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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 Medicaid agency began a mental health carve-out demonstration in March 1996 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. 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. However, other findings raise concerns about the HMO model in terms of stability, access to care, efficiency, and more generally about the shifting of risk and public responsibility "downstream" to private organizations without sufficient governmental oversight. These findings may offer guidance for other states implementing major managed care policy initiative for disabled Medicaid enrollees. [ABSTRACT FROM AUTHOR]

The relationship between two aspects of program quality (robustness of model implementation and service dosage), client outcomes of self-reported and observer-rated psychosocial functioning, and intensive mental health service utilization costs was examined for 132 persons with dual mental and substance disorders. Membership in the 'robustly implemented' behavioral skills intervention was significantly associated with higher levels of self-reported and observer-rated psychosocial functioning, while membership in the 'robustly implemented' 12-step group was significantly related to higher intensive mental health service costs. Dosage of supportive service exhibited a significant, positive relationship to lower intensive mental health service costs but not to functioning. Although the addition of qualitative data was useful in interpreting the findings from the main study analyses, it had no discernable statistical impact on the regression equations for three major outcome variables.

Three types of treatment-behavioral skills training, a 12-step recovery model, and intensive case management-provided to 132 clients at four facilities were identified as being robustly or not robustly implemented, depending on whether core elements of these treatments were emphasized. Outcomes and costs of services to clients were examined over 18 months. Clients receiving robustly implemented behavioral skills training had significantly higher psychosocial functioning and lower costs for supportive services than those receiving nonrobustly implemented training. Clients receiving robustly implemented case management also exhibited significantly higher psychosocial functioning and lower costs for intensive services than those in the nonrobust intervention. To be effective, dual diagnosis programs should better manage the robustness of implementation of planned interventions.

Historically the divisions between the mental health and substance abuse fields have been so deep that attempts to provide coordinated treatment across service sectors for people with dual diagnoses of psychiatric disorder and substance use disorder have failed. The authors describe a program in Maine designed to develop collaboratives, or communities of providers, who work together to offer coordinated mental health and substance abuse treatment and support. Surveys of provider agencies in one collaborative conducted one year and two years after the collaborative was established showed an increase in interagency referrals, joint assessments of clients, and jointly sponsored training and client services.

People with severe and persistent mental illnesses frequently suffer from addictive disorders as well. Managed care plans and at-risk providers who care for people with these conditions must understand, authorize, and provide evidence-based and cost-effective care. The authors of this article evaluated three specialized interventions for treating people with co-occurring severe mental illness and substance abuse. Treatment of both disorders was found to be essential. In addition, a behavioral skills training was found to improve outcomes and reduce total healthcare costs when compared with intensive case management and 12-Step recovery interventions. Supplemental supportive services further increase the overall value of care. Implications for managed care and at-risk providers are discussed.

Severely mentally ill people with co-occurring substance abuse disorders are difficult to treat and the course of their psychiatric treatment is worsened by substance abuse. Despite increased attention to the problem, few studies of specialized treatment are reported in the literature and most lack detail about the specialized interventions employed. Qualitative data, gathered as part of a larger study of the cost-effectiveness of three substance abuse interventions for severely mentally ill people, are presented which describe the interventions, their implementation in four community mental health centers over 18 months of the study, and their relationship to the quantitative outcomes. Illustrated is the difficulty of implementing innovative programs and the need for vigilance concerning program fidelity.

Objective: Case management was seen as the major strategy for integrating mental health, housing, and social supports for clients in the Robert Wood Johnson Foundation Program on Chronic Mental Illness, a five-year multisite demonstration project designed to test the effects of reorganizing mental health systems in large urban areas. The authors assessed data on case management programs in the demonstration project to try to explain the lack of consistent improvement in clients' outcomes that was found in the national evaluation of the project., Methods: Data on case management programs from five demonstration sites-Baltimore; Cincinnati; Columbus, Ohio; Denver; and Toledo, Ohio-were reviewed. Data sources included onsite interviews, documentary material, studies of case managers' contact with community agencies that were conducted in 1989 and 1991, and telephone interviews with coordinators of case management programs., Results: The characteristics and activities of case managers changed little between 1989 and 1991. Case managers tended to become the principal service providers for their clients rather than coordinating service provision among multiple service providers. Case managers reported that their clients received few services from other agencies in the local community support system., Conclusions: Although lack of change in case managers' activities during the demonstration project may help explain clients' lack of improvement over time, case management by itself does not constitute comprehensive treatment. More attention must be paid to the development and refinement of community-based medical-psychiatric and psychosocial treatments with a proven track record of improving clients' level of symptoms and quality of life.

A recent study examined the relative cost-effectiveness of three specialized interventions for treating people with both severe mental illness and substance abuse disorders: behavioral skills training, intensive case management, and 12-Step recovery. This article reports the changes in client psychosocial outcomes, psychiatric and substance abuse symptomatology, and service utilization and costs for the 31 women involved in the study, and compares these results to similar data on the men in the study sample and to the existing literature. Also presented are the most salient clinical impressions of the treating staff of issues affecting the course of treatment and outcomes for these women. Similarities were found in treated prevalence, service utilization, and related clinical issues in women with dual disorders compared to those reported in the existing psychiatric or substance abuse literature. Compared to men in the same sample, the women had higher functioning scores, more psychiatric symptomatology, and greater reductions in 24-hour acute or subacute treatment services used during the first six months of the specialized intervention programs. These results provide some insight into ways of serving dually diagnosed women more effectively in community-based treatment programs and of investigating these services more fruitfully.

Objective: The authors outline a minimal set of outcome indicators to assess the effects of specialized treatment for people with severe mental illness and substance use disorders and report on use of these indicators in a longitudinal study of such treatments., Methods: A total of 147 clients with dual disorders participated in a controlled clinical trial of three interventions--behavioral skills training, case management, and 12-step recovery--in a county mental health program. The clients were assessed every six months over a two-year period using multidimensional self-report and observer-rated outcome measures encompassing psychosocial functioning, psychiatric and substance abuse symptoms, and service utilization., Results: Client self-reports showed changes in psychosocial functioning, especially increased functioning in residential stability and work, and reductions in alcohol and drug symptoms and usage. Data on service utilization showed decreased use of acute and subacute mental health services and increased use of outpatient and case management services over time. Ratings by trained observers of psychiatric symptoms and psychosocial functioning improved dramatically., Conclusions: A minimal set of outcome indicators for clinical trials and demonstrations of interventions for clients with dual disorders should include client self-reports of social adjustment, life satisfaction, psychiatric and substance abuse symptoms, and current substance use; interviewers' ratings of psychosocial functioning and psychiatric symptoms; data on utilization of mental health treatment and support services; and data on clients' personal income, use of medical services, and contact with the criminal justice system.

This article describes the development of a 'key informant survey' to assess the performance of local systems of care for persons with a chronic mental illness. The measure yields ratings of: (1) the extent to which clients experience service delivery problems in 11 community support system elements, (2) overall performance of the community support system, and (3) the performance of local mental health authorities. Following pre-testing, the survey was administered to 699 respondents in nine U.S. cities. Internal consistency coefficients were found to be within acceptable ranges for all of the scales across all nine cities. Analyses comparing mean values for performance ratings showed that the nine sites could be arranged into three groups representing high, medium and low system performance. These findings support observations from site visits conducted over several years and suggest that the survey is a valid instrument for assessing local systems of care.

Interest in case management has grown in the substance abuse treatment field because of changes in the way we think about substance abuse, problems in the current delivery of treatment, subgroups of people have been identified who are unresponsive to currently available treatments or for whom special access problems are apparent. Case management is appealing because it involves accessing services and coordinating the care of individuals over long periods of time. This article briefly reviews the conduct of case management in substance abuse treatment by defining case management and discussing prevalent models, and then examining practical challenges faced in the implementation of case management.

This study examines the cost effectiveness of three intervention strategies for people with severe mental illness who are dually diagnosed clients in terms of service use and costs. The interventions represent three primary approaches to treating these disorders: 12-step recovery, case management, and behavioral skills training. Interim findings from the study indicate that all three approaches are reducing acute and subacute service use and increasing involvement with outpatient and case management treatments. However, both the case management and behavioral skills approaches reduce costs more than the 12-step recovery approach, although not to a statistically significant degree in the data collected thus far. Overall, the societal costs for these clients are reduced by 43% without increasing the burden on client families or on the criminal justice system.

The extent of change in the performance of local mental health authorities (LMHAs) and in the development of community support systems (CSSs) is assessed for nine demonstration cities that participated in the RWJF Program on Chronic Mental Illness and one comparison site. Parallel measures of LMHA and CSS performance were obtained from two data sources (key informant and interorganizational network surveys) conducted at each site at two times during the demonstration: 1989 and 1991. Findings indicate that the LMHAs were successfully implemented at most demonstration sites, but changes in the CSSs lagged behind LMHA performance levels. The amount of system change tended to be greater when estimated from network versus key informant data.

Community-based services for mentally ill individuals have developed in a fragmented and uncoordinated manner over the last 30 years. In response, the RWJF initiated a five-year demonstration in nine cities: the Program on Chronic Mental Illness (CMI). The project's background is described, as are its accomplishments and limitations. One outcome of sponsorship by the RWJF and the U.S. Department of Housing and Urban Development was to assure the problem of CMI a place in the public policy agenda. Despite specific improvements in quality of life for individuals with CMI, however, there was no general improvement for this population. The program thus demonstrated that structural changes alone are insufficient; quality of care must be attended to as well. Despite its drawbacks, the project revealed that interventions can be implemented with positive results.

In a national evaluation, we assessed the implementation and outcomes of a multisite demonstration program for homeless persons with alcohol and other drug problems. We developed comprehensive case studies from data on client characteristics, utilization of services, implementation of interventions, and community systems of care at nine project sites. Client-level outcome data were analyzed to estimate the effectiveness of the interventions in a subset of projects with experimental or quasi-experimental evaluation designs. After controlling for baseline predictors, treatment clients in the majority of sites were significantly more likely than comparison clients to report improvement on one or more outcome dimensions. On alcohol use, for example, under conservative assumptions the average treatment client was drinking less at follow-up than were 57 percent of comparison clients. Analyses of predictor-by-treatment interactions suggested that clients with fewer problems benefited most from the interventions. The implementation analysis yielded a number of lessons for policymakers and program planners.

The Robert Wood Johnson Foundation Program on Chronic Mental Illness provides support for broad change in the organization, financing, and delivery of services in public systems of care for chronic mentally ill persons. To address the lack of an organizational locus of responsibility in these systems, the foundation proposed that each of the nine cities participating in the program create a mental health authority that would centralize administrative, clinical, and fiscal oversight. The authors present site-by-site observations of the developing mental health authorities at the end of the program's two-and-a-half-year planning phase. They conclude that although the Robert Wood Johnson Foundation grant represented a significant incentive for innovation, at this relatively early stage in the demonstration authorities at only a few sites had achieved direct clinical responsibility for chronic mentally ill persons. Although services had expanded, no site had yet developed a comprehensive system of care that included inpatient services as well as a full range of ambulatory, housing, and social welfare services.

Among the frustrations of managing the dual disorders of chronic mental illness and alcohol and drug abuse is the fact that knowing what to do (by way of special programming) is insufficient to address the problem. The system problems are at least as intractable as the chronic illnesses themselves. Organizing and financing care of patients with comorbities is complicated. At issue are the ways in which we administer mental health and alcohol and drug treatment as well as finance that care. Separate administrative divisions and funding pools, while appropriate for political expediency, visibility, and administrative efficiency, have compounded the problems inherent in serving persons with multiple disabilities. Arbitrary service divisions and categorical boundaries at the State level prevent local governments and programs from organizing joint projects or creatively managing patients across service boundaries. When patients cannot adapt to the way services are organized, we risk reinforcing their overutilization of inpatient and emergency services, which are ineffective mechanisms for delivering the care these patients need. This article reviews the barriers in organization and financing of care (categoric and third party financing, including the special problem of diagnosis-related groups limitations) and proposes strategies to enhance the delivery of appropriate treatment.