Volume 26 -- Abstracts   
The Journal of Behavioral Health Services & Research
formerly The Journal of Mental Health Administration
Main Table of Contents
Issue 1     Issue 2     Issue 3   Issue 4

Volume 26 Issue 1, 1999
Abstracts

Eisen, S.V., Wilcox, M., Leff, H.S., Schaefer, E.., and Culhane, M.A. Assessing Behavioral Health Outcomes in Outpatient Programs: Reliability and Validity of the BASIS-32. The Journal of Behavioral Health Services & Research 1998; 26(1): 5-17
ABSTRACT: BASIS-32, a mental health outcome assessment instrument has been tested and used among severely ill patients treated on inpatient programs. However, its applicability and utility to mental health consumers treated in outpatient programs has not been determined. The objective of this study was to assess data quality, factor structure, reliability, validity and sensitivity to change of BASIS-32, when used among mental health consumers treated in outpatient programs. Four hundred seven outpatients completed BASIS-32 and the SF-36 at the beginning of an outpatient treatment episode and again 30-90 days later. Results suggested that standards of data completeness were met. Outpatients reported less difficulty at intake than did inpatients and BASIS-32 detected statistically significant change 30-90 days after beginning outpatient treatment. Factor structure and construct validity were partially confirmed on this sample of outpatient consumers. Analyses of data from a wide range of facilities and samples would add to validation efforts and to further refinement of BASIS-32.

Eisen, S.V., Leff, H.S., and Schaefer, E. Implementing Outcome Systems: Lessons from a Test of the BASIS-32 and the SF-36. The Journal of Behavioral Health Services & Research 1998; 26(1): 18-27.
ABSTRACT: With increasing pressure from third party payers to assess client outcomes, clinical programs want to know how to implement outcome systems. This paper focuses on practical and logistic questions involved in implementing an outcome assessment system in ambulatory behavioral care settings. Study questions focused on obtaining provider "buy-in," client consent and confidentiality, sampling and data collection methods, maximizing client participation, clinical utility of outcome data, resources needed for outcome assessment, consumer acceptability of the BASIS-32 and SF-36, and applicability of these measures to diverse populations. Specific suggestions for maximizing the success of an outcome assessment system include: 1) communicating with both providers and consumers about the purposes and methods to be used in assessing outcomes, 2) minimizing provider and consumer burden, 3) collaborating with all stakeholders to increase efficiency and decrease costs; and 4) providing feedback to stakeholders that can be used by all to guide continued outcome and quality improvement efforts.

Montoya, I.D., Carlson, J.W., and Richard, A.J. An Analysis of Drug Abuse Policies in Teaching Hospitals. The Journal of Behavioral Health Services & Research 1998; 26(1): 28 – 38.
ABSTRACT: The Drug-Free Workplace Act of 1988 mandated written drug abuse policies for recipients of certain government grants or contracts. The literature has reported costly side effects of employee drug abuse, such as decreased productivity and increased use of health benefits. Furthermore, litigation involving drug abuse policies has been increasingly won by employers. Now over 90% of Fortune 1,000 companies have adopted formal drug abuse policies. Using content analysis techniques, the current study examined the written substance abuse policies of 30 large American teaching hospitals. Results showed substantial variation in the style and content of the policies. In general, language used in the policies was vague. The study cites the potential use of strategic ambiguity in the development of the policies.

Marlys Staudt, M. Barriers and Facilitators to Use of Services Following Intensive Family Preservation Services The Journal of Behavioral Health Services & Research 1998; 26(1): 39 – 49.
ABSTRACT: The primary caregivers of 101 families who used short-term, intensive home based services were interviewed at two months after the services to ascertain use of the recommended aftercare services, perceived barriers to service use, and perceived facilitators of service use. While 88% of the families accessed at least some of the recommended services, over 50% failed to access all of the recommended aftercare services. The most often noted barriers to service use were enabling factors at the agency or community level. Yet many of the services were used, and the respondents indicated that professionals played a role in helping them link to services.

Granello, D.H., Granello, P.F., and Lee, F. Measuring Treatment Outcomes and Client Satisfaction in a Partial Hospitalization Program. The Journal of Behavioral Health Services & Research 1998; 26(1): 50 – 63..
ABSTRACT: Mental health practitioners are increasingly being called upon to evaluate the effectiveness of the treatment they provide. The partial hospitalization component of the mental health industry also has felt this call for outcome research. This article presents the results of one program’s attempts to answer that call through an assessment of treatment outcome and client satisfaction at a partial hospitalization program. Subjects (n=287) were evaluated at admission, discharge, and three-month follow-up. The article outlines the procedures used for assessment and uses the results as an example of the kind of data that can be obtained through outcomes measurement. The article is intended to provide an example of program evaluation that is easy and inexpensive to administer.

Junek, W., and Thompson, A.H. Self Regulating Service Delivery Systems: A Model for Children and Youth At Risk The Journal of Behavioral Health Services & Research 1998; 26(1): 64 – 79.
ABSTRACT: A conceptual model of self regulating service delivery is proposed than can be used by governments and other macro-level planners and policy makers to help children reach optimal adulthood functioning. It addresses most problems of present service delivery, and is applicable to the general population of children and youth as well as to those who are registered consumers of mental health, child welfare, special education, drug dependency and juvenile justice (young offender) services. It has four essential components, which are: (1) the regular collection of outcome measurements that reflect the mental health status of both children who use services and those in the general population, (2) the feedback, in a user-friendly format, of these outcome measures to governments, the public and service delivery organizations, (3) the provision of powerful and significant rewards and incentives for attainment of the most desired outcomes in order to increase their saliency and to motivate provider behavior, and (4) decision-making that can affect all entities that contribute to the mental health of children and youth. The evaluable expected benefits are improved mental health for children and youth and greater efficiency within the "system".

Friedmann, P.D., Alexander, J.A. , Jin, L., and D’Aunno, T.A. On-Site Primary Care and Mental Health Services in Outpatient Drug Abuse Treatment Units. The Journal of Behavioral Health Services & Research 1998; 26(1): 80 – 94.
ABSTRACT: Providing health services to drug abuse treatment clients improves their outcomes. Using data from a 1995 national survey of 597 outpatient drug abuse treatment units, this article examines the relationship between the organizational features of these units and the degree to which they provided on-site primary care (physical examinations, routine medical care, tuberculosis screening, treatment for acute HIV/AIDS conditions) and mental health services. In two-stage multivariate models, JCAHO-certified and methadone programs delivered more on-site primary care services. Units affiliated with mental health centers provided more on-site mental health services, but less direct medical care. In similar yet independent results, units with more dual diagnosis clients provided more on-site mental health, but fewer on-site HIV/AIDS treatment services. Organizational features appear to influence the degree to which health services are incorporated into drug abuse treatment programs. Fully integrated care may be an unattainable ideal for many drug abuse treatment units, but quality improvement across the treatment system may increase the reliability of clients’ access to health services.

French, M.T., Zarkin, G.A., Bray, J.W.., and Hartwell, T.D. Costs of Employee Assistance Programs: Comparison of National Estimates from 1993 and 1995. Pgs. The Journal of Behavioral Health Services & Research 1998; 26(1): 95 – 103.
ABSTRACT:The cost and financing of mental health services is gaining increasing importance with the spread of managed care and cost cutting measures throughout the health care system. The delivery of mental health services through structured employee assistance programs (EAPs) could be undermined by revised health insurance contracts and cut backs in employer-provided benefits at the workplace. This study uses two recently completed national surveys of EAPs to estimate the costs of providing EAP services during 1993 and 1995. EAP costs are determined by program type, worksite size, industry, and region. In addition, information on program services is reported to determine the most common types and categories of services, and whether service delivery changes have occurred between 1993 and 1995. The results of this study will be useful to EAP managers, mental health administrators, and mental health services researchers who are interested in the delivery and costs of EAP services.

John Fortney, J., Owen, R., and Clothier, J. Impact of Travel Distance on the Disposition of Patients Presenting for Emergency Psychiatric Care. The Journal of Behavioral Health Services & Research 1998; 26(1): 104 – 108..
ABSTRACT: For veterans presenting for emergency psychiatric care, this research tested the hypothesis that patients with poor geographical accessibility to ambulatory mental health services would be more likely to be hospitalized. Logistic regression results indicated that distant patients (>60 miles) were 4.8 times (p<0.05) more likely to be admitted for acute psychiatric treatment than proximal patients (<60 miles), controlling for clinical and demographic casemix factors. This finding suggests that the Department of Veterans Affairs may be less effective in its effort to substitute intensive outpatient care in place of expensive inpatient treatment for rural veterans with emergent mental health problems.

BOOK REVIEWS
Mental Health Outcome Evaluation. By David C. Speer. San Diego: Academic Press, 1998. Pg. 109. by John S. Lyons, Ph.D. [REVIEW]

Outcomes for Children and Youth with Behavioral and Emotional Disorders and Their Families: Programs and Evaluation Best Practices. By Michael H. Epstein, Krista Kutash, & Albert Duchnowski (Editors). Austin, TX: Pro-Ed, 1998, 783 pages. Pg. 110. by Elizabeth M.Z. Farmer, Ph.D. [REVIEW]

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Volume 26 Issue 2, 1999
Abstracts

Virgo, Katherine; Price, Rumi Kato; Spitznagel, Edward, and Ji, Ted H. C. Substance Abuse as a Predictor of VA Medical Care Utilization Among Vietnam Veterans The Journal of Behavioral Health Services & Research 1999; 26(2)
ABSTRACT: The primary objective was to determine whether Vietnam veterans who had alcohol or drug use problems prior to, during, or immediately after the war utilized VA health care services more intensively over the next two decades than Vietnam veterans without these behaviors. The secondary objective was to identify predictors of VA health services utilization among data collected at service discharge. Data sources include the Washington University Vietnam Follow-Up Study conducted in the early 1970’s and VA utilization data for fiscal years 1975-1995. Logistic and ordinary least squares regression were used to model the effect of predisposing, enabling, and need factors on utilization of VA health services for the two-decade period after discharge from Vietnam. Records of all veterans interviewed in both 1972 and 1974 were analyzed (N=571). Results show that Vietnam veterans who had substance use problems either before or immediately after Vietnam utilized VA health care services more intensively over the next two decades than Vietnam veterans without these behaviors. Drug use was the predominant predictor of utilization, particularly heavy marijuana use before Vietnam and downers use or care seeking for downers use in 1972-74. Depression and psychiatric care-seeking were also important predictors. More research is needed to evaluate the impact of health system characteristics and private sector use on the predictive ability of the models.

Edens, John, Poythress, Norman, Nicholson, Robert, and Otto, Randy. Effects of State Organizational Structure and Forensic Examiner Training on Pre-trial Competence Assessments The Journal of Behavioral Health Services & Research 1999; 26(2)
ABSTRACT: States differ widely in their delivery of pre-trial forensic evaluation services, both in terms of organizational structure and training requirements of forensic examiners. It was hypothesized that defendants adjudicated incompetent to proceed in states using community-based, private practitioner systems would show less impairment on a competence assessment measure, the MacArthur Competence Assessment Tool-Criminal Adjudication (MacCAT-CA), than defendants adjudicated incompetent in states using traditional, inpatient systems. It also was hypothesized that mean MacCAT-CA scores for incompetent defendants from states requiring forensic training/certification would be lower than defendants from states lacking such requirements. Results indicated significant differences across the four types of service delivery systems examined. However, planned comparisons revealed no differences between a state using traditional, inpatient model and a state employing a community-based, private-practitioner model. Furthermore, analyses examining the effects of mandatory forensic training failed to support the hypothesis that training requirements result in the adoption of higher thresholds for determining incompetence.

Keefe, Robert and Hall, Michael. Private Practitioners’ Documentation of Outpatient Psychiatric Treatment: Questioning Managed Care. The Journal of Behavioral Health Services & Research 1999; 26(2)
ABSTRACT: This study investigates how social workers, psychologists and psychiatrists document the treatment they provide clients' to managed behavioral health care organizations. The rosters of the Register of Clinical Social Workers, the American Psychological and American Psychiatric Associations ultimately yielded a sample of 168 private practicing social workers, 158 psychologists and 258 psychiatrists from across the nation. Results indicated that practitioners differed based on age, amount of time spent in private practice, racial self-identification, percent of time with clients diminished due to communicating with managed behavioral health care organizations, and documentation of clients' prognoses. Most practitioners report their clients' care needs accurately. However, some practitioners believe it is necessary to report treatment needs in ways to assure certification rather than in ways which accurately depict clients' clinical profiles. The ramifications for clinicians' evaluation of their own practices, reimbursement for their services, and meeting clients' needs while working under managed behavioral health care guidelines are discussed.

Ouellette, Philip, Lazear, Kathy , and Chambers, Tina. Action Leadership: The Development of an Approach to Leadership Enhancement for Grassroots Community Leaders in Children’s Mental Health. The Journal of Behavioral Health Services & Research 1999; 26(2)
ABSTRACT: The last decade has seen the development of a number of interagency systems for children with serious emotional disturbances and their families. Many public sector agencies, however, continue to have inadequate or fragmented services. It is believed that effective systems of care for children and families will not be adequate until more parents and community residents are involved in all phases of systems development. Consequently, the need for the development of leadership models that enhance the involvement of grassroots community leaders is crucial. This paper summarizes a research team's preliminary experience in developing an "action leadership" model that empowers grassroots community leaders toward action. The team discovered that leadership enhancement and development of grassroots community leaders is not a static skill attribute of an individual but rather it is acquired through a dynamic process in which both the facilitator of a community leadership initiative and its natural leaders are active participants in a shared learning and change experience.

Bickman, Leonard; Noser, Kelly; and Summerfelt, Thomas. Long Term Effects of a System of Care on Children and Adolescents. The Journal of Behavioral Health Services & Research 1999; 26(2)
ABSTRACT: This study evaluates an exemplary system of care designed to provide comprehensive mental health services to children and adolescents. It was believed that the system would lead to more improvement in the functioning and symptoms of clients compared to those receiving care as usual. The project employed a randomized experimental five wave longitudinal design with 350 families. While access to care, type of care, and the amount of care were better in the system of care, there were no differences in clinical outcomes compared to care received outside the system. In addition, children who did not receive any services, regardless of experimental condition, improved at the same rate as treated children. Similar to the Fort Bragg results, the effects of systems of care are primarily limited to system level outcomes, but do not appear to affect individual outcomes such as functioning and symptomatology.

Sturm, Roland; Zhang, Weiying; and Schoenbaum, Michael. How Expensive are Unlimited Substance Abuse Benefits Under Managed Care? The Journal of Behavioral Health Services & Research 1999; 26(2)
ABSTRACT: Substance abuse care has been excluded from recent federal and state legislation mandating equal benefits for mental health (MH) and medical care ("parity"), largely because of cost concerns. This paper studies how many patients are affected by substance abuse coverage limits and the likely implications of limits on insurance payments, using 1996/97 claims from 25 managed care plans with unlimited substance abuse (SA) benefits. The low coverage limits currently in existence leave some patients without insurance coverage for a large part of their treatment. Changing even stringent limits on annual SA benefits has a small absolute effect on overall insurance costs under managed care, even though a large percentage of substance abuse patients are affected. Removing an annual limit of $10,000 per year on substance abuse care is estimated to increase insurance payments by about 6 cents per member per year, removing a limit of $1,000 increases payments by about $3.40. As long as care is comprehensively managed, "parity" for substance abuse in employer-sponsored health plans is not very costly.

Chinman, Matthew J.; Allende, Marge; Weingarten,Richard ; Steiner, Jeanne; Tworkowski, Sophie; and Davidson, Larry. On the Road to Collaborative Treatment Planning: Consumer and Provider Perspectives. The Journal of Behavioral Health Services & Research 1999; 26(2)
ABSTRACT: Although consumers have made significant gains in having their voices heard in several areas within mental health, they have made less progress in being able to collaborate with their own treaters in setting treatment goals. Based on several years of ground-work by staff at the Connecticut Mental Health Center (CMHC), the Patient Care Committee conducted a needs assessment of providers and consumers to assess both groups’ current involvement, interest in, and attitudes toward collaborative treatment planning. The results indicate that providers tend to place much of the responsibility for the difficulties in implementing collaborative treatment planning on consumers. Also, providers tend to underestimate consumers’ interest in participating in this process. Implications of these findings for the development of an agency-wide training to enhance the collaborative nature of treatment planning are discussed.

Maynard, Charles; Cox, Gary; Krupski, Antionette; and Stark, Kenneth. Utilization of Services for Mentally Ill Chemically Abusing Patients Discharged form Residential Treatment. The Journal of Behavioral Health Services & Research 1999; 26(2)
ABSTRACT: Little is known about outcomes of treatment for individuals with mental illness and chemical dependencies. This paper compares services utilization pre-admission and post-discharge in 534 patients discharged from a residential treatment program in Washington State. A number of services, including chemical dependency detoxification, mental health crisis, inpatient psychiatric, medical emergency, and general medical inpatient hospitalization were used less frequently in the period after discharge. The total reimbursement for all Medicaid services decreased by 44% from $5 million in the year prior to discharge to $2.8 million in the year after discharge. Also, individuals (32%) who completed the program were less likely to use costly, acute care services. This study was limited by the absence of a control group and post treatment alcohol and drug use data. In addition, other unmeasured factors could have explained the association between program completion and better outcomes.

BOOK REVIEWS
Issues in community mental health : Respecting diversity: treatment in the context of family and culture. Friedman, Steven J. and Olko, Robert S. (editors). Canton, MA: PRODIST. 1998, 138 pages. by Ardis Hanson, M.L.S. [REVIEW]

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Volume 26 Issue 3, 1999

Abstracts

McGrew, J.H., Wright, E.R., and Pescosolido, B.A. Closing of a State Hospital: An Overview and Framework for a Case Study. The Journal of Behavioral Health Services & Research 1999; 26(3): 236-245.
ABSTRACT:This paper provides an introduction to trends in deinstitutionalization, the limitations of previous research, and the design and research questions of the Central State Hospital (CSH) Closing Studies. Previously, the central engine of deinstitutionalization has been the downsizing, and not the closing, of facilities to decrease available beds. Only 14 state hospitals closed between 1970 and 1990. However, since 1990, 40 hospitals have closed. Moreover, beginning in 1993, for the first time since deinstitutionalization began, funding for state psychiatric facilities was less than for community based services. Previous research on both the downsizing and closing of hospitals has focused predominantly on relatively short-term clinical and social outcomes of patients. The current study is a multidisciplinary, longitudinal, multiple stakeholder study of the closing of a state-run, long-term care facility in Indiana. The papers focus on the clinical, psychological, social and attitudinal outcomes for patients, workers, families and the public following the closing of CSH.

McGrew, J.H., Wright, E.R., Pescosolido, B.A., and McDonel, E.C. The Closing of Central State Hospital: Long-term Outcomes for Persons with Severe Mental Illness. The Journal of Behavioral Health Services & Research 1999; 26(3): 246-261.
ABSTRACT:The current study examined the clinical/community functioning of long-stay patients following closing of a large state psychiatric hospital. Two overlapping samples were followed: (1) the tracking project collected information on patient location, treatment provision, legal contacts, and level of functioning (LOF) and followed all discharged patients (n=303), (2) the research study sub-sample (n=88), drawn from the final group of discharged patients, gathered information on quality of life (QOL), LOF, and general physical and mental health. At follow-up, patients were functioning equal to or better than prior to discharge. There were consistent improvements in both QOL (especially safety and occupational satisfaction) and LOF (especially housing and income/benefits). Fewer than 27% of patients discharged into the community were re-hospitalized and fewer than 4% were either in jail or homeless after 24 months. The study demonstrates that even persons who have been hospitalized for extremely long periods can do well in the community.

Wright, E.R. Fiscal Outcomes of the Closing of Central State Hospital: An Analysis of the Costs to State Government. The Journal of Behavioral Health Services & Research 1999; 26(3): 262-275.
ABSTRACT: This study reports estimates of the pre- and post-closure costs of mental health services for patients directly affected by the closing of Central State Hospital (CSH). The data come from state budget documents and from the billing records of the Community Mental Health Centers serving the discharged clients. On average, it cost the State of Indiana approximately $68,347 (in 1995 dollars) to provide 12 months of state hospital care for this client cohort in FY 1993. In contrast, during the first year following the closure, the average per patient cost to the state was $55,417. When clients were served exclusively in community-care settings the average annual per patient cost was $40,618. Overall, the analyses suggest that the closing of CSH reduced the costs of caring for this cohort of patients by approximately 18.9%. A significant portion of the cost savings to the state mental health budget was achieved by shifting some of the direct patient care costs to Medicaid/Medicare.

Pescosolido, B.A., Wright, E.R., Lutfey, K. The Changing Hopes, Worries, and Community Supports of Individuals Moving from a Closing Long-Term Care Facility. The Journal of Behavioral Health Services & Research 1999; 26(3): 276-288.
ABSTRACT: This study examines clients' hopes, worries and social networks before, one year and two years following release from a long-term care facility. In-depth, face-to-face interviews of the last clients (N=88) released from Central State Hospital were conducted. More clients expressed hopes than worries pre-closure but, over time, hopes decreased and worries increased significantly. Before closing, "independence" was cited most often as a hope, followed by work and finances. Criminal "opportunities" headed up concerns, followed by mental health treatment, finances, living arrangements and independence. Over time, respondents were less excited about independence and living arrangements but more hopeful about social opportunities and everyday practicalities. Worries relating to family increased while concerns about deviance decreased. Respondents reported an average increase in network ties but the proportion of family members decreased while professional supports and ties with former CSH patients increased. The trends highlight particular vulnerability at the one year point; the necessity of viewing movement into the community as a non-linear process; and the importance of marking outcomes periodically. The lack of consistent socio-demographic or psychiatric correlates supports the contention that hospitalization is an equalizing experience and points to recommendations for administrators planning hospital downsizing and closure.

Wright, E.R., Avirappattu, G., Lafuze, J.E. The Family Experience of Deinstitutionalization: Insights from the Closing of Central State Hospital. The Journal of Behavioral Health Services & Research 1999; 26(3): 289-304.
ABSTRACT: Since the early 1970s, policy makers and researchers have expressed concern about the potential negative consequences of deinstitutionalization on families. This paper summarizes some of the results of a survey of family and lay caregivers of patients discharged from Central State Hospital due to its closing in June 1994. The survey was designed to assess the impact of the closing on family members, including their attitudes, caregiving responsibilities, and their involvement in the treatment of the focal patient. Results indicate that family members have mixed feelings about the closure. Family caregivers also reported that they have not been asked to take on significant amounts of the caregiving responsibilities since the clients were moved from the hospital. Family members, however, described a significant reduction in the frequency of contact they had with their loved ones and with professional caregivers since the closure. The implications of these findings for behavioral health policy makers considering or planning closing or downsizing long-term care facilities are discussed.

Mesch, D.J., McGrew, J.H., Pescosolido, B.A., and Haugh, D. The Effects of Hospital Closure on Mental Health Workers: An Overview of Employment, Mental and Physical Health, and Attitudinal Outcomes. The Journal of Behavioral Health Services & Research 1999; 26(3): 305-317.
ABSTRACT: This paper examines the physical, psychological, and attitudinal impact of the closure of Central State Hospital (CSH) on its former employees. Eighty-five former CSH employees were interviewed at two points in time, pre-closure and post-closure. Data on the psychological and physical health of workers, and employment attitudes were collected prior to and eight months after organizational closure. Over time, workers had more positive attitudes about the hospital closure as well as reporting less depression, less work stress, and use of more coping strategies at post closure. However, at post closure, they also reported increased work conflict, lower income, and a more pessimistic outlook toward their future. Implications for hospital closure are discussed.

Pescosolido, B.A., Wright, E.R., and Kikuzawa, S. "Stakeholder" Attitudes over Time toward the Closing of a State Hospital. The Journal of Behavioral Health Services & Research 1999; 26(3): 318-328.
ABSTRACT: For four groups B patients (N=80), their families or lay caregivers (N=120), hospital workers (N=124) and the public (N=108) B attitudes toward the decision to close the only long-term, urban state hospital are traced over time. Initially, patients were most supportive of the closing decision (65.4%), followed by family members (39.8%), the general public (27.8%) and workers (10.4%). A majority of all groups favored fixing the hospital. Almost half of the clients and more than half of those in other stakeholders expressed concerns about homelessness. Most attitudes were consistent despite respondents' socio-demographic characteristics. The overall profile of group attitudes remained remarkable stable although there is a good deal of change in individuals= positions. Public support for fixing the hospital decreased significantly and differences among stakeholders regarding homelessness disappear. These findings reinforce the importance of ascertaining different constituencies= positions and recognizing the slowly changing response of stakeholders even under massive and successful policy change.

Vander Stoep, A.,Williams, M., Jones, R., Green, L., and Trupin, E. Families as Full Research Partners: What’s in It for Us? The Journal of Behavioral Health Services & Research 1999; 26(3): 329-344.
ABSTRACT:This paper describes a children’s managed mental health care program that Incorporates both a family participation service model and a family-initiated evaluation model. The authors begin by tracing the evolution of the family support and the participatory research movements leading to current developments in children’s mental health services research. In the King County Blended Funding Project, three service systems pool funds which are spent flexibly by child and family teams. Family advocates have led efforts to design and implement the Project evaluation. During this process, many tensions have arisen between meeting the demands of both scientific rigor and multiple community stakeholders. Examples are given of the issues raised by family advocates and research scientists as together they established a theory of change, identified meaningful outcomes, selected measurement tools, and implemented the evaluation protocol. Guidelines are given for how services research partnerships can be successfully built to better address community needs.
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Volume 26 Issue 4, 1999
Abstracts

Sturm, R. Tracking Changes in Behavioral Health Services: How Have Carve-Outs Changed Care? The Journal of Behavioral Health Services & Research 1999; 26(4): 360-371.
ABSTRACT: This special issue of the Journal of Behavioral Health Services & Research on mental health carve-outs brings together some of the latest research on recent policy and market changes affecting behavioral health services. This introductory paper provides background information about carve-outs and the managed behavioral health care industry. This article also reviews prior research in the mental health carve-out field.

Cuffel, B.J., Goldman, W., and Schlesinger, H. Does Managing Behavioral Health Care Services Increase the Cost of Providing Medical Care? The Journal of Behavioral Health Services & Research 1999; 26(4): 372-380.
ABSTRACT: This study examined the possibility that managing behavioral health care services achieves savings by "cost shifting," i.e., by denying care or impeding access to care, and in that way encouraging patients to seek needed behavioral health care in the medical care system. In 1993, a large industrial company "carved-out" the behavioral health care for its employees from its unmanaged, indemnity medical care benefits and offered employees an enhanced benefit package through a managed behavioral health care company (MBHO). This study compared the use and cost of behavioral health care and medical care services for two years before the carve-out and for three years afterward. The rate of behavioral health care usage remained the same or increased in the years after the carve-out, while the cost of providing the care decreased. Controlling for trends that began before the inception of managed behavioral health, medical care costs decreased for users of behavioral health care services. No evidence supporting cost-shifting was found.

Grazier, K.L., Eselius, L.L., Hu, T., Shore, K.K., G'Sell, W.A. Effects of a Mental Health Carve-Out on Use, Costs and Payers: A Four-Year Study. The Journal of Behavioral Health Services & Research 1999; 26(4): 381-389.
ABSTRACT: This study examines the effects of a mental health carve-out on a sample of continuously enrolled employees (N=1,943) over a four-year time frame (1990-1994). The paper presents a health care services utilization model of the effect of the carve-out on outpatient mental health use, cost and source of payment in the three years post-implementation relative to the year prior to the carve-out model. In the first three years of the carve-out, the likelihood of employees seeking mental health care increased, in significant part because of the carve-out. For the outpatient mental health services user, the carve-out was not associated with the level of mental health services received. The carve-out was significantly associated over time with a reduction in the patient's and employer's mental health costs. This effect was more pronounced in the second and third years of the carve-out. The paper explores the policy implications of these and other findings.

Gresenz, C.R. and Sturm, R. Who Leaves Managed Behavioral Health Care? The Journal of Behavioral Health Services & Research 1999; 26(4): 390-400.
ABSTRACT: The growth of managed care and the possibility of biased enrollment and disenrollment rates have raised concerns about cost-shifting. This paper analyzes the duration of continuous enrollment in a managed behavioral health organization among members with and without behavioral health care utilization and distinguishing different mental health conditions. We study 11 large employers with over 250,000 members enrolled in managed behavioral health plans. Compared to managed care 10 years ago, the rate of disenrollment among patients with depression appears to have dropped. Moreover, there appear few differences in disenrollment among users and non-users of behavioral health services, except for employees where coverage is linked to job performance. However, patients with substance abuse problems or severe types of disorders are significantly more likely to disenroll than patients with less severe problems.

Ridgely, M.S., Giard, J., and Shern, D. Florida's Medicaid Mental Health Carve Out: Lessons from the First Years of Implementation. The Journal of Behavioral Health Services & Research 1999; 26(4): 400-415.
ABSTRACT: Florida, like many other states, has embarked on an experiment with managed mental health care for Medicaid enrollees. Under a 1915(b) waiver, the state's Agency for Health Care Administration began a mental health carve out demonstration in March 1996 to address the challenge of providing mental health services to both disabled and non-disabled children and adults in the Tampa Bay area. This qualitative case study seeks to ascertain the impact of the carve out (and, by comparison, HMO arrangements) on the public mental health sector and the vulnerable population it serves. The findings suggest that the carve out demonstration has succeeded in creating a fully integrated mental health delivery system with financial and administrative mechanisms that support a shared clinical model. This managed care arrangement combines the management expertise of a behavioral health care company with the clinical expertise of public sector service providers. However, other findings from this case study raise concerns about the HMO model in terms of stability, access to care, and efficiency, and about the shifting of risk and public responsibility "downstream" to private organizations in the absence of sufficient governmental or market regulation. These findings may offer guidance for other states implementing major managed care policy initiatives for disabled Medicaid enrollees.

Kapur, K., Young, A.S., Murata, D., Sullivan, G., and Koegel, P. The Economic Impact of Capitated Care for High Utilizers of Public Mental Health Services: The Los Angeles PARTNERS Program Experience. The Journal of Behavioral Health Services & Research 1999; 26(4): 416-429.
ABSTRACT: Los Angeles PARTNERS is a treatment program that uses capitation to shift risk for treatment costs of high utilizers of public mental health services to private community based treatment organizations. This analysis reveals two important findings from PARTNERS. First, the economic incentives created by capitation contributed to the disenrollment of PARTNERS clients; furthermore, factors such as not speaking English or Spanish or being schizophrenic increased the probability of disenrollment. Second, analyses of health costs for enrollees in the PARTNERS capitation program suggest that the program did not result in a change in total costs. However, the program increased the use of community based care and also increased treatment costs for clients with lower pre-program costs, but decreased costs for the clients with high pre-program costs. These results suggest that future capitation programs for this severely ill population would benefit from using detailed clinical information to determine program eligibility and to set risk adjusted capitation rates.

Peele, P.B., Lave, J.R., and Xu, Y. Benefit Limits in Managed Behavioral Healthcare: Do They Matter? The Journal of Behavioral Health Services & Research 1999; 26(4): 430-442.
ABSTRACT: Over half of Americans with insurance coverage for mental health services are enrolled in plans which "carve-out" behavioral health care services with a vendor specializing in the management of these services. However, utilization management has not taken the place of benefit limitations. Do benefit limits matter? This paper reports the percentage of enrollees people in managed behavioral health care carve-out plans that encounter benefit limits. Estimates are provided on the impact and savings of imposing benefit limits on enrollees in unrestricted plans. Costs to eliminate benefit limits are estimated to be very small. This study finds that benefit limits do matter, but only to a very small number of plan enrollees. Further, the results of this study show that for inpatient limits, children are especially vulnerable. These issues have important implications for the discussions about the impact of managed care in mental health and for discussions concerning parity legislation.

Manning, W.G., Liu, C., Stoner, T.J., Gray, D.Z., Lurie, N., Popkin, M., and Christianson, J.B. Outcomes for Medicaid Beneficiaries with Schizophrenia under a Prepaid Mental Health Carve-Out. The Journal of Behavioral Health Services & Research 1999; 26(4): 442-450.
ABSTRACT: The study examines the impact of a mental health carve-out program involving community mental health centers (CMHCs) in Utah on mental and physical health status of Medicaid beneficiaries with schizophrenia. Three CMHCs in Utah contracted to provide mental health care for all Medicaid beneficiaries in their service area under managed care arrangements, with financial risk phased in over a three and one half year period. Beneficiaries in the remainder of the state remained under traditional Medicaid. A pre-post evaluation of mental and physical health status was utilized, with a contemporaneous control group of Utah Medicaid beneficiaries under traditional Medicaid. The data are from face-to-face interviews, using mental health status (Brief Psychiatric Rating Scale or BPRS and the Global Assessment Scale or GAS) and physical health status as outcome measures. From 1991-1994, the average beneficiary's mental health status improved over the study period for the carve-out and comparison group, but the improvement was less (1.77 units on the BPRS, p = 0.005) under the carve-out program relative to what it would have been under traditional fee-for-service Medicaid. The difference in improvement was the greatest for beneficiaries with the worst mental health status at baseline, with effects growing over time. Medicaid beneficiaries with schizophrenia experienced less improvement in mental health status under a carve-out arrangement for mental health care compared to what would have happened under traditional Medicaid

Stein, B., Reardon, E., and Sturm, R. Substance Abuse Service Utilization under Managed Care: HMOs versus Carve-Out Plans. The Journal of Behavioral Health Services & Research 1999; 26(4): 451-456.
ABSTRACT: Managed behavioral healthcare organizations are increasingly managing American's substance abuse (SA) using carve-outs, but little information is available about how these changes have affected service utilization and costs when compared to HMOs. One employer's claims for SA services delivered under a carve-out arrangement are compared to prior HMO claims information. Under the carve-out arrangement, inpatient and outpatient service utilization are found to decrease, but intermediate service utilization dramatically increases. Costs per unit service decrease for all services. The pattern of changes is different from that seen for mental health (MH) services, suggesting that different factors may be applicable to SA services.

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