Managed care, meet community support: ten reasons to include direct support services in every behavioral health plan.

Managed care, meet community support: ten reasons to include direct support services in every behavioral health plan. As the United States United States,officially United States of America, republic (2005 est. pop. 295,734,000), 3,539,227 sq mi (9,166,598 sq km), North America. The United States is the world's third largest country in population and the fourth largest country in area. nears the third decade of what is generallyreferred to as managed behavioral health Behavioral health was first used in the 1980's to name the combination of the fields mental health and substance abuse. As an example, an organization serving both mental health and substance abuse clients might refer to its practice as behavioral health or ," state mental healthofficials, Medicaid policymakers, and managed care executives have begunto address the problem of how to serve adequately the multifaceted needsof customers who are disabled by serious mental illness. The paradigm ofmanaged mental health care as applied to healthier populations clearlywould be inadequate and possibly disastrous if adopted for a populationthat is poor, severely disabled, and already underserved. This articleis a call for public and private mental health decision makers to use atreatment approach that for 20 years has proven itself to be clinicallyefficacious, consumer friendly, and cost-effective - assertive communitytreatment Assertive community treatment, or ACT, is a form of total in-community care for people with serious, long-term mental illness.[1][2] DefinitionThe defining characteristics of ACT include: (ACT). Before state hospitals were depopulated, they provided acomprehensive bundle of services to patients. It was singlepoint servicethat could be delivered for a short period or a lifetime. Although the"total institution" described by Goffman (1961) calls to mindthe unfavorable aspects of institutionalization InstitutionalizationThe gradual domination of financial markets by institutional investors, as opposed to individual investors. This process has occurred throughout the industrialized world. , there also were someadvantages to this system - principally, the coordinated delivery ofintensive services to a population with severe illness. Whenpharmacology, concern for civil liberties, and budget cutting at thestate level emptied the hospitals, planning for aftercare in thecommunity was often an afterthought. Marx, Test, and Stein (1973),reporting on what was then termed "extrohospital management,"called into question the practice of preparing patients for communityliving only while in the hospital. Teaching basic living skills on aninpatient ward was shown to speed discharge, although there was verylittle effect on outpatient adjustment or length of stay in thecommunity. When Marx, Test, and Stein (1973) were working at Mendota StateHospital in Madison, Wisconsin Madison is the capital of the U.S. state of Wisconsin and the county seat of Dane County. It is also home to the University of Wisconsin–Madison.The 2006 population estimate of Madison was 223,389, making it the second largest city in Wisconsin, after Milwaukee, and , they pioneered a new concept in mentalhealth treatment. Rather than teach life skills in the hospital, theirinnovation was to provide training and support where it would be needed- in the community. This first generation of community support wascalled "total in-community treatment." In a controlled study,hospitalization rates were reduced dramatically, and competitive workactivity increased. Furthermore, the community was found to be receptiveto those participating in the program, and clinical gains did notincrease the burden on families. The intensive community support concept came to be referred to asthe "Madison Model," and underwent refinements throughout the1970s. Total in-community treatment was supplanted by the Training inCommunity Living (TCL See Tcl/Tk. Tcl - Tool Command Language ) program, which took more responsibility forlinking clients with basic services basic services,n.pl frequently insurance companies split dental procedures into basic and major categories. Basic services usually consist of diagnostic, preventive, and routine restorative dental services. and entitlements. In a major stepthe program also assigned total responsibility for client care to thetreatment team. If a service could not be brokered, the team was chargedwith providing it (Thompson, Griffith, & Leaf, 1990). The larger program at Mendota State Hospital that developed TCL wasthe Program for Assertive Community Treatment (PACT). Many programs thatreplicate the Madison Model are called PACT or ACT programs. Stein andTest each later modified the PACT concept, with Stein designing a MobileCommunity Treatment program, and Test developing assertive continuoustreatment teams (Stein & Diamond, 1985; Test, Knoedler, &Allness, 1985). Mobile outreach and continuous treatment approaches haveproliferated on the basis of this groundbreaking work. Today public orprivate agencies serving clients with serious and persistent mentalillness would be negligent if they failed to provide some variant ofcommunity support that can trace its roots back to the Madison Model. EVIDENCE OF EFFECTIVENESS Clinical Outcomes Hospitalization rates are the most critical indicator for acommunity-support program. To highlight the primary goal - less time inthe hospital and a more normalized lifestyle for the client - mostcommunity-support systems track admissions to general hospitals andstate institutions. Beginning with a controlled study of the TCL program(Stein & Test, 1980), community-support programs have been found toreduce time spent in the hospital. In the early TCL program, hospitaltime was reduced to only 6 percent for the experimental group comparedwith 58 percent for the control group. In a later study that was limitedto young adults with schizophrenia, Test et al. (1985) found that after18 months of TCL, clients spent a mean of 6.51 days in inpatient care inpatient careManaged care Services delivered to a Pt who needs physician care for > 24 hrs in a hospital ,compared with 38.74 days in inpatient care for clients receiving theusual care provided by the county. This statistic is all the moreremarkable given that the site for the study was Dane County, Wisconsin Dane County is a county located in the U.S. state of Wisconsin. As of 2000, the population was 426,526. Its county seat is Madison6. The United States Census Bureau's Madison Metropolitan Statistical Area includes all of Dane County (as well as neighboring Iowa and ,where the usual treatment afforded to clients with chronic mentalillness included crisis intervention crisis interventionPsychiatry The counseling of a person suffering from a stressful life event–eg, AIDS, cancer, death, divorce, by providing mental and moral support. See Hotline. , day treatment programs, anoutpatient clinic, vocational services, and a continuum of availablehousing (Stein & Diamond, 1985). The first reported adaptation of the Madison Model to a new servicearea took place in Chicago. The Thresholds Program, a large psychiatricrehabilitation Psychiatric rehabilitation, also known as Psychosocial rehabilitation, is the process of restoration of community functioning and wellbeing of an individual who has a psychiatric disability (been diagnosed with a mental disorder). agency that adopted ACT concepts, coordinated dischargeand aftercare for "heavy users" of inpatient services, with a19 percent decrease in hospital days over a three-year period, whereashospitalizations among the comparison group increased 18 percent(Dincin, 1990). Multisite studies (Bond, Miller, Krumwied, & Ward,1988; McGrew, Bond, Dietzen, McKasson, & Miller, 1995) andmeta-analyses (Burns & Santos, 1995; Olfson, 1990) uniformly showedreductions in use of psychiatric hospitals when ACT, TCL, or continuoustreatment team models were used to deliver community support services support servicesPsychology Non-health care-related ancillary services–eg, transportation, financial aid, support groups, homemaker services, respite services, and other services . Cost-Effectiveness Madison Model community services are certainly labor intensive Labor IntensiveA process or industry that requires large amounts of human effort to produce goods.Notes:A good example is the hospitality industry (hotels, restaurants, etc), they are considered to be very people-oriented.See also: Capital Intensive, Trading Dollars ,especially compared with case management programs that are limited to"brokering" for a vastly greater number of clients.Interdisciplinary teams that include a staff psychiatrist, nurse,vocational specialist, social workers, and clerical staff are expensiveif caseloads are kept in the recommended ratio of 10 to 1. Consequently,the cost savings of community treatment became an important researchquestion. A cost-benefit analysis was included in the research on theoriginal TCL program. Weisbrod, Test, and Stein (1980) found thatalthough there were higher direct costs associated with intensivecommunity support, these costs were offset by substantial savings inindirect social costs. It was estimated that the benefits outweighed thecosts by approximately $400 per patient per year. Providing superior treatment and rehabilitation services in thecommunity at equal or lower cost than custodial care Custodial CareNon-medical care that helps individuals with his or her activities of daily living, preparation of special diets and self-administration of medication not requiring constant attention of medical personnel. at increasinglyantiquated state hospitals appeared to benefit all of the stakeholders.However, in the highly politicized terrain of state mental healthpolicy, some legislators and administrators saw these clinical advancesas an opportunity to slash the budgets of large institutions with littleof the savings redirected to community-support programs. New federalprograms such as Supplemental Security Income Supplemental Security IncomeA Social Security program established to help the blind, disabled, and poor. (SSI (1) See server-side include and single-system image.(2) (Small-Scale Integration) Less than 100 transistors on a chip. See MSI, LSI, VLSI and ULSI. 1. (electronics) SSI - small scale integration.2. ) and Medicaid createda policy tug-of-war between states and the federal government thatcontinues to be a topic for discussion and debate (Grob, 1994; Isaac& Armat, 1990; Johnson, 1990). For community support to rise above the funding fray, programs wereexpected to demonstrate cost savings. Bond, Dincin, Setze, andWitheridge (1984) studied the Thresholds Clubhouse and Bridge ACTprograms and reported annual savings per client of $1,800 and $5,700,respectively. Community-support and psychosocial-rehabilitation programsbegan to prove their cost-effectiveness, yet there was no rush to startACT programs. Throughout the 1980s, community-support advocates had tocontend with powerful, politically entrenched state hospital systemsthat were unwilling to relinquish the funding and influence accrued overdecades of managing large institutions. In the early 1980s 70 percent ofevery dollar spent on mental health in the United States was forhospital services. During the same period in Dane County, Wisconsin, thebirthplace of ACT, only 17 percent of mental health funding was spent onhospital care, whereas 83 percent supported community-based treatment(Stein & Diamond, 1985). As more controlled studies were completed throughout the late 1980sand into the 1990s, it became increasingly clear that ACT andcommunity-support programs with a similar design were cost-effective.Savings were reported to be greater with certain subgroups of clients,such as those discharged from psychiatric hospitals compared with thosedischarged from general hospitals and veterans over age 45 (Burns &Santos, 1995). In reporting on three community mental health centersthat adopted a PACT-hybrid assertive case management (ACM (Association for Computing Machinery, New York, www.acm.org) A membership organization founded in 1947 dedicated to advancing the arts and sciences of information processing. In addition to awards and publications, ACM also maintains special interest groups (SIGs) in the computer field. ) program, Bondet al. (1988) found that one center saved an impressive sum of $5,490per client, one broke even, and one lost money with the ACM model.Interestingly, the center that proved to be cost-effective had the mostclient contact. Santos et al. (1993) cited a figure of $18,800 per year per patientfor public hospital care plus traditional outpatient care. Overall costwas reported to have decreased to $11,300 with ACT teams - a reductionof 40 percent. In discussing limitations of the study, it is noted that"expensive" patients were not included. Expensive patientswere defined as, "persons dependent on others for basic personalcare and patients with a history of violent behavior" (p. 503).Although the study included people with severe and persistent mentalillness (schizophrenia and schizoaffective disorder Schizoaffective DisorderDefinitionSchizoaffective disorder is a mental illness that shares the psychotic symptoms of schizophrenia and the mood disturbances of depression or bipolar disorder. ), the mention ofexpensive patients likely refers to a well-known subgroup of consumersthat uses a disproportionate share of available resources. Treatment forthis group is undeniably expensive. Reed, Hennessy, and Babigian (1995)estimated the annual average cost to society of maintaining people withsevere disabilities caused by mental illness in Rochester, New York This article is about the city of Rochester in Monroe County. For the town in Ulster County, see Rochester, Ulster County, New York. Rochester, once known as The Flour City, and more recently as The Flower City or , tobe $30,837 in 1992 dollars, excluding the cost of legal and socialservices social servicesNoun, plwelfare services provided by local authorities or a state agency for people with particular social needssocial servicesnpl → servicios mpl sociales. Wolff, Helminiak, and Diamond (1995) arrived at a similarfigure of $29,965 in 1994 dollars for clients in a Madison, Wisconsin,mobile community treatment program. In Philadelphia, the average annual cost per client in a communitytreatment team program was reported to be $58,000 (Hadley, Turk, Vasko,& McGurrin, 1997). Thus, promises of huge cost savings must beexamined critically. If money is saved from downsizing state hospitals,it is crucial that it follow the consumer into the community. Otherwise,the locus of care has not been shifted; rather, care has beendiscontinued. Consumer Satisfaction Consumer satisfaction was not extensively studied in the early TCLand ACT programs. The founding TCL study rated patient satisfaction withlife on an eight-item scale and rated self-esteem on a 10-item scale.Significantly greater satisfaction was reported at 12 months among theTCL patients; however, there was no significant difference inself-esteem (Stein & Test, 1978). In Seattle, Wright, Heiman, Shupe, and Olvera (1989) surveyedpatients in an intensive community support program, and 78.5 percentevaluated their lives as being somewhat or much better since enteringthe program. A study of six ACT programs in northeastern Indiana byMcGrew et al. (1995) found client quality-of-life ratings increased atthe six-month point and showed continued improvement at the 18-monthfollow-up. ACT was credited with decreasing the number of clientswithout regular income from 11.3 percent to 3.1 percent over 12 monthsby assisting these clients in obtaining disability payments. There wasless success with earned income, because the number of clients engagedin sheltered or competitive employment remained flat. Community-support models of all types seem to benefit consumers tosome degree over "deskbound" case management. Olfson (1990)noted that patients consistently preferred community services overhospital-based care, and every study measuring consumer opinion hasfound that those who received community treatment were more pleased withtheir care. Consumers are very capable of weighing the advantages anddisadvantages of a less restrictive environment. They consistently havefavored community-based services of sufficient quality not just tomaintain stability but to facilitate their integration into the fabricof the community. COMMUNITY SUPPORT AND MANAGED CARE In essence, public sector care always has been managed. Almshouses,asylums, psychopathic psy��cho��path��icadj.1. Of, relating to, or characterized by psychopathy.2. Relating to or affected with an antisocial personality disorder that is usually characterized by aggressive, perverted, criminal, or amoral behavior. hospitals, state hospitals, and community mentalhealth centers all had something in common - a fixed budget andresponsibility to serve all who seek services. This"metacapitation" worked well when times were good and budgetskept pace with demand and worked poorly when political decisions blockedexpansion or imposed cutbacks. Approximately during the past 10 years, psychiatric care forspecific populations of mental health consumers has been micromanagedthrough arrangements that have come to be known as "managedbehavioral health care," or more generically "managedcare." Because managed care has expanded from coveringpredominantly healthy enrollees to contracting for the care ofpublic-sector clients with severe illness or permanent disability, itseems fair to ask if the philosophy is compatible for this populationand if managed behavioral health organizations are up to the task. Although it is undeniable that the culture and assumptions ofprivate managed behavioral health care organizations are different fromthose of the public sector, they are not incompatible. Rose and Keigher(1996) asserted that managed behavioral health care is driven primarilyby two assumptions regarding costs: (1) that unnecessary care is beingprovided and (2) that the care is inappropriately intensive for thepatient's condition. ACT programs have an unparalleled record ofdiverting prospective patients from hospitalization, which is certainlythe most expensive treatment option. Mental health professionals arevery familiar with situations in which a client was admitted to apsychiatric unit simply because all other means of support hadcollapsed. ACT programs address both of the cost-driven assumptions ofmanaged care. Unnecessary inpatient care is eliminated, and consumersare maintained in the community with frequent intervention that is lessintensive and less costly than hospitalization. Quality of care in managed behavioral health care is to a greatextent determined by the culture and capabilities of the company.Evaluation seems to depend on whose perception is perceived as accurateand unbiased. Massachusetts was one of the first states to implementmanaged behavioral health care for its entire Medicaid population.Reviews of the transition have been mixed. Dumont (1996) was sharplycritical, Leadholm and Kerzner (1995) viewed the changes positively, andBeinecke, Shepard, Goodman, and Rivera (1997) recognized improvements aswell as deficiencies in the system. Massachusetts, Iowa, and Colorado reportedly have succeeded inredirecting some of their managed behavioral health care savings intostrengthening services. A savings of $47 million allowed Massachusettsto increase the range of 24-hour mental health and substance abuseservices. Iowa added 10 new services, including community support andmobile crisis outreach teams in the first year of a mental health accessprogram, and this addition ultimately saved $6 million more thanfee-for-service Medicaid. Colorado is credited with reinvestingsignificant managed care savings in systems improvement. Emergencyservices emergency servicesEmergency care '…services …necessary to prevent death or serious impairment of health and, because of the danger to life or health, require the use of the most accessible hospital available and equipped to furnish those services' , client transportation, family support, and wraparound WraparoundA financing device that permits an existing loan to be refinanced and new money to be advanced at an interest rate between the rate charged on the old loan and the current market interest rate. servicesreportedly have been strengthened (Croze croze?n.A groove inside the end of a barrel or cask into which the head is set.[French creux, from Old French crues, groove, from Vulgar Latin *crosus, , 1998). In California, Penner(1995) reported that pilot projects' demonstrated funds can berealigned under managed care for flexible service delivery withoutadverse effects on client outcomes. As encouraging as these reports may be, advocates for people withserious mental illness often see things differently. The NationalAlliance for the Mentally Ill published a "report card" onmanaged care in which the industry was given a failing grade for"too strong a focus on restrictive gate-keeping, . . . too manybarriers to care, . . . and provide the important clinical and supportservices necessary for people with disabling and chronic disorders"(Hall, Edgar, & Flynn, 1997, p. 40). In the section of the reportcard covering ACT, managed care nationally received an "F" forfailing to provide P/ACT programs or for severely restricting access. These diverse views of the same system illustrate how servingMedicaid recipients and other publicly funded clients is a much morecomplex task than managing employee assistance program benefits for alarge corporation. Severe and disabling illnesses that require alifetime of treatment call for a new approach to managed care. Hoge,Davidson, Griffith, Sledge, & Howenstine (1994) advocated a morecomprehensive variety of managed care in the public sector, involving"the organization of an accessible and accountable service deliverysystem that is designed to consolidate and flexibly deploy resources toprovide comprehensive, continuous, cost-efficient, and effective mentalhealth services health servicesManaged care The benefits covered under a health contract to targeted individuals in their home communities"(p. 1087). To operationalize such a definition would require a farbroader application of "medical necessity" than the managedbehavioral health industry is accustomed to, particularly for-profitcompanies. Dixon and Croze (1997), writing on behalf of the American ManagedBehavioral Health Care Association and several community mental healthorganizations, acknowledged that for recipients of public sectorbehavioral health services, the likelihood of achieving even minimaltreatment goals is diminished without "a broad array ofpsychosocial, vocational, and housing services typically not covered not coveredHealth care adjective Referring to a procedure, test or other health service to which a policy holder or insurance beneficiary is not entitled under the terms of the policy or payment system–eg, Medicare. Cf Covered. inprivate sector managed care plans" (p. 69). I interpret that tomean community support. The following 10 field-tested reasons forproviding community support in every behavioral health plan have beendeveloped through my direct service experience with clients whoseserious mental illness and psychosocial problems require assertiveintervention. TEN REASONS TO INCLUDE COMMUNITY SUPPORT 1. Decreased Hospitalization Means Lower Cost of Care Consumers who have access to more intensive support are unlikely todecompensate decompensate,n the development or worsening of a mental disorder. to a point where they are a danger to themselves or others.Home visits allow for consistent monitoring of consumer competence forself-care and accomplishing basic daily-living tasks. Lesshospitalization means less high-cost care for the payer and fewer socialcontrol measures associated with mental health treatment. Eliminating the revolving door of repeated hospitalizations onceassociated with severe mental illness has been made easier by theintroduction of new antidepressants and novel antipsychotic antipsychotic/an��ti��psy��chot��ic/ (-si-kot��ik) effective in the treatment of psychotic disorders; also, an agent that so acts. Antipsychotics are a chemically diverse but pharmacologically similar class of drugs; besides psychotic medicationswith minimal side-effects and superior efficacy compared with theirpredecessors. The integration of community support, basic socialservices, and state-of-the-art psychiatric treatment virtuallyguarantees that inpatient costs will decrease. In a Seattle study,Wright et al. (1989) reported an 80 percent reduction in the number ofhospital days. In a later study that included only patients with highrates of psychiatric hospitalization and noncompliance with medication,Santos et al. (1993) found that time hospitalized was decreased 94percent by implementation of 24-hour ACT teams. Jerrell (1995) compared PACT, broker, and hybrid models in acontrolled cost-effectiveness study, finding the PACT model to be mostsuccessful at reducing intensive (acute and subacute) expenditures;receipt of more supportive services was associated significantly withlower costs. The PACT adaptation was best able to provide the servicesneeded by each client and to control client use of costly intensiveservices, which were noted to be the "hallmarks of managedcare" (p. 206). 2. Normalization In relational database management, a process that breaks down data into record groups for efficient processing. There are six stages. By the third stage (third normal form), data are identified only by the key field in their record. Consumers respond favorably to interaction in the community that isnot associated with mental health treatment. An important function ofcommunity-support workers is to act as guides and assist withparticipation in activities that are not necessarily"treatment" in a narrow sense. But this process is sometimesslow, because establishing basic supports takes precedence. Whenpsychiatric and social services are in place and the recovery gainsmomentum, most consumers will identify an interest to pursue.Educational, vocational, and housing goals are most common; however,less challenging plans such as joining the YMCA YMCAin full Young Men's Christian AssociationNonsectarian, nonpolitical Christian lay movement that aims to develop high standards of Christian character among its members. or choosing a hobby alsolead to improvement. 3. Linkage to Resources Community support workers and teams must be familiar with everyaspect of entitlements and benefits their clients are eligible for andmust be prepared to link their clients to these programs. Investigating,facilitating, and following up on services provided by outside agenciesis crucial. These agencies, particularly social welfare and Medicaidauthorities, may not have a grasp of what is involved in treatingserious mental illness. In some instances they may be overtly hostile.Given how little is usually available for people with a disability,resource acquisition often determines whether life will be enhanced bySSI, safe housing, and food or whether life will be on the streets. 4. Effective Advocacy Mental illness, be it mild or severe, acute or persistent,potentially is stigmatizing and disempowering. Community-support staffcan confront individuals and institutions in a professional manner toresolve any attempt to slow progress or to defeat client goals.Advocacy, when successful, is a tremendous morale booster Noun 1. morale booster - anything that serves to increase morale; "the sight of flowers every morning was my morale builder"morale buildingboost, encouragement - the act of giving hope or support to someone for anindividual worker, team, or an entire agency. The avenues for advocacyare endless. Social security, family service agencies, Medicaidauthorities, state departments of mental health, clinics, housingauthorities, landlords, and employers are some of the collateralcontacts that may call for advocacy in support of psychiatricrehabilitation. Consumers greatly appreciate advocacy efforts, becausehighly bureaucratized systems often are too much to cope with in theearly stages of recovery. A community-support worker who can navigatethese systems successfully is rightly perceived as one who can producetangible results. 5. Improved Quality of Life Living conditions living conditionsnpl → condiciones fpl de vidaliving conditionsnpl → conditions fpl de vieliving conditionsliving for many mental health consumers are nothingshort of scandalous. In states that do not supplement SSI, the monthlypayment in 1999 is $500. Food stamp food stampn.A stamp or coupon, issued by the government to persons with low incomes, that can be redeemed for food at stores.Noun 1. assistance is sometimes as low as$10 per month. Even with subsidized housing Subsidized housing (aka social housing) is government supported accommodation for people with low to moderate incomes. To meet these goals many governments promote the construction of affordable housing. , after paying bills andrent, disabled consumers often are expected to get by on roughly $200per month - that is, they must purchase clothing, food, furniture, paperproducts, cleaning supplies, child care, transportation, and more with$200 per month, and with even less without Section 8 or other housingassistance. Frequently, social workers are the only mental healthprofessionals with intimate knowledge of just how difficult this taskcan be. Although community support interventions will not change socialpolicy instantly, they can ensure that clients have access to everyavailable support. Food pantries, energy grants, weatherizationprograms, and donations of any kind will make a dent in the poverty thattoo often coexists with mental illness. 6. Respite for Natural Caregivers Caring for a relative with a mental illness is a difficult,sometimes thankless, and always emotionally draining responsibility.Arranging doctor's appointments and lab work, making trips to thepharmacy, seeing that medications are taken correctly, and trying tounderstand the illness can be overwhelming. There is most likely amplecause for worry and a continuing need for coordination of care. The casemanagement component of community support relieves family anxiety aboutproviders and services, and the direct support guarantees that clientswill keep appointments and have an advocate to negotiate systems thatare often reluctant to serve clients with serious mental illness. 7. Consolidated Funding Fragmented funding is a major problem in the provision of mentalhealth services. Dollars for income support, health insurance,psychiatric services, primary medical care, medication, housing, food,and vocational rehabilitation usually come from different agencies and amaze of programs so complex even experienced case managers havedifficulty negotiating them. Capitation holds promise as a managed care innovation that couldtransform mental health services by redirecting care to consumers withmore severe illnesses and disabilities. However, as Reed (1994) stated,it is difficult to bring together the necessary funding streams. Eachentitlement agency would need to develop a method for capitation, andcooperation between related service sectors traditionally has been poor.A number of studies have commented on the risks. Lehman (1987) statedflatly that capitation "in no way protects against inadequatemental health coverage" (p. 33). Mechanic (1991) also noted thatcapitation "does not ensure optimal clinical decision making andmay . . . erect deterrents to needed care" (p. 800). Consequently,it falls on providers, mental health consumers, and their advocates tosee that funding mechanisms such as capitation are used to enhancerather than downsize DownsizeReducing the size of a company by eliminating workers and/or divisions within the company.Notes:When a company downsizes, it is attempting to find ways to improve efficiency and increase profitability.It is sometimes referred to as trimming the fat. community-support programs. 8. Equalization In communications, techniques used to reduce distortion and compensate for signal loss (attenuation) over long distances. of Two-Tiered Systems Traditionally, there have been two distinct approaches to mentalhealth care, depending largely on whether the private or public sectorwas involved. Private insurance plans evolved during the 1930s to covercatastrophic health events,including mental illness. Public health insurance came into beingduring the 1960s with the introduction of Medicare and Medicaid Medicare and MedicaidU.S. government programs in effect since 1966. Medicare covers most people 65 or older and those with long-term disabilities. Part A, a hospital insurance plan, also pays for home health visits and hospice care. ,providing poor, elderly, and disabled people with resources to pay forcare in the private sector. State hospitals and clinics served peoplewithout insurance of any kind. Goldman (1987) termed this situation a"two-class" system of care, which allows private facilities torelease patients into public care when patients are too sick or toodifficult to handle or have illnesses that are too chronic and costly. For people with serious mental illness, long-term public-sectorcare often was superior to the limited coverage provided by privateinsurance. This trend has continued in the managed care era, withMedicaid funding services not commonly offered under private insurance,including the latest medications, psychosocial rehabilitation, andcommunity support. For managing a serious and persistent mental illness,there are distinct advantages to publicly funded programs. Families fromall socioeconomic backgrounds do not hesitate to use these programs whenprivate insurance proves inadequate or is exhausted. Managed behavioral health has restructured the delivery of servicessuch that a particular managed care organization may be handlingprivately and publicly funded contracts. All payers could benefit fromincluding community-support intervention to maintain wellness and tomanage acute crises or serious and persistent illnesses. Keepingappointments, taking medication correctly, managing symptoms, copingwith side effects Side effectsEffects of a proposed project on other parts of the firm. , battling stigma, and averting a collapse of socialsupport are challenges that recognize no class boundaries. 9. Flexibility One of the advantages of community support is the wide variety ofoptions for managers, teams, and individual workers. Team caseloads,individual caseloads, interdisciplinary teams, homogeneous teams,criteria for services, services provided, service intensity, andtreatment domains are but a few of the variables. Morse et al. (1997)included a paraprofessional paraprofessional1. a person who is specially trained in a particular field or occupation to assist a veterinarian.2. allied animal health professional.3. pertaining to a paraprofessional. community worker on one team to assist withactivities of daily living and leisure activities - supports often notprovided by professionals. Community support can be deployed with astrong emphasis on teamwork, or discretion may be granted to individualworkers to provide a level of care matched with each client. 10. Continuum of Care Transferring clients between discrete programs is sometimes aclumsy process when the service intensity does not fit consumer needs.Mental health consumers span a continuum from millionaires to SSIrecipients, from movie stars to people who have total and permanentdisabilities. And, contrary to public perception, people do get better.A person entering treatment is unlikely to require exactly the sameservices one or two years later. Community support provides thefoundation for moving along a continuum toward less intensive treatment,more ambitious goals, and measurable progress in clinical outcomes. Manyconsumers who once had very serious illnesses have made dramaticrecoveries with state-of-the-art treatment. CONCLUSION Providing adequate mental health services always has been astruggle punctuated by hard-won victories against long odds. Managedbehavioral health care has the potential to solve the longstandingproblems of access, continuity, and accountability for consumers withserious and persistent mental illness. This article has contended thatcommunity support - providing direct services at home and anywhere inthe community - has a place in every behavioral health plan. Theproblems of the mental health care system are not new. Almost 20 yearsago, the U.S. Department of Health and Human Services Noun 1. Department of Health and Human Services - the United States federal department that administers all federal programs dealing with health and welfare; created in 1979Health and Human Services, HHS (1980) published areport on serious mental illness that is disturbing by its enduringaccuracy. Chronically disabled and liable to falling ill again, these highlydependent and vulnerable people live on the margin of society, shuffledinto uncertain shelter arrangements, ignored by service providers, andrejected by neighbors. Although most of these people live in communitiesrich in resources and opportunities, they do not fit the servicedelivery conventions of the systems set up to serve other needycitizens. Their behavior and appearance, their poverty and lifehistories evoke such deep-seated fears that, although they live in themidst Adv. 1. in the midst - the middle or central part or point; "in the midst of the forest"; "could he walk out in the midst of his piece?"midmost of the community, they are largely invisible to residents of thecommunity at large. (p. ES-1) For decades the expression, "The more things change, the morethey stay the same," has been eerily applicable to the mentalhealth field. Community support services in every managed behavioralhealth plan would provide a start on breaking the feedback loop ofrecurrent problems and weak solutions. In purchasing services to treatserious mental illness, departments of mental health, Medicaidauthorities, and insurance companies interested in improving behavioralhealth care coverage in private sector products would be wise to includePACT-model community support. Extensive experience in public andnonprofit agencies has shown PACT to be the most cost-effective optionfor treating populations with serious illnesses and disabilities nowbeing enrolled in Medicaid managed behavioral health plans. Behavioral health care services in the managed care era are at riskof declining in quality because of parsimony par��si��mo��ny?n.1. Unusual or excessive frugality; extreme economy or stinginess.2. Adoption of the simplest assumption in the formulation of a theory or in the interpretation of data, especially in accordance with the rule of in the service of profit.Policymakers must be convinced that social work has the tools to treatserious and persistent mental illness efficiently. Fundamental socialwork concepts that date back to the earliest days of the professioncontinue to be a perfect fit for facilitating the successful communityadjustment of clients with serious mental illness (Wintersteen, 1986).Although other disciplines now share an interest in case management andcommunity work, social workers who specialize in mental health remainuniquely qualified as clinicians and advocates to provide leadership forthe development of comprehensive, yet cost-effective care. REFERENCES Beinecke, R. H., Shepard, D. S., Goodman, M., & Rivera, M.(1997). Assessment of the Massachusetts Medicaid managed behavioralhealth program: Year three. Administration and Policy in Mental Health,24, 205-220. Bond, G. R., Dincin, J., Setze, P. J., & Witheridge, T. F.(1984). The effectiveness of psychiatric rehabilitation at Thresholds.Psychosocial Rehabilitation Journal, 7(4), 7-22. Bond, G. R., Miller, L. D., Krumwied, R. D., & Ward, R. S.(1988). 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State-owned assets may be sold to private owners, or statutory restrictions on competition between privately and publicly owned and mental health inMassachusetts. Smith College Studies in Social Work, 66, 292-303. Goffman, E. (1961). Asylums: Essays on the social situations ofmental patients and other inmates. Garden City, NY: Anchor Books. Goldman, H. H. (1987). Financing the mental health system.Psychiatric Annals, 17, 580-585. Grob, G. N. (1994). The mad among us: A history of the care ofAmerica's mentally ill. Cambridge, MA: Harvard University Press The Harvard University Press is a publishing house, a division of Harvard University, that is highly respected in academic publishing. It was established on January 13, 1913. In 2005, it published 220 new titles. . Hadley, T. R., Turk, R., Vasko, S., & McGurrin, M. C. (1997).Community treatment teams: An alternative to state hospital. PsychiatricQuarterly, 68(1), 77-90. Hall, L. L., Edgar, E. R., & Flynn, L. M. (1997). Stand anddeliver: Action call for a failing industry. Arlington, VA: NationalAlliance for the Mentally Ill. Hoge, M. A., Davidson, L., Griffith, E. H., Sledge, W. H., &Howenstine, R. A. (1994). Defining managed care in public-sectorpsychiatry. Hospital and Community Psychiatry, 45, 1085-1089. Isaac, R. J., & Armat, V. C. (1990). Madness in the streets:How psychiatry and the law abandoned the mentally ill. New York New York, state, United StatesNew York,Middle Atlantic state of the United States. It is bordered by Vermont, Massachusetts, Connecticut, and the Atlantic Ocean (E), New Jersey and Pennsylvania (S), Lakes Erie and Ontario and the Canadian province of : FreePress. Jerrell, J. M. (1995). Toward managed care for persons with seriousmental illness: Implications from a cost-effectiveness study. HealthAffairs, 14, 197-207. Johnson, A. B. (1990). Out of Bedlam Bedlam:see Bethlem Royal Hospital. bedlamfrom Hospital of St. Mary of Bethlehem, former English insane asylum. [Br. Folklore: Jobes, 193]See : ConfusionBedlam(Hospital of St. : The truth aboutdeinstitutionalization de��in��sti��tu��tion��al��i��za��tionn.The release of institutionalized people, especially mental health patients, from an institution for placement and care in the community. . New York: Basic Books. Leadholm, B. A., & Kerzner, J. P. (1995). Public managed care:Comprehensive community support in Massachusetts. Administration andPolicy in Mental Health, 22, 543-552. Lehman, A. F. (1987). Capitation payment and mental health care: Areview of the opportunities and risks. Hospital and CommunityPsychiatry, 38, 31-37. Marx, A. J., Test, M. A., & Stein, L. J. (1973). Extrohospitalmanagement of severe mental illness. Archives of General Psychiatry Archives of General Psychiatry is a monthly professional medical journal published by the American Medical Association. Archives of General Psychiatry publishes original, peer-reviewed articles about psychiatry, mental health, behavioral science and related fields. , 29,505-511. McGrew, J. H., Bond, G. R., Dietzen, L., McKasson, M., &Miller, L. D. (1995). A multisite study of client outcomes in assertivecommunity treatment. Psychiatric Services, 46, 696-701. Mechanic, D. (1991). Strategies for integrating public mentalhealth services. Hospital and Community Psychiatry, 42, 797-801. Morse, G. A., Calsyn, R. J., Klinkenberg, W. D., Trusty, M. L.,Gerber, F., Smith, R., Tempelhoff, B., & Ahmad, L. (1997). Anexperimental comparison of three types of case management for homelessmentally ill persons. Psychiatric Services, 48, 497-503. Olfson, M. (1990). Assertive community treatment: An evaluation ofthe experimental evidence. Hospital and Community Psychiatry, 41,634-641. Penner, S. (1995). An evolving managed care system: Public mentalhealth services in San Francisco San Francisco(săn frănsĭs`kō), city (1990 pop. 723,959), coextensive with San Francisco co., W Calif., on the tip of a peninsula between the Pacific Ocean and San Francisco Bay, which are connected by the strait known as the Golden . Administration and Policy in MentalHealth, 22, 273-287. Reed, S. K. (1994). Serious mental illness and capitationfinancing. Behavioral Sciences and the Law, 12, 379-388. Reed, S. K., Hennessy, K. D., & Babigian, H. M. (1995). Settingcapitation rates for comprehensive care of persons with disabling mentalillness. Psychiatric Services, 46, 127-129. Rose, S. J., & Keigher, S. M. (1996). Managing mental health:Whose responsibility? [National Health Line]. Health & Social Work,21, 76-80. Santos, A. B., Hawkins, G. D., Julius, B., Deci, P. A., Hiers, T.H., & Burns, B. J. (1993). A pilot study of assertive communitytreatment for patients with chronic psychotic disorders. AmericanJournal of Psychiatry, 150, 501-504. Stein, L. I., & Diamond, R. J. (1985). A program fordifficult-to-treat patients. In L. I. Stein & M. A. Test (Eds.), TheTraining in Community Living model: A decade of experience (pp. 29-39).San Francisco: Jossey-Bass. Stein, L. I., & Test, M. A. (1978). Alternatives to mentalhospital treatment. New York: Plenum Press. Stein, L. I., & Test, M. A. (1980). Alternative to mentalhospital treatment I. Conceptual model, treatment program, and clinicalevaluation clinical evaluationMedtalk An evaluation of whether a Pt has symptoms of a disease, is responding to treatment, or is having adverse reactions to therapy . Archives of General Psychiatry, 37, 392-397. Test, M. A., Knoedler, W. H., & Allness, D. J. (1985). Thelong-term treatment of young schizophrenics in a community supportprogram. In L. I. Stein & M. A. Test (Eds.), The Training inCommunity Living model: A decade of experience (pp. 17-27). SanFrancisco: Jossey-Bass. Thompson, K. S., Griffith, E. H., & Leaf, P. J. (1990). Ahistorical review of the Madison model of community care. Hospital andCommunity Psychiatry, 41, 625-634. U.S. Department of Health and Human Services. (1980). Toward anational plan for the chronically mentally ill (DHHS DHHS Department of Health & Human Services (US government)DHHS Dana Hills High School (Dana Point, California)DHHS Deaf and Hard of Hearing ServicesDHHS Deaf and Hard of Hearing Services Publication No. HE20.2: M g2). Washington, DC: U.S. Government Printing Office. Weisbrod, B. A., Test, M. A., & Stein, L. I. (1980).Alternative to mental hospital treatment II. Economic benefit-costanalysis benefit-cost analysisa technique of economic evaluation, particularly for complex projects over a long period of time and involving substantial capital, that takes into account social costs and benefits as well as financial considerations. . Archives of General Psychiatry, 37, 400-405. Wintersteen, R. T. (1986). Rehabilitating the chronically mentallyill: Social work's claim to leadership. Social Work, 31, 332-337. Wolff, N., Helminiak, T. W., & Diamond, R. J. (1995). Estimatedsocietal costs of assertive community mental health care. PsychiatricServices, 46, 898-906. Wright, R. G., Heiman, J. R., Shupe, J., & Olvera, G. (1989).Defining and measuring stabilization during 4 years of intensivecommunity support. American Journal of Psychiatry, 146, 1293-1298. RELATED ARTICLE: NASW NASW National Association of Science WritersNASW National Association of Social Workers (Washington, DC)NASW National Association of Social WorkersNASW National Association for Social Work (UK)PRESS POLICY ON ETHICAL BEHAVIOR The NASW Press expects authors to adhere to ethical standards forscholarship as articulated in the NASW Code of Ethics and Writing forthe NASW Press: Information for Authors. These standards include actionssuch as * taking responsibility and credit only for work they have actuallyperformed * honestly acknowledging the work of others * submitting only original work to journals * fully documenting their own and others' related work. If possible breaches of ethical standards have been identified atthe review or publication process, the NASW Press may notify the authorand bring the ethics issue to the attention of the appropriateprofessional body or other authority, Peer review confidentiality willnot apply where there is evidence of plagiarism Using ideas, plots, text and other intellectual property developed by someone else while claiming it is your original work. . As reviewed and revised by NASW National Committee on Inquiry(NCOI), May 30, 1997 Approved by NASW Board of Directors, September 1997 ABOUT THE AUTHOR William C. Hughes, MSW (MicroSoft Word) See Microsoft Word. , LCSW LCSW Licensed Clinical Social Worker , is an inpatient unit social worker,Metropolitan Psychiatric Center, 5351 Delmar Street, St. Louis, MO63112.