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Traditional and ethnographic content analyses of 23 position papers on mental health care reform issued during 1993 yield a comprehensive overview of the specific subjects and broad policy issues that were of concern at that time. Five concrete aspects of mental health service delivery systems and eight policy issues were identified as most important in position papers by service provider organizations and advocacy groups. These analyses identified overall similarities in the content of the position papers, although interesting differences among organizations emerged. The analyses also identified a measure of the quality of policy discussions that is derived from comparing the frequency of concrete references to aspects of mental health care with references to broader policy issues.

The Hispanic American population, the second largest and fastest growing minority population in the United States, faces barriers to access to both medical health and mental health care. This paper examines both financial and cultural barriers to utilization of mental health care services; it is a broad review of the literature and is not intended to be comprehensively detailed. The research review suggests that the financial barrier is a major determinant of mental health service access for Hispanic American populations. Also, nonfinancial barriers such as acculturation are examined. A two-part plan is suggested to reduce both financial and nonfinancial barriers. Very little literature on utilization of substance abuse services was found; suggestions for further research are thus proposed.

In 1984, the National Institute of Mental Health (NIMH) began funding its Child and Adolescent Service System Program (CASSP). In this paper, we present findings from a descriptive study of the experiences of the initial cohort of states to receive CASSP grants, conceived and conducted when the projects were approaching the end of their fifth and final year of NIMH funding. Detailed case studies were conducted of each of the 10 initial cohort projects, and the findings analyzed across projects. Data were collected from three major sources: (1) existing documentation about the projects, (2) site visits to each of the projects, and (3) information from relevant secondary sources. Findings suggest that the initial cohort projects utilized a variety of strategies and encountered a variety of barriers and facilitating factors. The projects generally implemented the intended CASSP program and did so by using a variety of strategies. The projects were judged by stakeholders in their states to have influenced the service systems in their states in the intended directions: toward a more comprehensive system of care that emphasizes community-based treatment; toward better integrated, more collaborative efforts among the state agencies involved; toward a more detailed understanding on the part of system stakeholders of the mental health problems of children and adolescents who have severe emotional disturbances, and of the influence of those problems on the lives of the children and their families; and toward increased involvement by parents and other family members in the care of these children and adolescents.

The purpose of this paper to describe the Department of Veterans Affairs' (VA) recent expansion and enhancement of its substance abuse treatment services. Several treatment innovations are considered from both clinical and administrative perspectives. These services include extended care programs for multiply impaired patients, programs for substance abuse patients with comorbid psychiatry conditions and services designed to improve continuity of care and community re-entry. Emergent themes include a broadening of services to meet the needs of a changing substance abuse population and an emphasis on providing more cost-efficient treatment.

Three major factors suggest a healthy future for data-based decision making within mental health authorities: (1) the improved knowledge base related to the treatment and management of serious mental illness, (2) advances in data-processing technology and (3) conceptual advances in management information system design, most notably the National Institute of Mental Health (NIMH) Mental Health Statistics Improvement Package. This paper briefly outlines these three factors and goes on to examine information needed by state mental health authorities (SMHAs) to enhance decision making. The client-level data necessary for data-based policy decisions, while still scarce, are increasingly available and are increasingly finding homes within SMHA management information systems. As SMHAs improve their information systems to accommodate such data, they face substantial implementation challenges and substantial payoffs in terms of increased knowledge for decision making.

This paper reports findings from two focus groups on managed care conducted in a large U.S. city in 1989. Questions addressed included how managed care had affected mental health practice, specific experiences with managed care, the mechanisms of managed care, and how managed care could be improved. The practitioners complained of multiple problems, but clearly distinguished between "good" and "bad" firms. Firms seen as more positive struck a balance between quality care and cost containment, built ongoing relationships with providers, and negotiated with providers, rather than prescribing a treatment plan. The authors conclude that some of the poor reception by providers of managed care may have been created unnecessarily by firms which have not attended to these factors, and that attention to such factors might lead to a more ready acceptance of managed care.

This paper traces the development of The Robert Wood Johnson Foundation's Mental Health Services Program for Youth, a private initiative designed to improve the organization, financing, and delivery of service to seriously mentally ill youth. The rationale and structure of this five-year initiative are discussed. In July 1989, 12 one-year development grants were awarded under the program's first phase. All of the grantees propose to utilize a number of strategies to restructure their mental health financing systems. Other common features include: the development of central intake units, early identification mechanisms, stronger utilization review protocols, and unified client tracking mechanisms.

Examines the role of statewide family advocacy networks (SFNs) in addressing children's mental health system of care and legislative issues in the United States. Developments and activities of SFNs; Diversity and types of organizational arrangements; Increase in outside financial resources; Extent to which ethnically and culturally diverse people are involved.

Describes the implementation of the Michigan Supported Education Research Project, a three-year federally funded collaborative effort providing support for consumers of public mental health services in metropolitan Detroit, Michigan. Program structure and staffing; Implementation activities and challenges; Networking and building awareness.

Describes the Value Accounting System, a clinical management tool developed for use by a national organization of psychiatric treatment facilities in the United States. Main components of the system; Implementation of the system; Implications for mental health administration and service delivery.

Describes patterns of service use over time by a group of persons with chronic mental illness who were homeless at the time of the index admission. Importance of understanding the new careers of persons with chronic mental illness; Demographic and clinical characteristics of Skid Row Mental Health Services; Sequential patterns of service use.

Focuses on the views of American parents on quality in support services for families who have a member with developmental disabilities. Family empowerment as a key principle of the support programs; Challenges to parents' participation in policy development, program management, and evaluation of programs; Parents' identified factor.

Opinion. Argues that the best mental health care is delivered within and through the larger medical system. Organization of primary and secondary mental health services within the medical system; Characteristics of the mental health systems; Developing a customer-oriented system; Features of a mental health benefit to support a continuum of services.

Describes an effort to develop a multiscale instrument to track the quality of mental health treatment in the United States. Accountability, cost effectiveness, and continuous quality improvement as essential features of a managed health care system; Problems on the application of the principles to mental health treatment; Criteria for the selection of outcome measures.

Opinion. Comments on health care reform in the United States. Impact on mental health services and academic psychiatric institutions; Research, education and clinical care responsibilities; Priorities.

Compares areas in Massachusetts that differ with regard to mental health service system structure and resource allocation. Stakeholders' perceptions of service system adequacy, availability, quality and coordination; Hospitalization rates; Clinical issues; Implications for mental health policy.

Reports on a systematic statewide effort to determine the residential needs and preferences of primary consumers of mental health services and family members of consumers in the United States. Comparables surveys regarding the residential needs of consumers; Comparison of the preferences of family members and consumers.