Hospital & community psychiatry最新文献

Managed care organizations have used psychiatrists primarily for their patient care skills, and their potential for performing administrative and managerial services for managed care organizations has not been fully appreciated. However, the role of physician managers is likely to expand with or without federal action on health care reform. Areas of opportunity for psychiatrists include utilization and quality management, network development, provider profiling, and credentialing. In addition, psychiatrists may serve as ombudsmen for managed care organizations and support internal operations. Although formal training beyond medical school and residency is not necessary for psychiatrists to become effective managers, various educational programs are available and are highly recommended.

Objective: The study assessed how clients' housing preference and other variables were related to the acquisition of Section 8 certificates, facilitating independent living, for homeless persons with severe mental illness who were being served by an experimental assertive community treatment team.

Methods: For 77 clients, demographic and clinical differences between receivers and nonreceivers of certificates were examined, and correlates of time from referral to the team to completion of the Section 8 application were analyzed. Reasons clients did not receive certificates and housing outcomes were summarized in relation to client preference.

Results: The 34 clients who received certificates (44 percent) had significantly less psychopathology after three months than did nonreceivers and tended to have affective disorders rather than schizophrenia. Of the 43 nonreceivers, the two largest groups were 19 clients who did not want certificates and ten clients who wanted certificates but whom staff considered unable to live safely in an unsupervised apartment. The mean +/- SD length of time for application for a certificate was 5.7 +/- 5.8 months. Longer time to apply was significantly associated with having schizophrenia, having the team as a representative payee, and showing increased psychotic symptoms at referral and at three months.

Conclusions: The study suggests that it is possible to honor the housing preferences of the majority of homeless persons with severe mental illness if adequate resources are provided. However, staff may view persons who have schizophrenia and more symptoms as needing more supervision than those clients prefer. Homeless mentally ill persons may also take longer than more symptomatic persons to pursue independent living through a Section 8 certificate.

Objective: This study examined diversity during the late 1980s in managed care programs for mental health, alcohol abuse, and drug abuse to identify ways in which research can generate more meaningful data on the effectiveness of utilization review programs.

Methods: Telephone interviews were conducted with representatives of utilization review programs for employee health insurance plans in 31 firms that employed 2.1 million people in 1990. Questions addressed qualifications of personnel, clinical criteria to authorize care, integration with employee assistance plans, penalties for not complying with utilization review procedures, outpatient review, and carve out of mental health and substance abuse review.

Results: Large variations in utilization review programs were found. Programs employed a range of review personnel and used a variety of clinical criteria to authorize care. More than two-thirds did not carve out mental health and substance abuse review from medical-surgical review. Some firms' employee assistance plans were integrated with utilization review programs, while others remained unintegrated. Penalties for not following program procedures varied widely, as did review of outpatient services.

Conclusions: Because of trends toward even more diversity in utilization review programs in the 1990s, research that identifies the specific features of managed care programs that hold most promise for controlling costs while maintaining quality of care will increasingly be needed.

Objectives: Patients with a diagnosis of borderline personality disorder were studied to learn how they experienced the disorder and its treatment.

Methods: Life history narratives were obtained from ten patients with borderline personality disorder in a series of 90-minute interviews held over the course of a year. The interviews had minimal structure; patients were simply asked to talk about themselves.

Results: The narratives revealed striking similarities in the patients' experience with borderline personality disorder. Reports of their experience differed markedly from clinical descriptions of the disorder. Common themes of estrangement, inadequacy, and despair were identified, as well as common coping strategies, primarily dissociation and avoidance of self-disclosure.

Conclusions: Patients' experiences with borderline personality disorder were highly consistent but differed markedly from clinical descriptions. The patient narratives provided information that could lead to more effective treatment of the disorder.