Serving street-dwelling individuals with psychiatric disabilities: outcomes of a psychiatric rehabilitation clinical trial.

OBJECTIVES: This study tested a psychiatric rehabilitation approach for organizing and delivering services to street-dwelling persons with severe mental illness. METHODS: Street-dwelling persons with severe mental illness were randomly assigned to the experimental program (called Choices) or to standard treatment in New York City. We assessed study participants at baseline and at 6-month intervals over 24 months, using measures of service use, quality of life, health, mental health, and social psychological status. The average deviation from baseline summary statistic was employed to assess change. RESULTS: Compared with persons in standard treatment (n = 77), members of the experimental group (n = 91) were more likely to attend a day program (53% vs 27%), had less difficulty in meeting their basic needs, spent less time on the streets (55% vs 28% reduction), and spent more time in community housing (21% vs 9% increase). They showed greater improvement in life satisfaction and experienced a greater reduction in psychiatric symptoms. CONCLUSIONS: With an appropriate service model, it is possible to engage disaffiliated populations, expand their use of human services, and improve their housing conditions, quality of life, and mental health status.

Florida's Medicaid mental health carve-out: lessons from the first years of implementation.

Florida, like many other states, has embarked on an experiment with managed mental health care for Medicaid enrollees. Under a 1915(b) waiver, the state's Medicaid agency began a mental health carve-out demonstration in March 1996 in the Tampa Bay area. This qualitative case study seeks to ascertain the impact of the carve-out (and, by comparison, HMO arrangements) on the public mental health sector. Findings suggest that the carve-out demonstration has succeeded in creating a fully integrated mental health delivery system with financial and administrative mechanisms that support a shared clinical model. However, other findings raise concerns about the HMO model in terms of stability, access to care, efficiency, and more generally about the shifting of risk and public responsibility "downstream" to private organizations without sufficient governmental oversight. These findings may offer guidance for other states implementing major managed care policy initiative for disabled Medicaid enrollees.

Housing outcomes for homeless adults with mental illness: results from the second-round McKinney program.

In the early 1990s the National Institute of Mental Health sponsored projects in four cities that served a total of 896 homeless mentally ill adults. Each project tested the effectiveness of different housing, support, and rehabilitative services in reducing homelessness. Most homeless individuals resided in community housing after the intervention. The proportion in community housing varied between sites. A 47.5 percent increase in community housing was found for those in active treatment conditions. At final follow-up, 78 percent of participants in community housing were stably housed. The findings indicate that effective strategies are available for serving homeless individuals with severe mental illness.

Service needs, receipt, and outcomes for types of clients with serious and persistent mental illness.

Classifying clients with serious and persistent mental illness (SPMI) into groups with differential demographic and clinical characteristics that relate directly to the need and receipt of services and changes in functioning provides a strong foundation on which to build program- or system-level planning, development, and evaluation efforts. In this study, clinician-generated problem data and cluster-analytic techniques were used to develop a four-group typology for a sample of 293 clients with SPMI. Each of the types--extremely disabled, young adult, personally distressed, and adapted--was profiled demographically and clinically in terms of human service needs, prognosis, and treatment outcomes. Each of the four types evidenced a unique pattern of needs and outcomes that was consistent with its clinical profiles. The typology, associated service needs, and outcomes provide valuable information for use in service planning and program development for clients with SPMI.

Consumers as peer specialists on intensive case management teams: impact on client outcomes.

OBJECTIVE: The study examined whether employing mental health consumers as peer specialists in an intensive case management program can enhance outcomes for clients with serious mental illness. METHODS: A quasiexperimental, longitudinal, nonequivalent control group design was used to compare outcomes of clients assigned to three case management conditions: teams of case managers plus peer specialists, teams of case managers plus nonconsumer assistants, and case managers only. Outcomes were measured at baseline and at three six-month intervals. Repeated-measures analysis of variance was used to assess between-group differences. RESULTS: Complete data were available for 104 clients. Compared with clients in the other two groups, clients served by teams with peer specialists demonstrated greater gains in several areas of quality of life and overall reduction in the number of major life problems experienced. They also reported more frequent contact with their case managers and the largest gains of all three groups in the areas of self-image and outlook and social support. No differences in outcomes were found between clients served by teams with nonconsumer assistants and those served by case managers only. CONCLUSIONS: Integration of peer specialists into intensive case management programs appears to lead to enhanced quality of life for clients and more effective case management.

Partial capitation versus fee-for-service in mental health care.

Reimbursement strategies represent a key tool in implementing public policy. Often the relationship between changes in reimbursement policy and changes in provider behavior is difficult to predict, particularly in complex service systems. Here we present findings from a multiyear study involving the comparison of alternative Medicaid reimbursement systems for intensive case management services: a fee-for-service arrangement developed specifically for this study, and the partial capitation system in use in New York State. We focus on the impact of these two reimbursement schemes on the number and types of services provided by case managers and on client outcomes.

Client outcomes II: Longitudinal client data from the Colorado treatment outcome study.

The outcomes of a reform of the Denver mental health system, cosponsored by the state and the RWJF, are contrasted with changes in a comparison area of the state. The study examines the structural characteristics of the mental health system, staff attitudes and satisfaction, and client-reported services and outcome. Results indicate that, in Denver, structural changes, the introduction of new services, and an intervening financial crisis increased worker dissatisfaction. Client reports documented parallel changes in the following variables: continuity of care, unmet need for case management services, frequency of symptoms, and satisfaction with services. The reform had no impact, however, on most quality-of-life indicators. The possibly adverse consequences of centralizing the system and the indirect influences of system integration on quality of life are discussed.

Screening CMHC outpatients for physical illness.

To assess the prevalence of physical disorders among outpatients treated in Colorado's public mental health system, a total of 175 patients from two community mental health centers received a comprehensive medical screening that included a standard physical examination and laboratory analyses. Of these patients, 46 percent had physical conditions or laboratory test results warranting further medical evaluation. A previously undiagnosed physical health problem was identified in 20 percent of the screened patients, and about 16 percent had conditions that could cause or exacerbate their mental disorder. The authors conclude that public mental health systems should ensure routine assessment of the physical health of psychiatric outpatients and suggest guidelines for developing medical screening procedures in public settings.

Incompetency and insanity: feasibility of community evaluation and treatment.

In order to examine the feasibility of doing more sanity and competency evaluations and treatment on an outpatient basis rather than at a state hospital, we gave a feasibility questionnaire to 288 CMHC and state hospital administrators and treatment staff members. The respondents indicated that, given enhanced community evaluation and treatment programs for forensic clients, (a) 41 percent of the sanity evaluations and 45 percent of the competency evaluations done at the hospital could be done in local communities, (b) 35 percent to 38 percent of the clients found incompetent could be treated in local communities, and (c) 39 percent to 50 percent of the clients found insane could be released to outpatient treatment six months earlier than presently. Other findings indicated several specific improvements needed in the community mental health system before it can properly handle more forensic clients.

Planning a continuum of residential/service settings for the chronically mentally ill: the Colorado experience.

Thinking regarding the needs of the chronically mentally ill has changed substantially in the post-deinstitutionalization period. Increasingly, the heterogeneity existing within this population has been recognized along with the need for an integrated continuum of residences and services. At a state level, this realization has stimulated the development of planning models which are used to predict the number and types of residential/service slots needed by the chronically mentally ill. In Colorado, a model was developed which uses data-based client profiles to predict needs along a continuum of services ranging from inpatient treatment to independent living with mental health support. In this paper, we discuss the development of the model and present the results of implementing it for a sample of 5,017 chronically mentally ill clients. The practical and heuristic value of the model is featured as well as its implications for further research.