent partial hospitalization must begin to address the lack of available effectiveness data. Partial-hospitalization advocates must compare both various program models and treatment of specific populations. In addition, studies comparing outcome of partial-hospitalization programs with outcome from other treatment modes are essential. The entire continuum of care must be subjected to rigorous and scientific study. The next decade will no doubt bring a large number of treatment-effectiveness studies, now lacking, for comprehensive analysis of options and outcomes.
Subject(s)
Child Psychiatry/standards , Day Care, Medical/statistics & numerical data , Health Services Research/methods , Hospitals, Psychiatric/statistics & numerical data , Treatment Outcome , Adolescent , Child , Day Care, Medical/standards , Forms and Records Control , Hospitals, Psychiatric/standards , Humans , Mental Disorders , Models, Theoretical , Program Evaluation/methods , Program Evaluation/statistics & numerical data , Referral and Consultation , Research Design , Surveys and Questionnaires , Tennessee , United StatesABSTRACT
This paper presents the demographic and clinical data necessary to define the population of children and adolescents served in a model day treatment program. On the day of admission, patients (N = 204) and parents complete a batter of instruments designed to measure reliably characteristics of the patient's system at three levels: individual, parental, and family. Design of the assessment establishes comparisons among self-report, parent/other report, and clinician report measures at each subsystem level. Results of the CBCL, YSR, PIC, Piers-Harris, MCMI, DAS, and FES indicate moderate levels of disturbance, usually consistent with norms reported on referred or clinical populations. Patients are being treated for a wide variety of childhood disorders within systems demonstrating dysfunction at parental, marital, and familial levels.
Subject(s)
Day Care, Medical/statistics & numerical data , Patient Admission/statistics & numerical data , Adolescent , Child , Child Behavior Disorders/epidemiology , Demography , Evaluation Studies as Topic , Family , Female , Humans , Male , Tennessee/epidemiologySubject(s)
Child Abuse, Sexual/psychology , Stress Disorders, Post-Traumatic/diagnosis , Child , Child Reactive Disorders/diagnosis , Child Reactive Disorders/etiology , Child, Preschool , Day Care, Medical , Female , Humans , Life Change Events , Male , Sex Factors , Stress Disorders, Post-Traumatic/etiologyABSTRACT
Proponents of day treatment for children and adolescents assert that this mode of intervention is a viable alternative to hospitalization based on both treatment and cost effectiveness. Preliminary studies on treatment effectiveness are beginning to appear in the literature. This paper focuses on the relative cost difference of treating children and adolescents in a day-treatment program vs three inpatient-hospital settings. The study finds that the populations in the two settings are similar with regard to demographic and diagnostic characteristics and that day treatment is significantly less costly on a daily basis. A conservative conclusion, based on the findings reported, is that over the course of treatment partial hospitalization is equal or less costly than hospitalization. The authors conclude that further research exploring both treatment efficacy and cost effectiveness is in order to define what role day treatment should serve in the continuum of mental health-care services for children and adults.
Subject(s)
Child Psychiatry/economics , Cost-Benefit Analysis , Day Care, Medical/economics , Hospitalization/economics , Adolescent , Child , Humans , Length of Stay/economics , Mental Disorders/classification , United StatesABSTRACT
A survey of 82 programs operating nationally is used to assess the present status of child and adolescent day-treatment services. Overwhelming variability in the responses leads the authors to suggest criteria for standards and definition. Survey results are presented for programming issues, patients, staff, clinical issues, funding, and research, followed by specific recommendations in each area. The authors conclude that without substantial changes toward standardization, child and adolescent day-treatment programs will continue to struggle in the highly competitive mental health-care market.
Subject(s)
Child Health Services/organization & administration , Day Care, Medical/organization & administration , Mental Health Services/organization & administration , Adolescent , Child , Data Collection , Humans , Patient Care Team , United StatesSubject(s)
Mother-Child Relations , Object Attachment , Anxiety/psychology , Communication , Female , Follow-Up Studies , Humans , Infant , Male , Play and PlaythingsABSTRACT
Since the inception of the University of Tennessee Child and Adolescent Day Treatment Program in 1982, a total of 53 patients has received services. This paper provides a broad overview of the patient population as well as descriptive data accumulated during the first 18 months of operation of the program. Several factors which determined patient eligibility and availability are briefly described. Special attention is given to the following variables: (1) age, (2) sex, (3) referral source to the program, (4) diagnosis, (5) length of stay in the program, and (6) discharge disposition. Interrelationships among these variables are also discussed.
