1 Integrating Service Delivery Systems for Persons with Severe Mental Illness Horwitz & Scheid, Ch. 24

2 Overview Past 50 years has seen shift from centralized, institutional model of care (large state psychiatric hospitals) to decentralized, community-based system involving large number of private and public providers Thousands of long-stay patients discharged to community settings (including nursing homes, board and care, etc.) Community mental health centers attracted large numbers of formerly unserved patients.

3 Result of changes Severely mentally ill (SMI) have been disadvantaged, according to some researchers SMI have multiple needs, not just mental health needs – Psychosocial rehabilitation – Income maintenance – Housing – Health care – Employment – Social supports – Substance abuse counseling

4 Need for service integration Given the multiple needs of SMI clients, many clients “fall between the cracks” of various service delivery systems Thus arose the need for “service integration” to develop linkages between sectors and enhance effectiveness and efficiency of services

5 Four major innovations in service integration in past decades Community Mental Health Centers (CMHC’s) Community Support Program (CSP) and Child and Adolescent Service System Program (CASSP) Program on Chronic Mental Illness (PCMI)—co- sponsored by Robert Wood Johnson Foundation and US Department of Housing and Urban Development Managed mental health care

6 Roots of services integration During 1960’s, the New Frontier and Great Society (Kennedy and Johnson presidencies) – Neighborhood service centers – Community action – Community mental health centers – Model Cities – Head Start – Older Americans Act – War on Poverty By early 1970’s service coordination was a buzzword in Department of Health, Education, and Welfare

7 Services integration strategies for persons with severe mental illness LEVEL OF INTEGRATION MECHANISMS PROBLEM TO BE SOLVED Client Case management Assertive community treatment Fragmentation Inaccessible services Organization Community mental health centers Lack of comprehensive services and continuity of care System Local mental health authorities Managed care Lack of organization and accountability Need to contain costs

8 Community Mental Health Centers Initiated in mid-1960’s Goals – Develop comprehensive community-based services (emergency, inpatient, outpatient, partial hospitalization, consultation and education) – Responsible for catchment area – Promote early treatment, continuity of care, prevention, rehabilitation

9 Community Mental Health Centers Began to serve “worried well” instead of SMI Only in late 1970’s did they begin to serve SMI population As federal funding disappeared, states took over funding and regulation of centers, put priority on SMI population

10 Community Support Program Created by National Institute of Mental Health to improve services for severely and persistently mentally ill (SPMI) Services to include psychosocial rehabilitation, medical and mental health care, case management, supportive living and working arrangements, crisis intervention to prevent hospitalization In early 1980’s began to include children and adolescents (CASSP)

11 Local mental health authorities Program on Chronic Mental Illness (PCMI) – A unique public-private partnership (Robert Wood Johnson Foundation and US HUD) – Mostly a demonstration project that occurred in 9 cities – Research did not support broad expansion of these programs

12 Managed Care Covers broad range of financing arrangements, different types of organizations, regulatory mechanisms Goals – Control access to care – Control types of care delivered – Control costs of care Mental health is frequently “carved out” and managed separately from other forms of health care Concerns—managed care is really all about saving money, not about providing care needed by SPMI

13 Effectiveness?? Research has demonstrated that services can be successfully integrated However, research has been unable to demonstrate that there is a significant difference in outcomes for clients who are served under “service integration” Further research is needed

14 How are decisions usually made? Research findings? NO Interest group politics YES