for the Study of
Healthcare Organizations & Transactions
MENTAL HEALTH SERVICES RESEARCH
Definition Origins Professionals Settings Access Who pays? Quality
Outcome-based evaluation Groups that require special attention References Glossary
Definition. Mental health services research is both a basic and applied multidisciplinary field which explores issues of access to care, utilization, cost, organization, financing, delivery, quality of care, and outcomes of mental health care services. Its purpose is to increase the knowledge and understanding of the structure, processes, and effects of mental health services that are provided to individuals and special populations.
What are the origins of mental health services research? Mental health services research which evolved from the social and behavioral sciences as well as from the field of psychiatric epidemiology, draws from a large body of theoretical and empirical research in these fields. It seeks to answer questions about basic individual, organizational, and systemic behaviors as well as practical questions that managers and policymakers may ask.
Prior to the 1950s, much of the research focused on state-operated hospitals and the care provided within them. Early behavioral science research that examined familial responses to mental illness and the precipitating factors that lead to an individual's hospitalization is still considered important to the field. The epidemiologic studies conducted prior to the 1960s focused on issues such as how individuals entered treatment, how long they remained in treatment once a referral was made, and the ways in which individual characteristics interacted with the type of treatment provided and the setting in which it occurred.
Between 1955 and 1975 the policy of deinstitutionalization facilitated a change in the way mental health services were provided. Much of the research conducted in the 1970s and early 1980s addressed two broad empirical questions: 1) whether the services provided in the community could effectively replace the services provided in the custodial hospital; and, 2) whether the cost of community treatment was less than the cost of treatment in the institution.
During the late 1970s and 1980s, as the focus shifted more toward the cost, financing, and reimbursement of services, economists entered the field of health services research. However, many economists were still somewhat reluctant to enter the mental health services research field because the definitions of mental illness were often unreliable and the effectiveness of many of the treatments had not been demonstrated. Currently, economic models and economic analyses are used increasingly to examine the effects of financial incentives on providers, organizations, and consumers of mental health services and the extent to which alternative methods of organizing and providing services are efficient.
At this same time, clinical researchers in psychology, social work, and psychiatry focused their efforts on systematically defining and measuring the components of mental health and illness. Both clinical drug trials and psychotherapy research expanded the knowledge base with respect to the effectiveness of particular mental health interventions. In the late 1980s and early 1990s, managed care became a predominant force in the field and much of this work evolved into clinical outcomes research.
A final shift in the focus of mental health services research involved vulnerable populations such as children, the elderly, and individuals who suffer from both mental disorders and substance abuse disorders (dual diagnoses). There are a growing number of studies that address issues unique to these populations.
While the strength of the field is that it requires a multidisciplinary approach to mental health and illness, adopting such an approach to scientific inquiry is problematic. Traditional disciplinary boundaries, competing theoretical and methodological approaches, and even the terminology employed by the various disciplines often present impediments to truly collaborative research. In an attempt to overcome these barriers, interdisciplinary programs in services research evolved within academic institutions, private sector research organizations and units, and funding agencies.
Who are the professionals that provide mental health services? Mental health services are provided both in formal psychiatric and health care organizations as well as in office-based practice settings by a variety of professionals including psychiatrists, clinical psychologists, clinical social workers, marriage and family therapists, psychiatric nurses, and mental health counselors.
Mental health services researchers have examined the relationships among skills, financing patterns, and treatment utilization. Early studies indicated that total hospitalization days among patients of psychiatrists were higher but that these patients were more impaired on several health status measures. On the other hand, psychologists' clients seemed to average a higher number of visits when compared to those of psychiatrists. Service patterns of the other professionals were not included.
In addition to these professionals, primary care clinicians have become an important part of the mental health services delivery system. These types of clinicians, e.g., office-based physicians and associated health providers in general internal medicine, general pediatrics, family practice, are often the primary source of health care of any kind for many individuals who suffer from mental disorders.
The existing research points to several findings that should be explored to a greater degree in the future. In general, primary care clinicians provide services to a large number of individuals, however, these clinicians generally under-recognize, under-diagnose and under-treat clients with mental disorders. Although interventions to alter the current situation have been made, further research is required to determine if these interventions would change mental health service delivery in primary care. The literature on mental health services that are provided in primary care settings is generally descriptive in nature and focuses on the process or clinical aspects of care; it has not generally examined the organizational and financial factors that affect service delivery.
In what type of settings are services provided? A vast array of organizations, both in the private sector and public sector, provide mental health services. The organizations range from outpatient mental health clinics that provide only ambulatory services to psychiatric hospitals (either public or private) that provide inpatient care. In between, the forms of organizations cover the entire spectrum. They include residential treatment centers for children with serious emotional disturbance, mental health organizations that offer only day or night partial care, multiservice mental health organizations that may include organizational forms such as community mental health centers, and finally, general hospitals that offer separate psychiatric services. Also, services may be provided by facilities operated by the Department of Veterans Affairs or other Federal agencies.
Over the period 1970-1990, the characteristics of the mental health system changed dramatically in the number, capacity, structure, and operation of organizations that provide service. As an example, during this period, the total number of mental health organizations increased steadily with almost all of the increase occurring in the number of private psychiatric hospitals, separate psychiatric services of general hospitals, and residential treatment centers for children with serious emotional disturbance. By contrast, the number of state and county mental hospitals and freestanding psychiatric outpatient clinics decreased.
In addition to these types of organizational forms, mental health services may also be provided to individuals through various managed care organizations. These organizational forms emerged in the 1970s and developed largely in the private sector primarily serving the employed population.
The health maintenance organization (HMO), the most familiar type of managed care organization, provides mental health services through a variety of approaches including the direct provision of mental health services through internal, formal departments as well as through a variety of external mechanisms such as referral agreements and contractual arrangements with private providers, specialized managed mental health care organizations, and arrangements with community agencies. Beginning in the late 1980s, the types of managed care organizations began to proliferate. As the forms began to change so too did the contracting arrangements and other mechanisms within these organizations for providing mental health services.
In the late 1980s and early 1990s, managed care organizations began contracting with states to provide mental health services to Medicaid beneficiaries. These arrangements can assume a variety of forms. For example, a state may choose to integrate mental health services into comprehensive systems of care or it may separate these services from the rest of health care benefits. Debate continues about the optimal way to design these approaches and about which approach will best meet the mental health needs of the Medicaid population.
How is access to care measured? Early findings reported in 1995 by Berk, Schur, and Cantor from the National Access to Care Survey sponsored by The Robert Wood Johnson Foundation (RWJF) suggest that 1.4 percent of those surveyed reported that they were unable to obtain mental health care. Although this is a relatively low percent, it is much higher than reported in previous studies. The RWJF investigators note that the estimate of 1.4 percent must be interpreted with caution because it represents only those individuals who realize that they require mental health services and who actively seek such services. The catchment area studies that have been conducted indicate that a much larger proportion of the population may require services but may not be receiving them.
Services research has attempted to focus on differences in access to care across income levels, racial groups, age, etc. Financial barriers, including the lack of insurance coverage, have been of particular interest to service researchers. However, barriers to appropriate care may also include sociocultural, organizational, as well as other nonfinancial factors such as geographic availability.
In many of the studies conducted, however, service utilization seems to be equated with access to care. That is, if service use is low for a particular group, then the low utilization often seems to be explained as an accessibility issue.
In reality, access to service may be more of an underlying construct whose indicators may be concretely measured by the length of waiting times, the difficulty in obtaining appointments, and the distance to a service site. However, access to care also involves individual perceptions and attitudes about such indicators. For example, for one individual, waiting for an appointment for two weeks may seem reasonable whereas for a second individual, two weeks may be perceived as inordinately long. For the second individual, the waiting period may have become a barrier to receiving timely, appropriate care.
Access to mental health care is a multifaceted issue that involves individual perceptions, demographic characteristics, organizational practices, and delivery system attributes. While it may be true that low levels of service utilization can be indicative of an access problem, service utilization cannot be causally linked to access without further analyses. What is troublesome is that, too often in the literature, the analyses have stopped with an examination of levels of service use.
Who pays for mental health services? In Mental Health, United States, 1994, Frank and McGuire identify and discuss three major categories of financing arrangements for mental health services: Federal, State, and private insurance. These particular categories were selected because they account for a large proportion of mental health payments and because the responsibility for payment varies among the three mechanisms.
Most individuals in the United States are covered by private health insurance offered through their employers and this arrangement represents the primary payment method for mental health services (1991 data). Usually, individuals must pay a monthly premium in order to receive employment-based health insurance. This insurance often imposes limits on both inpatient and outpatient coverage. Although these limits may vary by employer, typical limits include 30 days of inpatient care and 25 outpatient visits with 50 percent cost-sharing.
Historically, mental health care has been subject to coverage restrictions in private health insurance for a variety of reasons including its perceived ineffectiveness, the high levels of demand for mental health care when compared to other medical conditions, the risk of attracting more individuals who need services to plans that provide good coverage for mental health services, and the fact that the public, in general, seems to hold unfavorable stereotypes about mental illness and about those individuals who suffer from mental disorders.
Although subject to Federal mandates and oversight, Medicaid, the second type of financing system, is a State-run program financed through a combination of Federal and State contributions. The program varies widely by State in terms of benefit design and payment system provisions.
With respect to the coverage of mental health services, states may define particular services that will be paid for within general, broader categories of services. Therefore, services required to treat mental illness may not be covered even if services for other conditions are. Moreover, states may specify the amount and duration of each of the services and mental health treatment services may have different limits in the number of visits, periods of coverage, reimbursement amounts, and types of providers.
Recently, it has been argued that the Medicaid system of care for individuals with severe mental disorders was fragmented and, as a result, individuals could actually be harmed because many fail to receive needed services or they receive inappropriate services. To rectify this situation, a growing number of states began, in 1986, to reimburse mental health providers to manage the services required by these individuals. Currently, the majority of states pay for this type of service coordination.
The third type of financing system involves State governments primarily through State mental health agencies. As might be expected, the responsibilities and programs of State mental health agencies vary widely across the States. These agencies may be responsible for various types of services ranging from children's mental health to domestic violence services. The delivery of services may be provided through central Statewide organizations or may be controlled by local authorities.
With respect to expenditures, in 1990, 58 percent of the funds controlled by State mental health authorities were used for services provided by State mental hospitals while 38 percent went to programs operated in the community; in 1981, the proportions were 67 percent and 29 percent, respectively. Since 1981 the trend toward more community-based care has accentuated the role played by the more local levels of government such as city, county, or catchment area authorities.
Beginning in the early 1990s, states began to rely increasingly on privately owned providers (such as HMOs or subcontracted specialized firms) to manage mental health services in the public system. While it is too early to assess the impact of managed mental health care in the public system, early data suggest that problems in implementation and funding often slow the development and growth of managed care in this sector.
How should we think about quality? From the mid-1960s to the mid-1980s, studies that focused on quality of care were conducted by hospital accreditation and peer review committees. The classic conceptual framework used to examine quality of care involved the use of structural, process, and outcome measures.
Using this classic framework, two broad categories of studies were conducted and reported during the early 1970s and into the 1980s. The first category described peer review programs in various types of settings, e.g., hospitals, community mental health centers, and state/national professional associations. Critics of these peer review programs complained that in many cases investigators failed to employ external, predetermined standards. The second type of study addressed the appropriateness of psychotropic medication prescribing practices. Critics of this type of study argued that appropriateness was evaluated largely by relying on implicit rather than explicit criteria.
Beginning in the late 1980s, quality of care studies were incorporated into services and policy research for two primary reasons. First, emerging reimbursement strategies, e.g., prospective payment, raised issues about quality of care. For example, if these strategies encouraged clinicians to limit the quantity of care, what would the impact be on the quality of care? Second, several studies in the late 1970s and early 1980s documented variations in the cost, process, and outcomes of care across hospitals and providers.
Services researchers tend to examine two major aspects of the delivery process: technical process (the amount, type, and the way in which resources are used) and art of care (the interaction between the provider of care and the individual who seeks care). Each of these aspects can be examined in a variety of ways depending upon the disciplinary training of the investigator.
Several important types of this kind of research can be identified. First, governmental agencies, insurers, as well as employers, are interested in whether the outcomes achieved justify the expenditures. This is referred to as the cost-quality trade-off issue and can be conceptualized in the following manner: Initially, using more resources will probably result in higher levels of quality, but after a period of time, using additional resources will not increase the quality of care provided. Finally, at some point, using more resources (and increasing expenditures) may actually negatively affect the quality of care provided. Second, researchers examine the impact on the health and functional status of individuals when aspects of the delivery system change so that the individual's ability to obtain needed care is altered. Finally, a developing body of literature addresses the extent to which interventions are used appropriately. In the research on psychotherapy, clinical researchers in psychology have begun to assess, both through meta-analytic reviews of the literature and by clinically based investigations, which interventions are efficacious for particular disorders.
In the late 1980s and 1990s, various organizations, e.g., the American Psychological Association, the American Psychiatric Association, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), became actively involved in shaping both the guidelines used to assess the quality of care and the evaluation process itself.
In summary, for three decades, research on defining, measuring, and examining various aspects of quality has occurred and, as a result of these efforts, the field of mental health services research has made great strides. However, to continue the progress, the field requires 1) more data on the variation within clinical practice, 2) the adoption of a variety of techniques by which studies may be designed and complex data analyzed and, 3) a greater degree of collaboration among researchers from the various fields and disciplines.
What is outcome-based evaluation? The evaluation of programs and services began in the 1960s after the number of social programs grew and requests for evaluations of them emanated from both funding sources and governmental bodies/agencies. The purpose of evaluation is to inform decisionmakers, outline available options, and to provide feedback about programs or services. Recently a growing number of evaluation theorists have argued that evaluation projects are able to produce more useful information when they are grounded in a theoretical framework. Theories that guide evaluation projects may focus on the selection of an intervention, the intervention process itself, and/or the underlying theory or theories of the disorder under investigation.
The growth of managed systems of mental health care triggered a shift in the way in which evaluation is conceptualized and in the techniques that are used. In the world of managed care, evaluation became outcome-based. The vague question, Is the individual doing better?, is no longer acceptable. More precise questions such as, Does treatment work in ways that are measurably valuable to the individual, the payor of services, the clinician, and to the managed care organization?, must be answered. However, it must be emphasized that, in the mid 1990s, outcomes research in the mental health field is still in its infancy.
In general though, in 1995, McLellan and Durell note that there are several pragmatic guiding principles that should be followed when outcome-based evaluations are designed and conducted. First, it is necessary to assess an individual before the actual program or treatment begins as well as after the course of care has terminated. Second, the outcomes to be examined must include indicators of health, adaptive behavior, and role-specific social functioning and should not be limited simply to the diagnostic categories of illness. Third, whenever possible, outcome evaluations should employ standardized measures that are appropriate for the specific group being studied. Fourth, in follow-up contacts with individuals who have completed a program, the contact rate must be relatively high (above 70%) for the results to be valid. Finally, an assessment of change and outcome status offer differing perspectives, therefore, both a measurement of change in function from pre- to post- intervention as well as an assessment of actual functional status must be part of the evaluation.
The World Health Organization proposed a mental health outcomes framework that includes five broad elements and the major types of outcomes to be examined:
|Physical Health includes general health as well as the physiological effects produced by intervention. Outcomes focus on physical symptoms, mortality, medication side effects, and physical development and health.|
|Psychological Health includes well-being, self-esteem, affective states, and sensory and cognitive functioning. Outcomes encompass measures of psychological and cognitive development, symptoms and side effects, level of distress, and sense of well-being;|
|Level of Independence encompasses activities of daily living, capacity for communication, work, adaptive growth, and dependence on substances. Outcomes may include performance in work and school, reliance upon restrictive services, independent living, level of impairment from substance use, and criminal activity;|
|Social Relationships involve intimacy and loving relationships as well as the participation in giving and receiving social support. Outcomes encompass measures of the presence and strength of social supports, relationships with peers, family functioning, and parenting ability; and,|
|Environmental domain includes an examination of both the community and residential environment as well as safety issues, material resources, and the availability of adequate services. Outcomes include the adequacy and stability of housing and income as well as the level of protection from victimization.|
In 1995, Schalock offers three broad types of outcome-based analyses that can be conducted depending upon the purpose of the evaluation and the availability of information or data.
Effectiveness Analysis. This type of analysis addresses the question of whether the program or intervention met the intended goals and objectives. Its major purposes include describing results, establishing a feedback mechanism, and offering information that facilitates program/treatment change.
Impact Analysis. This type of analysis determines whether the program or intervention made a difference compared to either no intervention or an alternative intervention. An absolute requirement is that a comparison group or condition be present. The purpose of this type of analysis is to focus on the impacts of the intervention, determine whether the impacts can be attributed with reasonable certainty to the intervention or service being evaluated, and to provide feedback. This type of analysis includes controlled clinical trials.
Cost-Benefit Analysis. The primary issue addressed by cost-benefit analysis is whether the impacts of the program are large enough to justify the costs needed to produce them. It relies heavily upon the clear delineation and measurement of impacts and the costs involved in generating them.
The research on mental health outcomes is difficult to summarize effectively since much of the work focuses on particular groups with specific disorders, e.g., outcomes of juvenile-onset depression, particular drug therapies for specific disorders, e.g., relapse of individuals with mood disorders who are taking lithium, or on the use of particular treatment modalities or treatment settings, e.g., community-based treatment vs. inpatient treatment. The annual Faulkner & Gray Behavioral Outcomes & Guidelines Sourcebooks provide an extensive review of the literature and include state-of-the-art approaches to outcomes research.
Are there groups that require special attention?
Children. Although concern about children and adolescents with serious emotional disturbance has existed for over ten years, it recently has emerged as a critical issue in mental health policy. There are two broad areas in which advances have been made. First, progress has been made in developing instruments for assessing emotional disturbance in children. Second, it has been possible to determine treatment efficacy for specific mental disorders. However, in Mental Health, United States, 1994, Hoagwood and Rupp note that the extent of emotional disturbance among children, the actual but unmet need for care, the types of services utilized, and the ways in which children enter the mental health system are issues that will require additional research.
The reasons for such gaps in our collective knowledge about children's mental health needs and service patterns are numerous. For example, the way in which serious emotional or behavioral disturbances are defined with respect to children vary by profession, Federal agencies and States. As might be predicted, these variations confound any attempt to coordinate care across the different levels of government.
In addition, the responsibility for children's mental health services is dispersed across many service systems including education, welfare, the justice system, etc. Children with mental health needs are scattered across these systems and the needs of the children do not necessarily coincide with the system that provides the service, e.g., children with learning difficulties are not necessarily treated for learning difficulties in the educational system.
Despite the somewhat bleak picture presented, changes are occurring and research efforts are underway under the auspices of the National Institute of Mental Health to answer several important questions such as: What is the extent of unmet need for services by children and their families? What are the barriers to obtaining these services? What are the costs of care across program elements in the various service sectors? How are mental health services for children and adolescents financed? And, what impact will managed mental health systems of care have on the delivery of services to children?
The Elderly. In general, older adults are more likely to use inpatient than outpatient services, are more likely to use general hospitals than other treatment sites, and are likely to be treated by general medical practitioners rather than by mental health professionals. In addition, the underutilization of mental health services by the elderly has been documented and attributed to a number of factors including: reluctance to seek treatment because of the stigma attached to mental illness, inadequate detection of mental disorders among the elderly by clinicians, relatively low referral rates by general practitioners, and limited knowledge on the part of the elderly regarding the availability of mental health services.
In 1995, Estes identifies a lengthy research agenda for the future. The structure and performance of mental health delivery affects access, cost, and quality and studies that examine these relationships must be conducted. More information is needed about the extent to which the elderly are served by varying types of organizations, e.g., for-profit, not-for-profit, or public, and about the effects of various financing mechanisms, e.g., capitation, on service use and access to care. Further research is required on the types of interorganizational relationships that are forming between local mental health providers and other types of providers of services to the elderly.
The number of elderly is predicted to increase in the next two decades and the demand for services by this group will more than likely increase as well. Very little is known about the effects of mental health policy on the elderly, therefore, this area must be one that receives special attention in the future.
Ethnic Minorities. In 1996, Takeuchi and Uehara review the existing research and suggest the areas that will require more attention from researchers in the future. They note that although the details may vary across ethnic groups, in general, the research indicates that the mental health needs of ethnic minorities are largely unmet. In addition, when services are available, they are, more often than not, inappropriate.
Assessing the prevalence of mental disorders and the need for services among ethnic minority groups has proved to be problematic. Treatment data have often been employed in an attempt to estimate the prevalence and need for service. Early studies seemed to indicate that African Americans have been overrepresented and Asian Americans underrepresented in mental hospitals. The evidence for Latino Americans remains ambivalent. It is important to point out that most epidemiologists believe that service use is an unreliable indicator of actual need and this may be particularly true for ethnic minority groups because many members of these groups have difficulty accessing and using services as they are currently designed.
Although methodological problems hamper the generalizability of community studies that have been conducted on the extent of mental health problems in ethnic minority populations, two general points can be made. First, several of the community studies contradict the evidence derived from treatment data. For example, about one half of the community studies conducted in recent years have demonstrated that African Americans had a higher rate of psychopathology (supporting the conclusions that were drawn from treatment studies); however the other half of the studies conducted reported that the rate of psychopathology was comparable or even lower than that found in White Americans.
Second, there seems to be controversy surrounding the issue of whether the differences in prevalence rates should be attributed to ethnic minority status or social class phenomena. Two theoretical frameworks are employed in an attempt to explain the ethnic minority-White American differences in psychological distress and psychopathology. The first framework suggests that forms of psychopathology and distress, in general, derive from the fact that society tends to stratify individuals according to their ethnic and racial backgrounds thereby creating serious obstacles to equality in economic, occupational, and educational opportunities. The second framework argues that race differences in psychopathology disappear when social class is taken into account in the study design. This framework suggests that barriers created by lower incomes, not ethnicity per se, can result in debilitating effects on individuals or groups.
Finally, a number of empirical studies suggested that ethnic minorities do not seek professional treatment for mental health issues as often as other groups do. Moreover, when ethnic minorities use mental health services, treatment tends to be inappropriate or inadequate. Minority service providers and researchers have suggested that the mental health system must become more sensitive and responsive to the needs of ethnic minorities. However, few studies have described what such sensitivity entails or identified what factors might contribute to a more effective mental health system.
Persons with Severe Mental Illness. In 1989, the National Institute of Mental Health in collaboration with the National Center for Health Statistics provided supplementary information to the National Health Interview Survey. The purpose of the project was to update the estimates of the number of persons with severe mental illness in the household population of the United States and to examine the use of various mental health services.
The survey findings suggest that the number of persons with severe mental illness can be conservatively estimated to include 2.1 to 2.6 percent of the adult population. This estimate has various components including individuals living in households, nursing homes, mental hospitals, State prisons, and individuals who are homeless.
A 1991 report, Caring for People With Severe Mental Disorders: A National Plan of Research to Improve Services, prepared by the National Advisory Mental Health Council offered recommendations for research designed to improve the quality of care for individuals suffering from severe mental disorders. However, even if knowledge from this line of research was available, issues of providing such services in an efficient, economical, and equitable manner would still exist.
The dilemma of how to develop effective service systems for persons with severe mental illness as well as persons with both severe mental and substance abuse disorders (dual diagnoses) will continue to confront providers of service, planners, and service researchers. The National Advisory Mental Health Council's report identifies crucial areas that will require the attention of mental health service researchers in the future. For example, given the number of agencies, eligibility criteria, and recertification requirements that exist for programs attempting to serve these groups, what are the optimal organizational and procedural arrangements for providing health insurance coverage, housing, income maintenance, and rehabilitation? In many parts of the country adequate resources are simply unavailable. Moreover, the delivery system, as it exists, may not have adequate staffing levels or financing arrangements. As the report indicates, research that addresses the development and evaluation of strategies for improved community and State systems of care for individuals with severe mental illness must be given priority.
Persons with Mental Illnesses Who Have Been Arrested. The number of persons who are incarcerated and who exhibit mental disorders is increasing. Those persons with mental disorders who have been arrested for serious offenses should, it has been argued, remain in jail but receive mental health treatment while incarcerated. How best to provide the needed array of services both while the individual is in jail and especially after the individual is released remains controversial.
It has also been argued that individuals with mental disorders who have been arrested for nonviolent crimes may benefit more from diversion programs than from incarceration. Although these programs begin to address the issue of the growing number of persons with severe mental disorder who are incarcerated for minor offenses, in general, the literature offers little assistance with respect to definitions or guiding principles for developing effective programs. Additional longitudinal studies are required using client-based and organizational outcome measures.
Access to Care: The timely receipt of appropriate care.
Cost-sharing: Methods, such as deductibles and coinsurance, that are employed to spread the cost of a program among interested parties and/or to contain the costs of a program.
Deinstitutionalization: A movement that began in the mid-1950s and continued through the mid-1970s whose goal was to shift individuals suffering from mental disorders out of the state hospitals and into community-based treatment settings.
Diversion Programs: Mechanisms and personnel used to 1) screen and evaluate individuals for mental health disorders while they are detained in jail; 2) negotiate with other agents within the legal and mental health system to produce a disposition that facilitates treatment rather than mere detention; and, 3) link detainees with follow-up services in the community.
Health Maintenance Organization (HMO): As originally conceived in 1971, this type of organization offered health care services using five key features that differed from the traditional fee-for-service practice: 1) Contractual responsibility was built in to provide or assure the delivery of a stated range of health services; 2) The population to be served was defined by enrollment in a specific plan; 3) Enrollment was voluntary; 4) The enrollee or consumer paid a fixed annual or monthly payment that was independent of the services used; and, 5) The organization assumed at least part of the financial risk or gain in the provision of services.
Managed Care: This is a generic term for organized systems of care that include precertification requirements, a limited network of providers, and risk-based payment.
Offset Effects: Mental health services that, when used, reduce costs in other service areas provided by the insurance plan.
Outcome: Changes in adaptive behavior(s) and role status that are logical consequences of mental health services.
Quality of Care: The degree to which mental health services for individuals and populations increase the likelihood of desired mental health outcomes and which are consistent with current professional knowledge.
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This article is derived from "Mental Health Services Research", by Lucy Canter Kihlstrom, which appeared in the Encyclopedia of Mental Health, Vol. 2, pp. 653-663 (Academic Press, 1998).
Lucy Canter Kihlstrom, PhD
Copyright © 2000 Institute for the Study of Healthcare Organizations & Transactions
Last modified: 04.08.2010 02:58 PM