JBHSR Recent Issues
The Table of Contents and abstracts for recent issues of the JBHS&R are listed below.
Volume 27, 2000
Number 1 / January 2000
Alcohol Drinking Patterns and Medical Care Use in an HMO Setting...3-16
Rice, D.P., Conell, C., Weisner, C., Hunkeler, E.M., Fireman, B., and Hu,T.
Abstract: The objective of this study was to examine the association of medical care use (outpatient visits and hospitalization) with alcohol drinking patterns in a large health maintenance organization (HMO). Data were gathered from a random sample of 10,292 adult respondents through a telephone survey conducted between June 1994 and February 1996. Findings indicate that current non-drinkers who had no past history of drinking had higher rates of outpatient visits and hospitalizations than current drinkers. Among current drinkers, medical care use declined slightly as drinking levels increased. Among non-drinkers, those with a drinking history exhibited significantly higher use of outpatient visits and hospital care than non-drinkers without a drinking history and current drinkers. Controlling for demographic and SES factors, health status, and common medical conditions in multvariate analyses suggests that non-drinkers with a drinking history use more services because they are sicker than other non-drinkers or current drinkers.
Behavioral Health Funding for Native Americans in Arizona: Policy Implications for States and Tribes...17-28
Provan, K.G. and Powers Carson, L.M.
Abstract: This paper examines the principal structures and mechanisms used by federal and state government to fund the behavioral health needs of Native American Indians. Using Arizona as a case study, the paper provides an overview of both federal and state programs, especially Medicaid, discussing the problems and strengths of each. The paper concludes with a discussion of the policy implications of these programs for both states and tribes, focusing on issues concerning administrative complexity, tribal sovereignty, improving behavioral health services, and assignment of financial risk.
Comparing Provider Perceptions of Access and Utilization Management in Full-Risk and No-Risk Medicaid Programs for Adults with Serious Mental Illness...29-46
Fried, B.J., Topping, S., Morrissey, J.P., Ellis, A.R., Stroup, S., and Blank, M.
Abstract: This paper compares provider perceptions of access to services and utilization management (UM) procedures in two Medicaid programs in the same state: a full-risk capitated managed care (MC) program and a no-risk fee-for-service (FFS) program. Survey data were obtained from 198 mental health clinicians and administrators. The only difference found between respondents in the FFS and MC sites was that outpatient providers in the MC site reported significantly lower levels of access to high intensity services than did providers in the FFS site (p<.001). Respondents in the two sites reported similar attitudes towards UM procedures including a strong preference for internal over external UM procedures. These findings support the conclusion that, through diffusion of UM procedures, all care in the Medicaid program for persons with a serious mental illness is managed, regardless of risk arrangement. Implications for mental health services and further research are discussed.
Predicting Service Utilization with the Child and Adolescent Functional Assessment Scale in a Sample of Youths with Serious Emotional Disturbance Served by Center for Mental Health Services-Funded Demonstrations...47-59
Hodges, K., Doucette-Gates, A., and Kim, C.
Abstract: In previous studies, the CAFAS total score at intake was found to be a predictor of subsequent service utilization and costs. The purpose of this paper is to examine the same issue, however, with a sample that is quite different. Unlike the previous studies, the youths in this study met the criteria for serious emotional disturbance (SED) and were for the most part living in families that are described as socioeconomically disadvantaged. The present study investigated level of restrictiveness of living arrangements and number of days in out-of-family care at 6 months post intake, based on the CAFAS, the CBCL, gender, age, and level of family income at intake. A multinomial logit model was used in the analysis of level of restrictiveness of living arrangements, and an OLS regression model was conducted on number of days in out-of-family care. The CAFAS score at intake was found to be a significant predictor of service utilization between intake and 6 months and was a more consistent predictor than the CBCL. Results from this study suggest that the CAFAS can be used to match service needs with resource allocation and to monitor performance-based outcome indicators.
Motivational Versus Confrontational Interviewing: A Comparison of Substance Abuse Assessment Practices at Employee Assistance Programs...60-74
Schneider, R.J., Casey, J., and Kohn, R.
Abstract: Despite the popularity and growth of employee assistance programs (EAPs), there is very little empirical data about current EAP substance abuse assessment practices or the effectiveness of different assessment approaches. The aim of the present study was to conduct a quasi-experimental comparison of two EAP assessment approaches with substance abusers: confrontational interviewing (CI) and motivational interviewing (MI). A total of 176 EAP clients from 14 study sites met the study criteria and 89 (51%) agreed to participate in the study. At 3- and 9-months post-assessment, both the MI and CI groups showed similar changes in readiness for change, completion of initial treatment plans and subsequent treatment. Most importantly, both the MI and CI subjects showed significant and comparable improvement on all the substance abuse baseline measures as well as measures of family-social well-being and effects of drinking/drugging on work performance. The results of this study open the door for EAP counselors to use an empirically-supported assessment style that is at least as effective as the traditional confrontational approach.
Psychometric Evaluation of an Inpatient Psychiatric Care Consumer Satisfaction Survey...75-86
Kolb, S.J., Race, K.E.H., and Seibert, J.H.
Abstract: This study assessed the psychometric properties of a questionnaire designed to measure consumer satisfaction with inpatient psychiatric care. To this end, 37 inpatient psychiatric units from across the United States agreed to participate. The questionnaire was completed by 1,351 individuals, or a responsible party, for an average response rate of 53%. The factor analysis identified six scales: Nonclinical Services, Psychiatric Care, Staff, Medical Outcome, Patient Education and Program Components/Activities. The internal reliability of the scales was high to moderate (.88 to 74). Results of a stepwise regression model showed good criterion-related validity explaining 58% of the variance in overall quality ratings. Little shrinkage in this variance occurred when the model was cross-validated. Also, differences in satisfaction levels were noted for select facility and consumer characteristics. Results are interpreted as providing support for the reliability and validity of a newly developed consumer satisfaction survey for use in evaluating inpatient psychiatric care.
Distributive Justice in Medicaid Capitation: The Evidence from Colorado...87-97
Callaway, M.E. and Hall, J.
Abstract: In 1995, the state of Colorado began a new funding program for the provision of mental health services to Medicaid recipients. Medicaid funding was restructured from a fee-for-service system into a capitated managed care system. The restructuring altered the way in which mental health resources were allocated within Colorado's mental health system. This article explores the ethical principles inherent in the allocation of mental health resources within Colorado. The allocation system before and after the capitation pilot is analyzed according to three models of distributive justice. Under capitation, access to care corresponds to egalitarian ideals, while service delivery and outcomes follow a more utilitarian philosophy. Results from several empirical studies of the Colorado Medicaid system are used to support this ethical analysis. The analysis leads to the suggestion that the fair-opportunity rule may be a useful principle for developing just distribution systems in other states in the future.
Cross-System Service Use among Psychiatric Patients: Data from Department of Veterans Affairs.
Hoff, R.A. and Rosenheck, R.A.
Abstract: This study examines the cross-system use of non-VA services in a sample of psychiatric patients from the Department of Veterans Affairs (VA) in 1990. Data were collected over a two-week period on all mental health outpatients, and included demographic information, diagnoses, and self-reported use of non-VA services in the previous two weeks and six months. In the entire sample 10.6% and 23.3% reported cross-system use in the previous two weeks and six months respectively. Predictors of cross-system use were lower VA utilization, a non-schizophrenic diagnosis, not having a VA service-connected disability, and being female. These data indicate that a substantial proportion of VA mental health patients are using non-VA services. Utilization patterns indicate that they may be substituting non-VA for VA services. These results are unlikely to be unique to VA, and rates of cross-system use will likely increase in all health care systems as financial restrictions increase.
Linking Substance Abuse and Serious Mental Illness Service Delivery Systems: Initiating a Statewide Collaborative...107-113
Barreira, P., Espey, B., Fishbein, R., Moran, D., and Flannery, R.B.
Abstract: In the past persons with serious mental illness and substance abuse often found themselves in parallel systems of care that inadequately addressed their needs. Recent advances have seen the development of an integrated approach to care for these disorders in both the public and private sectors. While some state departments of mental health have developed integrated systems of care for public sector patients, no department appears to have developed such a system for both public and private clients, and there appears to be no published journal report of a model to induce cooperation by all stakeholders. This paper outlines a two-step approach by the Massachusetts Department of Mental Health to foster stakeholder cooperation in designing an integrated system of care for both public and private clients with co-occurring disorders.
Number 2 / April 2000
Workplace Managed Care: Collaboration for Substance Abuse Prevention...125-130
Galvin, D.M.
Abstract: This article describes the history, purpose, and overall methodology of the Workplace Managed Care (WMC) study sponsored by the Substance Abuse and Mental Health Services Administration (SAMHSA), Center for Substance Abuse Prevention (CSAP). This study was initiated to discern best practices for workplaces and managed care organizations integrating their substance-abuse prevention and early-intervention programs, strategies, and activities for employees and their families. CSAP funded nine WMC grants to study their retrospective and prospective data. Results of the WMC study suggested the addition of substance abuse prevention material to existing workplace health promotion offerings resulted in improved substance abuse attitudes without jeopardizing existing health promotion programs. Stress management programming was successful at improving substance abuse attitudes indirectly. This study provides a platform for multidisciplinary research in workplace and managed care settings.
Substance Abuse Intervention for Health Care Workers: A Preliminary Report...131-143
Lapham, S.C., Chang, I., and Gregory, C.
Abstract: The Workplace Managed Care Cooperative Agreement project targets 3,300 health care professionals and support staff members in hospital, specialty clinic, and primary care settings located in metropolitan New Mexico communities. This project will evaluate whether enhancements to existing substance abuse prevention/early intervention programs can prevent the onset of risky drinking, reduce prevalence of risky drinking, better identify employees who abuse alcohol and drugs, and improve employee wellness. This paper describes one such enhancement (Project WISE), which was implemented at Lovelace Health Systems. Project WISE includes relatively low-cost elements such as supervisor and employee training in substance abuse awareness, literature and videos on how to reduce drinking, and brief motivational counseling for employees and family members. Evaluation will consist of baseline comparisons of the intervention and comparison sites; a process evaluation; a qualitative analysis using focus groups; and an outcome evaluation using results of health risk appraisals, employee satisfaction surveys, health and work records, and use of medical care services. The effect of Project WISE will be assessed through repeated measures analysis. Methodological challenges, solutions, and implications for researchers undertaking similar projects are presented in this paper.
Methodological Issues in Workplace Substance Abuse Prevention Research...144-151
Hersch, R.K., Cook, R.F., Deitz, D.K., and Trudeau, J.V.
Abstract: Substance abuse among working adults represents billions of dollars in preventable health care costs and industry financial loss. Therefore, it is imperative to develop and test effective substance abuse prevention programs for the workplace. However, applied workplace substance abuse prevention research is fraught with numerous methodological challenges. This article highlights a number of these challenges, which include: 1) reaching a broad audience with prevention messages, (2) handling the concerns of the employer, (3) collecting substance use data in the workplace, (4) accessing and using record-based data, and (5) linking survey and records-based data. Using examples from the authors' on-going research assessing a workplace health promotion and substance abuse prevention program, funded by the Substance Abuse and Mental Health Administration's Center for Substance Abuse Prevention (CSAP), the authors address these challenges.
The Employee Stress and Alcohol Project: The Development of a Computer-Based Alcohol Abuse Prevention Program for Employees...152-165
Matano, R.A., Futa, K.T., Wanat, S.F., Mussman, L.M., and Leung, C.W.
Abstract: The Employee Stress and Alcohol Project (ESAP) developed an interactive computer-based alcohol abuse prevention and early intervention program accessible to employees over the Internet. The website is designed to complement and supplement employee health care services available through workplace managed care. The health care literature recommends incorporating primary, secondary, and tertiary prevention strategies in dealing with employee alcohol-related problems. These recommendations call upon behavioral health specialists to develop and provide comprehensive, yet cost effective, approaches to alcohol abuse prevention, early intervention and treatment within the context of workplace managed care. ESAP is implementing this website for a diverse 8,567-employee Silicon Valley worksite. ESAP's website enables employees to self-assess their stress levels, coping styles, and risk for alcohol-related problems. It provides personalized feedback, recommendations, mini-workshops, a drinking journal, links to other online resources, and an interactive forum where ESAP participants can communicate with one another. In addition, ESAP's website provides resources for employees who are concerned about another individual's drinking, as well as information about adolescent alcohol use. This article discusses the implications of incorporating the ESAP website into worksite alcohol abuse prevention and early intervention programming.
Methods for Evaluating a Mature Substance Abuse/ Early Intervention Program...166-177
Becker, L.R., Hall, M., Fisher, D.A., and Miller, T.R.
Abstract: The authors describe methods for work in-progress to evaluate four workplace prevention and or early intervention programs designed to change occupational norms and reduce substance abuse at a major U.S. transportation company. The four programs are an employee assistance program, random drug testing, managed behavioral health care, and a peer-led intervention program. An elaborate mixed-methods evaluation combines data collection and analysis techniques from several traditions. A process-improvement evaluation focuses on the peer-led component to describe its evolution, document the implementation process for those interested in replicating it, and provide information for program improvement. An outcome-assessment evaluation examines impacts of the four programs on job performance measures (e.g., absenteeism, turnover, injury, and disability rates) and includes a cost-offset and employer cost savings analysis. Issues related to using archival data, combining qualitative and quantitative designs, and working in a corporate environment are discussed.
Why Carve Out? Determinants of Behavioral Health Contracting Choice among Large US Employees...178-193
Hodgkin, D., Horgan, C.M., Garnick, D.W., Merrick, E.L., and Goldin, D.
Abstract: During the 1990s, many employers in the United States carved substance abuse and mental health services out of their medical plans, changing the way millions of people access these services. Employers who take this approach contract directly with specialized vendors, bypassing their general health plans. The spread of carve-outs has raised concerns about possible effects on access and treatment, as well as a need to understand why employers take this approach. This paper reviews the various hypotheses about why purchasers carve out and tests them using data from a survey of America's largest employers, the Fortune 500 firms. Size is the strongest predictor of an employer's decision to carve out behavioral health, once other characteristics are controlled for. Employers who report they value coordination are less likely to carve out, while those who value special expertise are more likely to carve out. Employers are less likely to carve out enrollees in health maintenance organizations (HMOs) than those in other types of plan.
Provision of Drug Treatment Services in the Juvenile Justice System: A System Reform...194-214
Terry, Y.M., VanderWaal, C.J., McBride, D.C., Van Buren, H.
Abstract: This paper proposes a systemic reform of the organizational structure and delivery of substance abuse services for adolescents within the juvenile justice. The paper first discusses the impact of substance use on the juvenile justice system and then review which drug treatment programs and services are currently available. Following an evaluation of the most effective drug treatment programs and modalities, recommendations for system reform are given. The recommendations are based on a graduated sanctions framework, supported by systems collaboration and comprehensive case management. Systems collaboration between service providers must exist in order for juveniles to receive appropriate and comprehensive services. Case managers both assesses juveniles and help them move through and between judicial, drug treatment, and social service systems. In this way, juveniles receive the most suitable and complete services which a community can offer while still remaining firmly under juvenile justice system supervision.
Managed Care and Fee Discounts in Psychiatry: New Evidence...215-226
Scheffler, R.M., Garrett, A.B., Zarin, D.A., and Pincus, H.A.
Abstract: This paper describes the extent of managed care and fee discounting in psychiatric practice using data on 970 randomly sampled American Psychiatric Association (APA) members from the 1996 National Survey of Psychiatric Practice. Seventy percent of psychiatrists were found to have some patients in managed behavioral health care programs. The survey data illustrate that psychiatrists' involvement in managed care spans primary practice settings, and is fairly evenly distributed across regions of the United States. Nationally, psychiatrists discount fees for 35% of their patients, with significant variation by practice type and extent of involvement in managed behavioral health care. The average level of discount is 25% with little variation by practice type or extent of involvement in managed behavioral health care. There is little evidence that psychiatrists with patients in managed care have higher fee levels than psychiatrists with no patients in managed care.
Criminal Behavior and Emotional Disorder: Comparing Youth Served by the Mental Health and Juvenile Justice Systems...227-237
Rosenblatt, J.A., Rosenblatt, A., and Biggs, E.E.
Abstract: This study explored whether youth involved in joint service systems differed from single-agency users in terms of types of crimes committed and clinical functioning. Data from 4924 youth involved in one county's public mental health and juvenile justice service systems were examined. Twenty percent of those youth receiving mental health services had recent arrest records and thirty percent of youth arrested received mental health services. Of all youth arrested in the county, mental health service users had more arrests than non-mental health service users. A subsample of 94 mental health service users with arrests was matched on demographics with 94 mental health service users without arrests. Youth with arrests had a higher frequency of conduct disorder, higher Child Behavior Checklist Externalizing and Total Problem Scale scores, and more functional impairment on the Child and Adolescent Functional Assessment Scale as compared to youth without arrests. Implications for behavioral health service delivery were discussed.
Number 3 / July 2000
Detoxification Centers: Who's in the Revolving Door?..245-256
McCarty, D., Caspi, Y., Panas, L., Krakow, M., and Mulligan, D.H.
Abstract: Data from 443,812 admissions to publicly funded detoxification centers in Massachusetts (fiscal year 1984 to fiscal year 1996) were analyzed to assess changes in the population served. Substantial increases in admissions of women, African-Americans, and Hispanics were apparent. Mean age at admission declined and unemployment increased. A 25 percent decline in admissions reporting alcohol use was coupled with a two-fold increase in reported cocaine use and a four-fold increase in heroin use. Detoxification services have evolved. The older, white, male alcoholic is no longer the primary consumer. Policy initiatives (e.g., increased services for women) and the changing epidemiology of drug abuse (e.g., increased access to heroin) contributed to the changing population served in detoxification centers.
Client Typology Based on Functioning Across Domains Using the CAFAS: Implications for Service Planning...257-270
Hodges, K. and Wotring, J.
Abstract: Cluster analysis was used to develop a five-group typology based on the eight subscales of the Child and Adolescent Functional Assessment Scale (CAFAS) using data on 4,758 youths referred to Community Mental Health Service Providers in Michigan. The groups are described in terms of clinical diagnoses, overall impairment in functioning, past and current usage of services from other agencies (i.e., juvenile justice, social services), and caregiver resourcefulness. From most to least impaired, the clusters were: Substance Users/Externalizers, Comorbid/Self-Harmful, Delinquents, Marked/School Problems, and Adjustment Problems with Impairment/Secondary Prevention. The results are being used to help identify the most impaired SED youths, develop specific programs and services for the different types of youths being served, determine staff training needs, and foster clinical practice in which the youth's progress is continually monitored.
Help-seeking Steps and Service Use for Children in Foster Care...271-285
Zima, B.T., Bussing, R., Yang, X., and Belin, T.R.
Abstract: This study describes help-seeking steps and service-use patterns for school-aged children in foster care. It also examines how these access indices are moderated by sociodemographic, enabling, and child disorder factors. Two home interviews and a telephone teacher interview were conducted using a sample of 302 randomly selected children (aged 6-12 years) in foster care. The majority of children (80%) were given a psychiatric diagnosis, and 43% of the foster parents perceived a need for mental health services for the child. In the past year, about one-half of the children had received mental health (51%) and special education services (52%). Age and ethnicity, foster parent education, placement history, level of monthly benefits, number of caseworker visits, and disorder characteristics were related to help-seeking steps and mental health service use. Strategies to improve access to mental health services for children in foster care should include interventions at the caregiver and system levels.
Longitudinal Effects of Integrated Treatment on Alcohol Use for Persons with Serious Mental Illness and Substance Use Disorders...286-302
Herman, S.E., Frank, K.A., Mowbray, C.T., Ribisl, K.M., Davidson, W.S., BootsMiller, B., Jordan, L., Greenfield, A.L., Loveland, D., Luke, D.A.
Abstract: A randomized experimental design was used to assign participants to an integrated mental health and substance use treatment program or to standard hospital treatment. A multi-level non-linear model was used to estimate hospital treatment effects on days of alcohol use for persons with serious mental illness and substance use disorders over 18 months. The integrated treatment program had a significant effect on the rate of alcohol use at two months post-discharge, reducing the rate of use by 54%. Motivation for sobriety at hospital discharge, post-treatment self-help attendance, and social support for sobriety were also found to reduce the rate of use during the follow-up period. Implications for mental health treatment and aftercare support are discussed.
Issues and Outcomes in Integrated Teatment Programs for Dual Disorders...303-313
Jerrell, J.M., Wilson, J.L., and Hiller, D.C.
Abstract: In an integrated, dual disorder treatment program delivered at two sites, the authors address numerous barriers to delivering services to dually diagnosed consumers, and employ a set of multidimensional indicators to assess outcome. Consumers who received services through the well-implemented, integrated services program for 12 months were functioning better in the community. There was a cost-shifting from mental health to drug and alcohol services, as well as a one-third increase in the total costs of care by the end of the first year of treatment. Program implementation issues are described and the clinical management implications for more effectively serving dually diagnosed consumers through integrated treatment programs are discussed.
The American Red Cross Disaster Mental Health Services: Development of a Cooperative, Single Function, Multidisciplinary Service Model...314-320
Weaver, J.D., Dingman, R.L., Morgan, J., Hong, B.A., and North, C.S.
Abstract: Not until 1989 did the Red Cross officially recognize a need for a systematic and organized plan for the mental health needs of disaster survivors. Over the next decade, the Red Cross Disaster Mental Health Services program has developed and evolved to assist both disaster victims and the Red Cross workers who serve them to cope with the overwhelming stresses encountered by both groups in the aftermath of disasters. The Red Cross now coordinates a large and diverse group of mental health professionals from fields of psychology, psychiatry, nursing, social work, marriage and family therapy, and counseling who work together cooperatively. Cross-disciplinary conflicts are minimized by the Red Cross' generic approach to the various mental health professional specialties as functionally interchangeable in performing Red Cross duties. This article reviews the development of this process and describes one local Red Cross chapter's early experience as part of this effort.
Identifying Clinical Competencies that Support Rehabilitation and Empowerment in Individuals with Sever Mental Illness...321-333
Young, A.S., Forquer, S.L., Tran, A., Starzynski, M., and Shatkin, J.
Abstract: Individuals with severe mental illness often do not receive appropriate treatment or rehabilitation. One approach to improving their care begins by identifying competencies that clinicians should possess. This project developed a set of core clinical competencies that pertain to community-based care and support the goals of empowerment and rehabilitation. Development of the competency set began with review of existing literature and competency statements, and focus groups and interviews with clients, family members, clinicians, managers, experts, and advocates. Representatives from each of these groups participated in a national panel, and used a structured process to identify 37 final competencies. Panel members agreed that the these competencies are very important in determining outcomes and often are not present in current clinicians. This project demonstrates that it is possible to develop a core competency set that can be strongly supported by diverse groups of stakeholders. These competencies may be useful in clinician training, recruitment, and credentialing efforts.
Large Employers' Selection Criteria in Purchasing Behavioral Health Benefits...334-338
Rost, K., Smith, J., and Fortney, J.
Abstract: In order to determine the criteria other than cost large employers use in selecting and monitoring behavioral health benefits, this study interviewed 31 of 44 (70.4%) randomly selected corporations employing at least 5,000 workers. While over 60% of employers considered administrative efficiency and provider access to be very influential in their selection of behavioral health benefits, only 12.9% (95% confidence interval (CI) 0.7%-25.1%) considered clinical outcomes. Employers who considered clinical outcomes in their purchasing decision reported significantly greater satisfaction with the quality and cost of their behavioral health benefits. Following selection, 38.7% of corporations used employee complaints to monitor quality problems in their behavioral health benefits; 3.2% used clinical outcomes. If society expects employers to purchase behavioral health care on the basis of quality as well as cost, more employers need better indicators of quality.
Predictors of Patient Entry into Alcohol Treatment after Initial Diagnosis...339-346
Kirchner, J.E., Booth, B.M., Owen, R.R., Lancaster, A.E., and Smith, G.R.
Abstract: To improve the quality of care for alcohol-related disorders, key transitions in the continuum of care, including treatment entry must be fully understood. The purpose of this study was to investigate identifiable predictors of patient entry into a substance use treatment program following the initial diagnosis of an alcohol-related disorder on a medical or surgical inpatient unit. An administrative computerized database was used to identify the sample for this study. Inpatient and outpatient records were obtained from the Little Rock VAMC/DHCP. Predictors of patient entry into treatment within six months of the initial diagnosis of an alcohol related disorder included: age less than 60 (OR=4.6), not married (OR=1.7), primary diagnosis of an alcohol-related disorder (OR=7.7), diagnosis of a comorbid drug (4.3) or psychiatric disorder (OR=3.6), and diagnosis by a medical as opposed to a surgical specialty (OR=6.0).
HIV-Related Services for Persons with Severe Mental Illness: Policy and Practice in New Hampshire Community Mental Health...347-353
Brunette, M.F., Mercer, C.C., Rosenberg, S.D., Carlson, C.L., and Lewis, B.
Abstract: Rates of Human Immunodeficiency Virus (HIV) and HIV risk behaviors are elevated among people with severe mental illnesses (SMI). Little is known about the extent to which community mental health (CMH) centers screen, refer, and educate their clients regarding HIV and sexually transmitted diseases (STDs). The authors surveyed CMH administrators and clinicians in New Hampshire regarding HIV/STD policy, practices, knowledge, and attitudes. HIV/STD service availability varied and the amount of services provided was unrelated to the prevalence of HIV and AIDs in that region. Clinicians were knowledgeable about general HIV information but lacked specific knowledge about HIV related to persons with SMI. CMH staff had positive attitudes about helping clients with HIV issues. Administrators were interested in receiving training. Policy leadership, CMH practice guidelines, and training are warranted in light of the pressing public health implications of HIV/STDs among people with SMI.
Number 4 / October 2000
The Impact of Women's Family Status on Completion of Substance Abuse Treatment...366-379
Scott-Lennox, J., Rose R., Bohlig, A., and Lennox, R.
Abstract: This study examines the role of family status and demographic characteristics in explaining the nearly 60% dropout rate for women in substance abuse treatment. Data from the administrative record files of the Illinois Office of Alcoholism and Substance Abuse (OASA) for the fiscal year 1996-1997 were analyzed for women age 12 or older who completed intake for publicly funded substance abuse treatment and whose outpatient treatment records were closed at yearend. Multivariate logistic regression models found that the likelihood of not completing treatment was greatest for women who were African American, pregnant, had custody of minor children, or were under age 21. However, African American women who had children in foster care were more likely to complete treatment. Implications for treatment and research are discussed.
Developing Services for Substance Abusing HIV-positive Youth with Mental Health Disorders...380-389
Stanton, A., Kennedy, M., Spingarn, R., and Rotheram-Borus, M.
Abstract: Models of program development have primarily focused on the internal organizational processes needed to plan, implement, and evaluate new service programs. However, creating an external demand for new programs by policymakers, administrative bureaucracies, public health officials, and funders is critical to establishing new programs. A series of deaths of seropositive youth and an absence of local service settings with staff trained to address the needs of youth living with HIV provided the impetus for Larkin Street Youth Center (LSYC). In particular, the agency with expertise in serving high-risk and seropositive youth had to overcome stigma associated with having both substance use and mental health disorders in order to establish service programs to recruit and to mobilize staff within the agency and the local community, in order to establish a comprehensive housing program for symptomatic HIV-infected adolescents. This article examines how a residential assisted care facility for HIV-seropositive adolescents was established using organizational strategic planning processes, problem solving, and social marketing frameworks.
What Happens When Capitated Behavioral Health Comes to Town? The Transition from the Fort Bragg Demonstration to a Capitated Managed Behavioral Using the CAFAS: Implications for Service Planning... 390-405
Heflinger, C. and Northrup, D.
Abstract: Capitated managed care contracts for behavioral health services are becoming more prevalent across the country in both public and private sectors. This study followed the transition from a demonstration project for child mental health services to a capitated managed behavioral health care contract with a for-profit managed care company. The focus of the study was on the impact--at both the service system and the individual consumer level--pertaining to the start up and maintenance of a capitated managed behavioral health program. A case study using multiple methods and multiple sources of information incorporated a program fidelity framework that examined micro to macro levels of program implementation. The findings of this study include: access to services decreased, the lengths of stay and average daily census in the more intensive levels of treatment declined, difficult-to-treat children were shifted to the public sector, and ratings of service system performance and coordination fell. Implications for health planners, funding agencies, and program administrators are discussed.
Predictors of Posttraumatic Stress Symptoms in OK City: Exposure, Social Support, Peri-Traumatic Responses...406-416
Tucker, P., Pfefferbaum, B., Nixon, S. and Dickson, W.
Abstract: Eighty-five adults seeking mental health assistance six months after The Oklahoma City bombing were assessed to determine which of three groups of variables (exposure, peri-traumatic responses, and social support) predicted development of posttraumatic stress symptoms. Variables most highly associated with subsequent PTSD symptoms included having been injured (among exposure variables), feeling nervous or afraid (peri-traumatic responses), and responding that counseling helped (support variables). Combining primary predictors in the three areas, PTSD symptoms were more likely to occur in those reporting counseling to help and those feeling nervous or afraid at the time of the bombing. Implications of these findings are discussed for behavioral health administrators and clinicians planning service delivery to groups of victims seeking mental health intervention after terrorist attacks and other disasters.
The Co-occurrence of Psychiatric and Substance Use Diagnoses in Adolescents in Different Service Systems: Frequency, Recognition, Cost, and Outcomes...417-430
King, R., Gaines, L., Lambert, W., Summerfelt, W., and Bickman, L.
Abstract: The comorbidity were analyzed in the Fort Bragg Demonstration Project. Comorbidity was defined as the co-occurrence of substance use disorder (SUD) with other psychiatric diagnosis. The sample consisted of 428 adolescent clients whose providers' diagnoses were compared with research diagnoses. The project identified 59 clients (13.8 %) with SUD, all with additional psychiatric diagnoses. Providers recognized only 21 of these 59 comorbid cases. The frequency and severity of comorbidity did not differ between service system samples though recognition did. Comorbid clients had more behavior problems and more functioning impairment, and their average treatment cost ($29,057) was more than twice as high as that of non-comorbid clients ($13,067). Mental health outcomes were not influenced by type of service system nor by comorbid diagnosis or treatment. Screening for and prevention of SUD are discussed as a potential cost savings opportunity in mental health services.
The National Outcomes Management Project: A Benchmarking Collaborative...431-436
Dewan, N., Daniels, A., Zieman, G., and Kramer, T.
Abstract: Traditional evaluation of heath care quality usually involves the measurement of the structure, process, and outcome of care.1 Most quality improvement programs involve a cycle that includes a setting of goals, a measurement of either process or outcomes, and a real-time or retrospective feedback of the results of data measurement.2 Benchmarking, a well known efficient business technology, can lead to practice innovations necessary to survive in an environment that has a need for decreasing cost and increasing quality. The purpose of this article is to present a novel use of benchmarking in managed ambulatory behavioral healthcare and its application in a model collaborative outcome management project at over sixteen sites and nine states in the United States.
Implementing Capitation of Medicaid Mental Health Services in Colorado: Is "Readiness" A Necessary Condition?...437-445
Bloom, J., Devers, K., and Wallace, N.
Abstract: Two consortia of community mental health centers in Colorado varied in their administrative readiness for changing to a capitated system and, ultimately, implemented capitation using different organizational arrangements. The objective was to assess the impact of this natural experiment on administrative change, costs, and utilization of services during the first two years post-capitation. Prior to capitation, one was rated as having greater "readiness" than the other and received a capitation contract from the state while the other did not. A private, for-profit managed behavioral health organization was awarded a contract and formed a joint venture with the less "ready" consortium, providing managed care expertise to compliment the consortium's expertise in delivering mental health services. Two years later, these consortia do not look different either administratively or in their patterns of service utilization and costs. These findings suggest alternative ways of successfully implementing a capitated public mental health system.
Screening and Brief Intervention for Hazardous Drinking in an HMO: Effects on Medical Care Utilization...446-453
Freeborn, D., Polen, M., Hollis, J., and Senft, R.
Abstract: This study examined whether a brief intervention to reduce hazardous alcohol consumption among primary care patients reduced use of medical care. In a parent, randomized controlled trial, at-risk drinkers identified in HMO outpatient waiting rooms were randomly assigned to receive usual care or brief clinician advice plus a 15-minute motivational counseling session. The current study (n=514) examined the groups' use of outpatient and inpatient medical services during two-years after intervention. Although the intervention reduced alcohol consumption at 6-month follow-up, intervention and control groups made similar numbers of outpatient visits (mean 17.7 vs. 18.3, respectively; p=.47), were equally likely to be hospitalized (21.2% vs. 22.0; =.81), and, among those who were hospitalized, had similar lengths of stay (4.7 vs. 6.6 days; p=.37). Although brief interventions to reduce hazardous drinking may potentially reduce medical care utilization, more evidence is needed to substantiate their practicality and cost-effectiveness.
Utilization of Local Jails and General Hospitals by State Psychiatric Center Patients...454-459
Banks, S., Stone, J., and Pandiani, J.
Abstract: The idea that the deinstitutionalization of state psychiatric centers has resulted in increased utilization of general hospitals and correctional facilities by people with severe and persistent mental illness is widely held. This hypothesis of transinstitutionalization was tested by examining hospitalization and incarceration rates of people who had been or would be institutionalized in state psychiatric centers in 16 upstate New York counties. The results do not support the hypothesis of transinstitutionalization. Assumptions underlying the hypothesis are examined, potential explanations for the observed patterns are discussed, and areas for further research are suggested.
