Organization of Mental Health Services

Barbara M. Rohland, M.D

March 1, 2000

Learning Objectives

• Be aware of political, social and economic forces that have influenced the delivery of mental health services in America

• Be aware of the complexity of the mental health service system

• Know features that are unique to the organization of rural, telemedicine, and managed care systems

History of Mental Health Services in America

• Civil war to WW II– Mental disease viewed as incurable – Belief that mentally ill persons should receive

humane, custodial care– State mental institutions were overcrowded,

inadequately financed, and understaffed

WW II

• WW II was a catalyst for change– Recognized “shell-shock” (post-traumatic stress

disorder) as treatable, and treatable in out-patient settings

Post WW II

Freud (psychoanalytic theories)

• Generated public interest in psychiatry

• Applications to the “worried well” – Interest in neurotic conditions did little to

promote effective treatment for persons with serious mental illness

National Mental Health Act (1946)

National Institute of Mental Health (NIMH)

• promoted research in the field of mental disease

• encouraged training of personnel

• established state mental health authorities to develop mental health programs

1950’s

STATE AND FEDERAL PROGRAMS BROADENED

• Promoted research in mental health

• Trained specialized personnel

• Promoted community based services

Community Mental Health Centers Act (1963)

• Funded construction and staffing for comprehensive, community-based mental health centers throughout the country – “Reliance on the cold mercy of custodial

isolation will be supplanted by the open warmth of community concern and capability.” (JFK)

Community Mental Health Centers Act (1963)

Obligation to provide five essential services for 20 years

1) inpatient care

2) outpatient care

3) partial hospitalization

4) twenty four hour emergency care

5) consultation and education

Community Mental Health Centers Act (1963)

Services not required but encouraged

• Diagnostic services

• Rehabilitative services

• Precare and aftercare

• Training

• Research and evaluation

Community Mental Health Centers Act (1963)

CORE DISCIPLINES

1) psychiatry

2) psychology

3) social work

4) nursing

1960’s

• Deinstitutionalization – CMHC act (1963)

• Political

• Social

– Discovery of antipsychotic agents (thorazine)• Economic

• Medical

1970’s

• Recognition that the needs of the seriously mentally ill were not being meet by most existing CMHCs– Demedicalization of CMHCs– Treatment focused on the “worried well”

Community Support Program (NIMH, 1977)

• Heavy emphasis on case management

• States to plan and develop coordinated, comprehensive systems of community based care

CSP Components

1) outreach

2) referral

3) housing

4) mental health treatment

5) crisis intervention

CSP Components

6) social and vocational rehabilitation

7) family and community support assistance and education

8) coordination/development of natural support systems

9) protection and advocacy

10) service coordination

Case Management

• A function which can be the responsibility of a single person, team or agency

Omnibus Budget Reconciliation Act (1981)

• Alcohol drug abuse and mental health administration (ADAMHA) – Shifted funding from the federal government to

state mental health authorities

Comprehensive Mental Health Service Act (1986)

• States required to plan and implement comprehensive, community-based programs of care for the seriously mentally ill in order to receive ADAMHA block grant funds

Substance Abuse and Mental Health Service Administration (SAMHSA) - 1992

• Federal, non NIMH

• Center for mental health services– Federal administration of state mental health

block grants– Provides consultation to state programs– No research component

Mental Health Services Macro Versus Micro

• Government versus private– Socialist versus capitalist

• National versus local

• Then versus now

Organization of Mental Health Services

• Who provides services

• Who receives services

• Where are services provided

• Where are services received

• How are services organized

What Are Mental Health Services?

Medical management

• Evaluate symptoms in order to make an accurate diagnosis

• Recommend and implement treatment likely to be effective in reducing symptoms

• Evaluate the efficacy of the prescribed treatment on an ongoing basis

Who Provides Services?

Medical management

• Psychiatrists (medical doctors with specialty training in the diagnosis and treatment of mental illness)

• Primary care physicians

• Nurses

• Physician assistants

Who Receives Mental Health Services?

• Children and adolescents

• Adult – General– Spmi

• Prisoners

• Geriatric

DSM-IV Diagnoses

• Depression• Anxiety• Psychosis• Alcohol and/or drug abuse• Dementia

Sites of Service Provision

• Emergency rooms

• Community hospitals

• Private homes

• Nursing homes

• Primary care settings

• Mental health centers

• Prisons

Mechanisms of Service Provision

Delivery Systems

• Inpatient– Hospital

• Outpatient– Ambulatory– Community based– Home health care

• Institutional– Residential

Delivery Systems

• Primary care

• Specialty care

• De facto service system

Specialty Versus Primary Care

• Of the 15% of the adult population who reported mental health treatment over a one year period (1994), the largest proportion, 43%, sought treatment in the general medical sector

De Facto* Mental Health Care Delivery System

• Religious/spiritual

• Cultural

• Family or friends

• Peer groups– Support groups– Internet

*Existing or being such in actual fact though not by legal establishment or official recognition

Service Delivery Systems

• Case studies– Rural– Telemedicine – Managed care

Mental Health Service Delivery Systems

Rural

Rural Realities

•Difficult to recruit and retain physicians

•Low population density

•Lack of comprehensive services and services for special populations

•Limited access to public transportation

•Poverty/uninsured

•Stigma

Rural Mental Health Services

• General medical care

• Other human service professionals

• Voluntary support networks– Self-help groups – Family– Friends

Rural Mental Health Services

• Physical health providers in rural areas may act as substitutes for mental health specialists even if it is not recognized by either patient or provider as specialty care

Mental Health Service Delivery Systems

Telemedicine

Telepsychiatry in the Heartland

If We Build It, Will They Come?

In “Will They Come”, Who Is They?

• Patients

• Providers

• Payers

• Community

Barriers to Implementation and Sustainability

• Technical

• Economic

• Sociological

• Political

• Clinical

Technical

If you can’t count on it working,

No one will use it

Technical

If you can watch yourself on TV,

Other people might be watching you, too

Economic

• Things cost less when you don’t have to pay for them

Socio-economic

• Most rural delivery systems are fragile. Telemedicine should seek to supplement or support local resources rather than to replace, substitute or compete with them

Socio-political

• If you are not a part of the community, no one will care how big your equipment is or if you’re giving it away for free

Clinical

A clinician should be present to

• Trouble shoot technical problems (e.g., Turn up the sound or refocus the camera)

• Technically, take care of problems (e.g., Trouble or shooting)

Rural Telepsychiatry

Is not necessarily

• Faster

• Easier

• Cheaper

• Better

Rural Telepsychiatry

• IS a mechanism to increase access to necessary or desirable services by patients who would otherwise not receive services or be underserved

Mental Health Service Delivery Systems

Managed care

Managed Care

• “If you’ve seen one managed care program...You’ve seen one managed care program.”

Managed CareSources of Variability

– Local geography– Pre-existing service system– State regulations– Contractor priorities– Targeted population group– Local politics

“Good” Managed Care

• Gatekeeping - facilitates access to services that are necessary and appropriate

• Population-based resource utilization• Provision of comprehensive services• Continuity of care• Accountability

“Bad” Managed Care

• Difficulty finding and accessing services• Denial of services to patients in need• Absence of accountability and follow-up for

individual patients• Lack of coordination among multiple providers• Lack of continuity in treatment planning over time

Study Questions

• What were some of the societal beliefs that lead to institutionalization?

• What were some of the forces that lead to deinstitutionalization?

Study Questions

• What was the significance of the community mental health centers act of 1963?

Study Questions

• What are some of the most frequent sources of mental health services– Providers– Places

Study Questions

• What are some of the problems intrinsic to the delivery of mental health services in rural areas?

• What are some of the problems of implementing and sustaining telemedicine?

• What are some of the sources of variability among managed care programs?