Provider perspectives on employment for people with serious mental illness.

BACKGROUND: Persons with serious mental illnesses (SMI) can lead productive lives, and the majority want to work. Mental health providers can play an important role in helping their clients gain and maintain employment. AIMS: The Provider Survey was developed to shed additional light on providers' views toward employment and recovery, and the utilization of Individual Placement and Support (IPS) supported employment (SE) services for people with SMI. METHODS: A total of 1,306 providers of the State of Connecticut participated in the survey. Four main questions were addressed in the survey: what do providers do, what do they view as most important regarding employment, what are their views when it comes to what promotes recovery and what barriers do providers face in attempting to refer their clients to IPS services. RESULTS: Referring clients to additional supports was rated as the most important aspect of what providers do; encouragement was rated as the most important component to enable clients in gaining and maintaining employment; agency, belonging and medical care were rated as most important in promoting recovery; and expectations that clients would be discriminated against at work was the most important barrier to referring clients for SE. Also, employment and finances were seen as the least important factors in promoting the recovery of people with SMI. CONCLUSION: This survey suggests that one reason that more clients may not be referred to IPS programs is that clinicians do not view employment or financial self-sufficiency as important factors in recovery, further compounding the historical view that these persons are unable to, and uninterested in, working. Such findings call for a provider education and training campaign to highlight the fact that most persons with SMI - like most persons in general - do want to work and, with supports, most are capable of doing so.

Poor and depressed, the tip of the iceberg: the unmet needs of enrollees in an indigent health care plan.

Depression is a leading cause of disability [World Health Organization (WHO), 2001] with economic costs exceeding 63 billion dollars per year in the US [U.S. Department of Health and Human Services (DHHS), 1999]. The challenges of treating depression among the poor are compounded by broader social needs. This study examined the prevalence of depression and psychosocial needs among enrollees in an indigent health care plan. Results indicated clinical levels of depression were present in 28.6% of respondents (n=1,405). Depressed respondents were significantly more likely (p<0.001) to have co-occurring alcohol (OR=1.78; CI(95) =1.32-2.40), drug (OR=2.67; CI(95) =1.80-3.98), and health (OR=5.44; CI(95) = 4.12-7.19) problems compared to non-depressed respondents. Significantly more social needs were also associated with depression. Depressed respondents averaged 7.8 needs compared to 3.6 among non-depressed respondents. Needs included a significantly increased likelihood (p<0.001) of lacking sufficient food (OR=2.56; CI(95) =1.97-3.34), shelter (OR=3.67; CI(95) =2.23-6.05), or money (OR=3.18; CI(95) = 2.39-4.23) and having more legal (OR=2.95; CI(95) =2.22-3.92) and family (OR=3.00; CI(95) =2.32-3.86) problems. The high rates of co-occurring social needs among individuals with clinical depression underscores the need for comprehensive, coordinated care in order to improve their quality of life and also reduce high utilization of crisis management services.

The role of coercion in the treatment of women with co-occurring disorders and histories of abuse.

Debate continues on issues of involuntary treatment for individuals with behavioral healthcare problems. Women with co-occurring disorders and histories of abuse are an especially vulnerable population. This study seeks to increase our knowledge about the experiences of coercion for women in the behavioral healthcare system. Patterns of coercion are explored. This study did not find the predicted relationship between high levels of interpersonal violence and frequent involuntary treatment experiences. The results do offer support for the hypothesis that women are more likely to be currently mandated to treatment if they have been recently arrested, and that being mandated to treatment does not appear to be related to clinical issues such as recidivism and acute symptoms. As expected, women currently required to be in treatment report having less choice in other aspects of their care. Implications for future research in the current climate of increasingly coercive policies are presented.

Managed behavioral health care: an instrument to characterize critical elements of public sector programs.

OBJECTIVE: To develop an instrument to characterize public sector managed behavioral health care arrangements to capture key differences between managed and "unmanaged" care and among managed care arrangements. STUDY DESIGN: The instrument was developed by a multi-institutional group of collaborators with participation of an expert panel. Included are six domains predicted to have an impact on access, service utilization, costs, and quality. The domains are: characteristics of the managed care plan, enrolled population, benefit design, payment and risk arrangements, composition of provider networks, and accountability. Data are collected at three levels: managed care organization, subcontractor, and network of service providers. DATA COLLECTION METHODS: Data are collected through contract abstraction and key informant interviews. A multilevel coding scheme is used to organize the data into a matrix along key domains, which is then reviewed and verified by the key informants. PRINCIPAL FINDINGS: This instrument can usefully differentiate between and among Medicaid fee-for-service programs and Medicaid managed care plans along key domains of interest. Beyond documenting basic features of the plans and providing contextual information, these data will support the refinement and testing of hypotheses about the impact of public sector managed care on access, quality, costs, and outcomes of care. CONCLUSIONS: If managed behavioral health care research is to advance beyond simple case study comparisons, a well-conceptualized set of instruments is necessary.