The impact of managed care on mental health services for children and their families.

For more than a decade, the philosophy of community-based systems of care has guided the delivery of mental health services for children and adolescents served by publicly funded agencies. This philosophy supports system attributes that include a broad array of services; interagency collaboration; treatment in the least-restrictive setting; individualized services; family involvement; and services responsive to the needs of diverse ethnic and racial populations. The notion of systems of care emerged in an era when managed health care also was gaining popularity. However, the effect of managed care on the delivery of mental health and substance-abuse services--also known as behavioral health services--has not been widely studied. Preliminary results from the nationwide Health Care Reform Tracking Project (HCRTP) inform discussions about the impact of managed behavioral health care on services for children and adolescents enrolled in state Medicaid programs. Most states have used some type of "carve-out design" to finance the delivery of behavioral health services, and there is a trend toward contracting with private-sector, for-profit companies to administer these benefits. In general, managed care has resulted in greater access to basic behavioral health and community-based services for children and adolescents, though access to inpatient hospital care has been reduced. Under managed care, it also has been more difficult for youths with serious emotional disorders, as well as the uninsured, to obtain needed services. With managed care has come a trend toward briefer, more problem-oriented treatment approaches for behavioral health disorders. A number of problems related to the implementation of managed behavioral health care for children and adolescents were illuminated by the HCRTP. First, there is concern that ongoing efforts to develop systems of care for youths with serious emotional disorders are not being linked with managed care initiatives. The lack of investment in service-capacity development, the lack of coordination with other agencies serving children with behavioral health problems, and cumbersome preauthorization requirements that may restrict access to appropriate service delivery were other concerns raised by respondents about managed care. As the adoption of managed behavioral health care arrangements for Medicaid beneficiaries expands rapidly, the HCRTP will continue to analyze how this trend has affected children and adolescents with behavioral health problems and their families.

State health care reforms: how they affect children and adolescents with emotional disorders and their families.

This article reports on the Health Care Reform Tracking Project, a national study designed to describe and analyze state health care reforms and their impact on children and adolescents with emotional disorders and their families. It summarizes the results of the baseline survey of states conducted in 1995, exploring the nature and extent of the reforms in which states are engaged, most of which involve applying managed care technologies to their Medicaid programs. Trends across states are identified with respect to mental health service delivery, particularly with respect to children and adolescents. The article concludes with a discussion of issues and concerns related not only to mental health service delivery for children and adolescents with emotional disorders and their families but also to the systems of care that have been developing over the past decade to serve them. Some of these concerns include the lack of pilots or demonstrations, limited mental health coverage in some reforms, the lack of integration between mental health and substance abuse systems, the lack of special provisions for children, the need for more reliable bases for deriving capitation rates, the limited incorporation of systems of care, the need to incorporate interagency treatment planning and service delivery approaches, the lack of outcome measures specific to and appropriate for children, and the need for greater family involvement in the planning and implementation of these reforms.

Implications of the Health Security Act for mental health services for children and adolescents.

Lack of adequate insurance coverage is one reason that the percentage of children who currently utilize mental health services is significantly lower than the estimated percentage of children with serious mental disorders. Principles of a reformed health care system with particular relevance for children's mental health services include coverage of a broad array of home- and community-based services, provision of organized systems of care for children with serious and persistent mental illness, mechanisms to ensure appropriate utilization of services, and provision of mental health services on the same terms and conditions as other health services. The Clinton Administration's proposed Health Security Act embodied many of these principles. In addition, its call for universal coverage and for elimination of insurance exclusions for preexisting conditions would extend mental health coverage to children who are currently uninsured or underinsured; the plan would also expand the range of services covered to include state-of-the-art approaches such as intensive nonresidential services and other alternatives to hospitalization. Implementation of the proposed plan would require developing the service and workforce capacity to provide a full continuum of services, ensuring availability of existing services, integrating existing and new systems of care, guarding against underserving children with serious mental illness, and planning for the role of Medicaid funding in the reformed health care system.

Study of community-based services for children and adolescents who are severely emotionally disturbed.

This article presents the results of a descriptive study of community-based services for children and adolescents who are severely emotionally disturbed. The study was funded by the National Institute of Mental Health Child and Adolescent Service System Program (CASSP) and was designed to obtain state-of-the-art information about several promising and innovative treatment approaches emerging in the field--home-based services, crisis services, and therapeutic foster care. The methodology involved literature reviews, a survey to identify programs, detailed questionnaires to learn about identified programs, and site visits to a sample of programs in each category. Two of the service components explored in the study are described in this article. Home-based services include intensive counseling, support, and case management services provided on an outreach basis to troubled children and their families in their own home. Both crisis-oriented and longer-term home-based models are discussed. The crisis services described include a variety of innovative residential crisis services which have been highly successful as alternatives to more restrictive placements in crisis situations. The authors emphasize that these services should not be seen as panaceas but as essential components of a comprehensive, community-based system of care for emotionally disturbed youngsters and their families.

Residential crisis services: a review.

Crisis assistance for persons with long-term mental illnesses is a critical part of comprehensive community support systems. Residential crisis services, while still not widely used, have been established in some communities and appear to have growing appeal as alternatives to acute psychiatric hospitalization for some clients. The services provide acute treatment in supportive, homelike settings, usually either private homes or small group facilities, and intensive discharge planning to link clients with community sources of long-term care. This review describes typical models and goals of residential crisis services and some of the factors that have impeded their development.