Organization of Mental Health Services Barbara M. Rohland, M.D March 1, 2000.
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Transcript of Organization of Mental Health Services Barbara M. Rohland, M.D March 1, 2000.
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Organization of Mental Health Services
Barbara M. Rohland, M.D
March 1, 2000
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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
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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
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WW II
• WW II was a catalyst for change– Recognized “shell-shock” (post-traumatic stress
disorder) as treatable, and treatable in out-patient settings
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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
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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
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1950’s
STATE AND FEDERAL PROGRAMS BROADENED
• Promoted research in mental health
• Trained specialized personnel
• Promoted community based services
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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)
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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
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Community Mental Health Centers Act (1963)
Services not required but encouraged
• Diagnostic services
• Rehabilitative services
• Precare and aftercare
• Training
• Research and evaluation
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Community Mental Health Centers Act (1963)
CORE DISCIPLINES
1) psychiatry
2) psychology
3) social work
4) nursing
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1960’s
• Deinstitutionalization – CMHC act (1963)
• Political
• Social
– Discovery of antipsychotic agents (thorazine)• Economic
• Medical
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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”
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Community Support Program (NIMH, 1977)
• Heavy emphasis on case management
• States to plan and develop coordinated, comprehensive systems of community based care
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CSP Components
1) outreach
2) referral
3) housing
4) mental health treatment
5) crisis intervention
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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
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Case Management
• A function which can be the responsibility of a single person, team or agency
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Omnibus Budget Reconciliation Act (1981)
• Alcohol drug abuse and mental health administration (ADAMHA) – Shifted funding from the federal government to
state mental health authorities
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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
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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
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Mental Health Services Macro Versus Micro
• Government versus private– Socialist versus capitalist
• National versus local
• Then versus now
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Organization of Mental Health Services
• Who provides services
• Who receives services
• Where are services provided
• Where are services received
• How are services organized
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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
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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
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Who Receives Mental Health Services?
• Children and adolescents
• Adult – General– Spmi
• Prisoners
• Geriatric
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DSM-IV Diagnoses
• Depression• Anxiety• Psychosis• Alcohol and/or drug abuse• Dementia
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Sites of Service Provision
• Emergency rooms
• Community hospitals
• Private homes
• Nursing homes
• Primary care settings
• Mental health centers
• Prisons
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Mechanisms of Service Provision
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Delivery Systems
• Inpatient– Hospital
• Outpatient– Ambulatory– Community based– Home health care
• Institutional– Residential
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Delivery Systems
• Primary care
• Specialty care
• De facto service system
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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
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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
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Service Delivery Systems
• Case studies– Rural– Telemedicine – Managed care
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Mental Health Service Delivery Systems
Rural
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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
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Rural Mental Health Services
• General medical care
• Other human service professionals
• Voluntary support networks– Self-help groups – Family– Friends
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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
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Mental Health Service Delivery Systems
Telemedicine
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Telepsychiatry in the Heartland
If We Build It, Will They Come?
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In “Will They Come”, Who Is They?
• Patients
• Providers
• Payers
• Community
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Barriers to Implementation and Sustainability
• Technical
• Economic
• Sociological
• Political
• Clinical
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Technical
If you can’t count on it working,
No one will use it
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Technical
If you can watch yourself on TV,
Other people might be watching you, too
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Economic
• Things cost less when you don’t have to pay for them
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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
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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
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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)
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Rural Telepsychiatry
Is not necessarily
• Faster
• Easier
• Cheaper
• Better
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Rural Telepsychiatry
• IS a mechanism to increase access to necessary or desirable services by patients who would otherwise not receive services or be underserved
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Mental Health Service Delivery Systems
Managed care
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Managed Care
• “If you’ve seen one managed care program...You’ve seen one managed care program.”
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Managed CareSources of Variability
– Local geography– Pre-existing service system– State regulations– Contractor priorities– Targeted population group– Local politics
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“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
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“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
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Study Questions
• What were some of the societal beliefs that lead to institutionalization?
• What were some of the forces that lead to deinstitutionalization?
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Study Questions
• What was the significance of the community mental health centers act of 1963?
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Study Questions
• What are some of the most frequent sources of mental health services– Providers– Places
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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?