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Objective: The authors aimed to identify prominent financing approaches for coordinated specialty care (CSC) of patients with first-episode psychosis, alignment or misalignment of such approaches with sustained CSC implementation, and CSC provider perspectives on ideal payment models., Methods: Semistructured interviews were conducted with informants from CSC provider organizations. Purposeful sampling of CSC program directors, team leaders, and other administrators from a national e-mail Listserv was supplemented by snowball sampling via participant recommendations. Interview data from 19 CSC programs in 14 states were analyzed by using an integrated (inductive and deductive) approach to derive themes., Results: The results indicated that financing approaches to CSC were patchwork and highly varied. Three major sources of funding were cited: insurance billing (largely fee for service [FFS] to Medicaid and private insurance), set-aside funding from the federal Mental Health Block Grant (MHBG) program, and state funding. The findings revealed limited coverage and restrictive rules associated with FFS insurance billing that were misaligned with CSC implementation. The grant nature of MHBG and other public funding was seen as a threat to long-term CSC sustainability and deployment. CSC stakeholders endorsed a bundled-payment approach by public and private payers and supported tying payment to client outcomes to reflect CSC's recovery orientation., Conclusions: Reliance on FFS insurance billing and public funding is likely to be unsustainable. Additionally, FFS billing is misaligned with CSC goals. Because of the diversity in CSC programs, populations, and existing funding mechanisms and rules, payer-provider collaboration will be essential in designing a bundled-payment model that meets local needs.

Objective: In recent years, optimizing the process of transition and discharge from coordinated specialty care (CSC), a program that provides early intervention in psychosis, has emerged as an important focus area for program administrators, clinicians, and policy makers. To explore existing CSC policies and practices and to understand frontline provider and client views on discharge, the authors conducted a comprehensive analysis of staff and client interview data from the Mental Health Block Grant 10% Set-Aside Study., Methods: Data from 66 interviews with groups of CSC providers and administrators representing 36 sites and 22 states were analyzed, as well as data from interviews with 82 CSC clients at 34 sites. Transcripts were coded by using systematic content analyses., Results: Analyses of data from providers and administrators showed the heterogeneity of CSC program practices and strategies regarding discharge and highlighted a range of concerns related to postdischarge service accessibility and quality. Analysis of data from client interviews reflected the heterogeneity of transition challenges that clients confront. A significant number of participants reported concerns about their readiness for discharge., Conclusions: CSC discharge policies and practices vary across CSC programs and states. Frequent clinician and client concerns about optimal program length, transition, and postdischarge services highlight the importance of sustained policy and research efforts to develop evidence-informed practice guidelines and possible modifications to the time-limited CSC model that currently dominates the field.

Background: People with psychosis struggle with decisions about their use of antipsychotics. They often want to reduce the dose or stop, while facing uncertainty regarding the effects these decisions will have on their treatment and recovery. They may also fear raising this issue with clinicians. The purpose of this study was to develop and test a shared decision making (SDM) tool to support patients and clinicians in making decisions about antipsychotics., Methods: A diverse editorial research team developed an Encounter Decision Aid (EDA) for patients and clinicians to use as part of the psychiatric consultation. The EDA was tested using 24 semistructured interviews with participants representing six stakeholder groups: patients with first-episode psychosis, patients with long-term psychosis, family members, psychiatrists, mental health counselors, and administrators. We used inductive and deductive coding of interview transcripts to identify points to revise within three domains: general impression and purpose of the EDA; suggested changes to the content, wording, and appearance; and usability and potential contribution to the psychiatric consultation., Results: An EDA was developed in an iterative process that yielded evidence-based answers to five frequently asked questions about antipsychotic medications. Patients with long-term psychosis and mental health counselors suggested more changes and revisions than patients with first-episode psychosis and psychiatrists. Family members suggested more revisions to the answers about potential risks of stopping or adjusting antipsychotics than other respondents., Conclusions: The EDA was perceived as potentially useful and feasible in psychiatric routine care, especially if presented during the consultation.

Objective: This study explored the association between Medicare cost-sharing requirements and the probability of use of various mental health outpatient services among Medicare enrollees with schizophrenia., Methods: Multivariate logistic regression was used to estimate the probability of use of each of seven types of services over six months. Patients were recruited from public and private mental health treatment provider organizations in six states. The analyses included 1,088 Medicare enrollees, of whom approximately 55 percent were also enrolled in Medicaid., Results: Medicare-only patients (with greater cost-sharing) were 25 to 45 percent less likely to have used rehabilitation services, individual therapy with nonpsychiatrist mental health providers, and case management. No association was found between Medicaid enrollment and probability of service use for medical clinic visits, group therapy, individual contact with a psychiatrist, or receipt of second-generation antipsychotics., Conclusions: Among Medicare enrollees with schizophrenia, gaps in Medicare coverage may be more problematic for rehabilitation, case management, and contact with nonpsychiatrist providers. Local public and private subsidies for mental health treatment may compensate for some of the gaps in coverage. However, such subsidies are not universally or uniformly provided.

Objective: This study measured state public policy makers' ratings of the importance of several key schizophrenia treatment outcomes and compared them with the ratings of primary stakeholders in schizophrenia treatment., Methods: Three groups of policy makers (40 administrative decision makers, 40 state legislators, and 20 legislative aides) and three groups of core stakeholders (20 persons with schizophrenia, 13 of their family members, and 20 of their mental health care providers) were recruited in Florida. Participants rated 12 descriptions of schizophrenia-related health states that reflected better and worse outcomes in six domains: psychotic symptoms, deficit symptoms, medication side effects, productive activity, daily activity, and social activity., Results: All participants valued functional outcomes, such as improved productive and social activity, more than they valued improvements in symptoms. Public policy makers and primary stakeholders differed in the value they placed on two of the six outcomes. Compared with primary stakeholders, policy makers valued improvements in social functioning significantly more and improvements in medication side effects significantly less., Conclusions: Policy makers and primary stakeholders place similar value on some of the major goals of schizophrenia treatment, with both groups valuing functional outcomes most highly. However, the difference between groups in the importance placed on medication side effects may lead to conflicts in the allocation of resources to the provision of newer and more expensive medications, which are associated with fewer side effects. This initial examination of policy makers' views provides a starting point for developing consensus about schizophrenia treatment policies.

Objective: To develop an instrument to characterize public sector managed behavioral health care arrangements to capture key differences between managed and "unmanaged" care and among managed care arrangements., Study Design: The instrument was developed by a multi-institutional group of collaborators with participation of an expert panel. Included are six domains predicted to have an impact on access, service utilization, costs, and quality. The domains are: characteristics of the managed care plan, enrolled population, benefit design, payment and risk arrangements, composition of provider networks, and accountability. Data are collected at three levels: managed care organization, subcontractor, and network of service providers., Data Collection Methods: Data are collected through contract abstraction and key informant interviews. A multilevel coding scheme is used to organize the data into a matrix along key domains, which is then reviewed and verified by the key informants., Principal Findings: This instrument can usefully differentiate between and among Medicaid fee-for-service programs and Medicaid managed care plans along key domains of interest. Beyond documenting basic features of the plans and providing contextual information, these data will support the refinement and testing of hypotheses about the impact of public sector managed care on access, quality, costs, and outcomes of care., Conclusions: If managed behavioral health care research is to advance beyond simple case study comparisons, a well-conceptualized set of instruments is necessary.

Objectives: This study tested a psychiatric rehabilitation approach for organizing and delivering services to street-dwelling persons with severe mental illness., Methods: Street-dwelling persons with severe mental illness were randomly assigned to the experimental program (called Choices) or to standard treatment in New York City. We assessed study participants at baseline and at 6-month intervals over 24 months, using measures of service use, quality of life, health, mental health, and social psychological status. The average deviation from baseline summary statistic was employed to assess change., Results: Compared with persons in standard treatment (n = 77), members of the experimental group (n = 91) were more likely to attend a day program (53% vs 27%), had less difficulty in meeting their basic needs, spent less time on the streets (55% vs 28% reduction), and spent more time in community housing (21% vs 9% increase). They showed greater improvement in life satisfaction and experienced a greater reduction in psychiatric symptoms., Conclusions: With an appropriate service model, it is possible to engage disaffiliated populations, expand their use of human services, and improve their housing conditions, quality of life, and mental health status.

In the early 1990s the National Institute of Mental Health sponsored projects in four cities that served a total of 896 homeless mentally ill adults. Each project tested the effectiveness of different housing, support, and rehabilitative services in reducing homelessness. Most homeless individuals resided in community housing after the intervention. The proportion in community housing varied between sites. A 47.5 percent increase in community housing was found for those in active treatment conditions. At final follow-up, 78 percent of participants in community housing were stably housed. The findings indicate that effective strategies are available for serving homeless individuals with severe mental illness.

The outcomes of a reform of the Denver mental health system, cosponsored by the state and the RWJF, are contrasted with changes in a comparison area of the state. The study examines the structural characteristics of the mental health system, staff attitudes and satisfaction, and client-reported services and outcome. Results indicate that, in Denver, structural changes, the introduction of new services, and an intervening financial crisis increased worker dissatisfaction. Client reports documented parallel changes in the following variables: continuity of care, unmet need for case management services, frequency of symptoms, and satisfaction with services. The reform had no impact, however, on most quality-of-life indicators. The possibly adverse consequences of centralizing the system and the indirect influences of system integration on quality of life are discussed.