The mental health provider's view.

What do we want from primary care physicians to make their care of our patients better and our jobs less difficult? We want reasonable access to primary care services, effective communication, reduction in excessive practice interference, and flexible collaboration.

The integrated system's view.

Truly integrated systems in public sector settings have been few, and most of us are operating in uncharted waters. However, we can embark on this new effort with some eagerness and confidence that collaboration will contribute significantly to the care of our mutual patients.

Is there a role for physician assistants in community mental health?

The authors briefly describe the history and development of the medical discipline of physician assistants (PAs). A careful review of the literature reveals the limited use of PAs in psychiatry, usually only for primary health care needs. A model for using PAs as psychiatric assistants is presented, including the training required and a description of the clinical and administrative functions. The advantages of such a model are multiple. These include: 1) more effective and efficient use of the psychiatrist; 2) reduced costs of service; 3) increased primary medical screening capability in the CMHC; and 4) increased presence of ethnic minorities on the professional staff of the CMHC. Disadvantages of the model relate to training and "turf" issues. In view of the shortage and dissatisfaction of psychiatrists in CMHC settings, and other challenges to the provision of quality mental health care in the community, this model should be considered as a logical and positive response to that challenge. If the model is valid, then training facilities must make a systematic effort to recruit, train, and place psychiatric physician assistants in community agencies.

Population-based guidelines for performance measurement: a preliminary report.

This paper describes the development of--and early efforts to validate--guidelines that indicate average amounts of service expected to be used by a population of patients with a given disorder who are served by a comprehensive mental health system. These guidelines address expected service use by individuals in 55 diagnostic groups. The purpose of these guidelines is to provide a gauge for evaluating the amounts of service being delivered by managed care organizations. Three population-based guidelines (for attention-deficit/hyperactivity disorder, major depressive disorder, and schizophrenia) are compared to actual amounts of service delivered to enrollees in large behavioral health care systems.

Prioritization of mental health services in Oregon.

The Oregon Health Plan is an approach to health care reform that increases access to mental health and chemical dependency services. A key feature is the integration of mental and physical health care. The mental health community had to educate policy makers about the importance of mental health and chemical dependency services. They constructed a prioritized list of mental health and chemical dependency services and interdigitated the list with the set of physical health services. The result is a unique attempt to develop a seamless health care system that minimizes discrimination against persons affected by mental illness. The opportunity to achieve parity for mental health must not be delayed or compromised; to do so would worsen the lives of persons already affected by the trauma and stigma associated with mental illness.

Ethics and value strategies used in prioritizing mental health services in Oregon.

The authors describe the ethical considerations underlying the inclusion of mental health services into a prioritized health care system. The Oregon Health Plan is a process for defining and delivering basic health services to an entire state. As the plan was developed, the mental health community needed to decide whether or not to participate in the process and, if so, how. Lengthy discussions among mental health consumers, family members, and providers led to a strategy that emphasized the integration of mental health and chemical dependency services into a comprehensive and universal health care program. This approach appears to have achieved relative parity for mental health.

Psychiatry in community mental health centers: everyone can win.

The purpose of this paper is to describe the psychiatrist's role in community mental health programs, beginning with the evolution of psychiatric involvement in community mental health centers (CMHCs). There is a discussion of the current state of psychiatry in community mental health programs with descriptions of the types of roles psychiatrists occupy and their thoughts about those roles. The concluding sections focus on the ways psychiatrists can be utilized in community mental health programs so that both the psychiatrist and the agency benefit and are satisfied.

Education and training in public psychiatry.

The Public Psychiatry Training Program offers an education in the unique knowledge, attitudes, and skills essential for working with persons with severe and chronic illness in both hospital and community settings.