Journal of mental health administration最新文献

The Implementation Study of the Fort Bragg Evaluation documented how the Demonstration was executed and whether it met the expectations of the continuum of care philosophy upon which it was based. Based on the theory-driven and component approaches to program evaluation, a case study methodology was employed. First, the theories and assumptions about the Demonstration were explicated to derive a program model. Next, the program-as-implemented was compared to the program-as-planned. Barriers responsible for diluting full-scale implementation were documented. This study provides a comprehensive description of how the Demonstration was put into place and the evidence necessary to conclude that the Demonstration was executed with high fidelity, despite barriers, to provide an excellent test of the program theory.

The aim of this study was to examine management decisions made at the time of assessment of an episode of deliberate self-harm seen in the general hospital and examine the extent of referral to a specialized addiction unit. Factors involved in making a clinical decision regarding the appropriate management of self-harm cases when alcohol factors were identified are reviewed. Simply referring to a specialized addiction unit was found to be an unsatisfactory method of providing a comprehensive response to the problem of substance misuse and deliberate self-harm. It is suggested that services should be developed using active posthospital discharge community follow-up. Motivational interviewing used in such a setting may increase the number of patients who will go on to accept specialist care.

A key question of the Fort Bragg Evaluation was whether the continuum of care model implemented at the Demonstration produced better mental health outcomes for children and adolescents than a traditional system of care. This article describes a few of the key methodological issues that were addressed to help ensure that findings about mental health outcomes were valid. The research design was quasi-experimental and longitudinal. Nearly 1,000 families participated, and attrition was low throughout the study. Multiple informants responded to a comprehensive array of widely used instruments in the area of children's mental health and mental health services. Despite the absence of random assignment, sites were comparable upon entry to the study on numerous factors that might affect outcome. Further, data lost through the course of study did not vary appreciably across sites. Finally, some evidence suggests that the findings of the Outcome Study may generalize to other populations of low-middle to middle-class youth in treatment.

This article introduces the Fort Bragg managed care experiment. This study was a 5-year, $80 million effort to evaluate the cost-effectiveness of a full continuum of mental health services for children and adolescents. The article describes the development of the Demonstration, the program theory underlying intervention, and how this theory was tested.

This article reviews the legislative process that resulted in the most significant reform of California's public mental health system in nearly 25 years. The reform, termed "Program Realignment," decentralized administrative and fiscal control of the mental health system from the state to the county level. The system prior to Program Realignment is discussed here to reveal an already diverse and decentralized county mental health system, fiscal distress, and general dissatisfaction with the system. From these conditions, the objectives of the relevant political actors arose. By tracing the policy development process of Program Realignment, several independent variables are revealed that help explain how and why this legislation came into being and allow generalization of this case to other states' experiences. These independent variables are an urgent need for action within a limited timeframe, a preexisting knowledge base and well-developed policy networks, a spirit of bipartisan cooperation, and the presence of strong leadership. Preliminary evidence suggests that consolidation of fiscal and programmatic authority at the local level has reduced fragmentation of services and increased fiscal flexibility. However, there is concern that the quality of care offered by the state's 59 local mental health programs will become increasingly disparate and that increased financial flexibility may not be used to improve services for clients but to save money for local governments. Lessons from California's experience can alert other states to the pros and cons of this policy approach to providing mental health services and inform policymakers in other states of the steps involved in bringing about such a policy change.

Residential alternatives to hospitalization for adults with severe mental illness in crisis were not designed for, and often exclude, persons with coexisting substance abuse disorders. Given high comorbidity rates, however, it is important to know whether residential alternatives can be effective for patients with dual diagnoses. To explore the impact of comorbidity on treatment outcomes, structured interviews were conducted at admission and discharge with 92 consecutive admissions to a residential alternative. Using the Structured Clinical Interview for DSM-III-R, two groups were identified: 24 patients with and 68 patients without comorbid substance abuse disorders. At admission, the two groups were similar in demographic and clinical characteristics. The treatment was effective independent of comorbidity; at discharge, treatment success, symptom improvement, and patient satisfaction were similar for both groups. Persons with coexisting substance abuse disorders remained in residence a week longer, but the difference was not statistically significant. Residential alternatives appear suitable for patients with dual diagnoses.

This article describes a clinical management tool, the Value Accounting System, developed for use by a national organization of psychiatric treatment facilities. The system integrates patient case-mix variables with data on services provided, key administrative and clinical processes, clinical effectiveness, and cost/price. A comprehensive database links critical quality information with fiscal information, yielding a management tool that is national in scope, standardized, and versatile enough (1) to address general questions of the effectiveness and value of psychiatric services and (2) to provide an empirical base for rational, clinical management decision making. Descriptive data are presented from an attempt to establish a database and implement the system. The management and scientific potential of the Value Accounting System to improve the quality and efficiency of mental health services are discussed.

This study indicates that the majority of patients admitted to VA hospitals for medical detoxification could have those services provided on an outpatient or less intensive basis. However, inpatient medical detoxification services appear to be appropriate for those alcoholics at risk for potential life-threatening complications of withdrawal such as delirium tremens, or those with concurrent associated medical conditions such as pancreatitis, gastrointestinal bleeding, or complications of cirrhosis. Data were obtained from a national random sample of hospitalizations in Department of Veterans Affairs (VA) inpatient medical and surgical units. Medical records for 144 alcoholism-related medical admissions to 35 VA medical centers were reviewed using the Appropriateness Evaluation Protocol (AEP), a clinically based utilization review instrument widely used in the private sector. The medical records for the admission and each day of medical/surgical inpatient stay were reviewed using clinical criteria for the appropriateness of acute inpatient care as opposed to lower levels of care.

Service delivery under two systems of care--a traditional Civilian Health and Medical Program of the Uniformed Services (CHAMPUS) reimbursement system and an innovative continuum of care--was examined along six dimensions: access, type, mix, volume, timing, and continuity of services received by children and adolescents. It was found that the Demonstration served over three times as many children as the Comparison. In addition to serving more children, the Demonstration also provided more and different types of services to each child treated. Finally, the Demonstration appears to have delivered services in a more timely fashion and made a considerable effort to match children's and families' needs with services.

This article presents findings from a quasi-experiment that included the use of satisfaction scales to compare parent's satisfaction with the services their children received through two different mental health care delivery systems. Satisfaction with the following three types of service were compared: (1) intake assessment during the admission process to any service setting, (2) outpatient services, and (3) residential treatment including inpatient hospitalization and residential treatment centers (RTCs). Additionally, satisfaction with several areas of care (e.g., access, treatment process, therapist relationship, parent and family services, discharge and transition planning), as well as global satisfaction, was assessed. In general, parents whose children received services through an innovative continuum of care system reported significantly higher satisfaction with intake assessment and outpatient services than did parents whose children received care in a traditional fee-for-service system. Fewer differences were found in satisfaction with residential services.