Managing physical and mental health conditions: Consumer perspectives on integrated care

Despite the growing trend of integrating primary care and mental health services, little research has documented how consumers with severe mental illnesses (SMI) manage comorbid conditions or view integrated services. We sought to better understand how consumers perceive and manage both mental and physical health conditions and their views of integrated services. We conducted semi-structured interviews with consumers receiving primary care services integrated in a community mental health setting. Consumers described a range of strategies to deal with physical health conditions and generally viewed mental and physical health conditions as impacting one another. Consumers viewed integration of primary care and mental health services favorably, specifically its convenience, friendliness, and knowledge of providers, and collaboration between providers. Although integration was viewed positively, consumers with SMI may need a myriad of strategies and supports to both initiate and sustain lifestyle changes that address common physical health problems.     

“We don't want to talk about that”: Overcoming barriers to rural aging research and interventions on sensitive topics

Geographical, economic, social and cultural barriers to accessing services in rural areas are widely reported. Less widely discussed are dilemmas posed by individual and community reluctance to address sensitive health issues. This article, focusing on the highly sensitive area of mental health, and employing a participatory action approach, describes the natural history of a project, the Mental Health and Aging Initiative (MHAI) to enhance awareness of mental health issues in rural Kentucky-Appalachian communities and overcome the reluctance of individuals in these communities to seek assistance. Funded by the United States Department of Agriculture (USDA), MHAI involved an educational intervention to improve knowledge about mental health and aging in rural Appalachian counties. The need to overcome significant community reluctance to engage in discussion of mental health resulted in significant modification of the protocol. The intervention was grounded in recognition of four key aspects of the local situation: (1) the need to understand the sensitivity of mental health as an element of rural culture; (2) the critical role of local community leaders as points of entry, acceptance, and action; (3) the need to overcome social stigma and reframe the topic of mental health in a more positive light; and (4) the need for methodological innovation in developing an empowering educational action plan oriented toward community-wide long-term impact. The intervention model that emerged from these considerations was based on engaging community leaders, providing educational and technical resources, and nurturing the acceptance by individual rural residents of responsibility for monitoring community mental health. This motif became a central theme in a strategy designed to facilitate culture change and acceptance of mental health as a community concern. It involved active engagement of community representatives in defining and implementing an intervention consistent with participatory action research as a means of empowering rural residents in monitoring and addressing sensitive health care issues. Given that many issues in rural health are difficult to address because of such sensitivity, the approach described is considered to have application in other contexts.     

Helping parents with mental illnesses and their children: a call for family-focused mental health care

1. Large numbers of individuals with mental illnesses are parents to minor children. 2. Recommendations to improve services suggest that services provided by the adult mental health system and child service agencies be coordinated. 3. Nursing care intersects both the adult and child systems, and nurses have the expertise to offer a variety of services. 4. There is an urgent need to improve family-focused mental health nursing care to benefit parents with mental illnesses, their children and families, and the overall community and society.     

Managed care and the rationalization of mental health services

Managed care represents a response to the wider institutional demand for technical rationality and efficiency, and it may be in conflict with professionally generated logics of mental health care which emphasize the delivery of quality care, as well as providing services to all who need care. The organizational and policy conundrum is to balance conflicting institutional demands for efficiency (cost savings) and effectiveness (access and quality). This paper examines managed care in one public sector mental health care system that has attempted to incorporate the principles of managed care into a community based system of care and to overcome the potential contradictions between demands for efficiency and professional logics of care. Both qualitative and quantitative data are used to examine changes in organizational structure and service offerings; providers' experience of managed care, and the effect of managed care on working conditions and work experiences, and changes in the goals of the organization as measured by the specification of client outcomes. I find that, while increased performance accountability and outcome assessment (in keeping with demands for efficiency) have the potential to improve mental health care services, in fact, providers report that the primary effect of managed care has been an emphasis on cost containment, and there has been a corresponding de-emphasis on the provision of community based services for clients with long term care needs. However, there is potential for professional logics to be maintained by larger institutional forces demanding quality care.     

An Experiment in Overseas Field Instruction

This paper reports on a study that examined the knowledge needed for practice in community mental health and the primary source for this knowledge. Differences were found in knowledge areas needed for practice in community mental health settings when contrasted with practice in more traditional mental health agencies. The most frequently indicated source of knowledge for social work roles in community mental health was on-the-job experience. Courses in social work schools were not a primary source of knowledge for the many nonclinical roles undertaken by social workers in community mental health.     

Learning opportunities through camping for mental health nursing

1. To equip nurses with the skills necessary for working with disturbed people, nurse educators need to be mindful of not watering down the essential skills necessary for nurses to deal with difficult behaviour in all branches of nursing. 2. These components of a mental health clinical experience should equip the graduate to deal with the pressures of dealing with disturbed people in any environment, as the skills learned generalize to any branch of nursing. 3. Universities can combine with traditional hospital services and community mental health services to provide services to clients with mental illness. An additional benefit is in providing students with an intensive clinical learning experience that reinforces the theory taught in the classroom.     

Community mobilization and health care in rural China

This study is based on interviews conducted in Xiao San Jiang Township, China. This article describes the health care system before and after the reforms of the late 1970s and the impact on community mobilization and health care provision. The success of the Chinese health care system is attributed to mass participation in disease prevention. There were the public health campaigns of the 1950s at the brigade level that mobilized people to adopt personal and environmental sanitation, pest control, and primary health education. There were organizations, such as the Youth Leagues and the Women's Federations. The large groups encouraged use of services, such as family planning services, gynecological screening, and immunization. The Barefoot Doctor and Cooperative Medical Care Insurance Schemes were introduced. Brigades became directly involved in health care delivery, and health workers increased access to primary health services. There was multisectoral collaboration between mass and government organizations. Each commune official had multiple roles and information flowed between sectors. The end result was community mobilization of resources in an organization-intensive social structure and increased hopes for improvements in health. The propaganda was effective in health promotion. In the late 1970s, township management districts and village committees replaced the brigades and communes. The responsibility system gave households responsibility for the productivity of specific plots of land in order to fulfill government quotas. Members of a health project funded by a Hong Kong-based primary health care organization discovered a number of problems. Community mobilization was waning, and mass organizations were not effective. The insurance system collapsed. People tired of political slogans. Although other countries are now adopting community health approaches, China is moving away from this approach.     

Multilevel community health promotion: How can we make it work?

The need for multilevel, comprehensive health promotion programmeshas become widely accepted, as has the importance of communityapproaches. However, many health promotion programmes focuson change at the individual level, no doubt partly due to thedifficulty of implementing all-inclusive health promotion. Thispaper discusses two strategies for guiding multilevel projects:multiple methods for community assessment and charting projectactivities by level of change (a possibility framework). Thesestrategies help ensure a multilevel focus and provide valuableinformation that can assist with the implementation of multilevelhealth promotion research projects in specific community contexts.Our primary purpose, therefore, is not to focus on theory orresearch findings. Rather, our goal is to make visible two strategiesthat have been helpful in one health promotion research projectin Victoria, British Columbia, Canada.     

Evaluation approaches in mental health: Implications of the new federalism

Since the introduction of federal mental health legislation in 1963, there has been a changing emphasis on evaluation and accountability. With direct federal funding of community mental health services, accountability demands were met through expectations for local agency evaluation activities which were overseen by federal authorities. The advent of the New Federalism and the shift to block grant funding of mental health services to state mental health authorities have shifted responsibility for evaluation to the states and local programs. This paper reviews federal mental health statutes to trace the extent and locus of required evaluation activities and discusses two approaches to carrying out program evaluation: "top-down" where the evaluation topic, method, and data collection are mandated by an administering or funding body; and "bottom-up" approaches where the subject, method of study, and data to be collected are developed in response to a felt need at the local agency level. A case study of each approach as used at the state level in mental health is examined. Based on the literature and the case studies, conclusions are presented on the pro's and con's of each method in meeting accountability demands and the barriers which must be overcome for either method to be successful.     

A case study in defining developmental costs for quality assurance in mental health center programs

Issues related to the state-of-the-art of ambulatory mental health care review as well as to the resources necessary for planning and operating a quality assurance program may be hampering development of such programs in community mental health centers nationwide. Faced with the problem of responsible and prudent program management, it has become increasingly difficult for CMHC directors to implement innovative, but unproven, and often unpriced programs which have the potential to draw scarce professional resources away from direct service delivery. Pressure to implement CMHC program requirements that are not ordinarily considered revenue-producing in nature, for example, consultation and education services and quality assurance activities, may further create anxiety for mental health program directors, especially during periods when they are ostensibly confronted with the need to maximize CMHC revenues. Before mental health professionals and administrators of mental health programs can be expected to introduce quality assurance programs, they need to have some idea how much the system costs. The figures reported from three North Carolina mental health centers may offer some indication of what other mental health centers might expect to spend in developing a quality assurance program. Salary expenses for multidisciplinary staff participation in quality assurance activities are presented.     

Evaluating a community based mental health programme in West Bengal,India: Description of the methodology and lessons learned

Mental disorders impose an enormous burden on society. In developing countries like India, there is a lack of adequate number of trained mental health professionals to provide specialized care and 75–85 % of affected individuals do not have access to appropriate mental health services. The National Mental Health Programme (NMHP) is being implemented by the Government of India to support state governments in providing mental health services in the country. The Urban Mental Health Programme (UMHP) is a pilot initiative that has attempted the integration of mental health services in primary health care settings in two municipal wards in Kolkata, West Bengal, India. The overarching aim of this paper is to describe the methodology used for the evaluation of the community based mental health programme and to understand the processes of the programme in terms of barriers and facilitators. The current evaluation is based on a concurrent nested design, where qualitative and quantitative data are both collected at the same time but analysed separately and priority was given to qualitative data. This experience will contribute in helping other researchers to make some evaluations more effective, useful and manageable. Ethics approval was obtained from an institutional ethics committee of an organization (Ekjut) based in Ranchi, Jharkhand, India. The evaluation was undertaken by the George Institute for Global Health, New Delhi from February- June 2016.     

Nursing in tele-mental health

This article discusses a cooperative project involving an academic health sciences center, a state university, a women's shelter, and a community mental health center in East Texas, a medically underserved, rural region of Texas. The U.S. Department of Commerce provided grant funding to develop a telehealth network to provide an evaluation, referral, and treatment program for victims of domestic violence. Nurses were involved in all phases of the project, from initial conception through development, implementation, and evaluation. The authors concluded that all of the women involved in the study had significant mental health issues and other health concerns that were not being addressed by the existing health care delivery system. Without the use of telehealth, these women would have had limited access to primary health care and virtually no access to mental health services. The East Texas Tele-Mental Health Network demonstrates the value of the clinical and organizational skills that nurses bring to innovative models of mental health service delivery.     

Are case management services associated with increased utilization of adolescent mental health treatment?

Retention in treatment is one of the strongest predictors of positive mental health outcomes. Adolescents, however, are particularly challenging to retain in mental health treatment. Concurrent case management services may offer one strategy for retaining youth in mental health treatment as it aims to reduce barriers to services, coordinate multiple services, and establish a consistent relationship between each client and a single contact person. This study combines three extant data sources from the state of Kansas to examine whether youths' participation in case management is associated with increased utilization of individual and group mental health treatment, controlling for client satisfaction, severity of mental health symptoms, and demographic factors. Linear regression results indicate that participation in case management services predicts increased utilization of both individual and group mental health treatment. Case management may be a useful tool for retaining adolescent clients in mental health services. Practical implications for community mental health service delivery are discussed.     

Health status risk factors of people with severe and persistent mental illness.

High rates of medical comorbidity and premature death have become normative health outcomes for individuals with mental illness. On average, people with mental illness die 10 to 15 years earlier than the general population. To date, little research and programmatic attention has focused on the health promotion and prevention needs of people with mental illness. Many factors have been cited as contributing to this problem, including the stigma of being mentally ill, poverty, and limited knowledge and access to health promotion services. Future health planning interventions should restructure the funding mandates of current health care delivery system from an illness and treatment model to one of illness prevention and health promotion.     

Use of Various Health Care Services by Students in Helsinki

Abstract

Review of the working of various health care schemes has revealed predominant use by a certain group of “large-scale consumers.” The concomitant use of various services (health, dental, and mental health care) was studied within the Helsinki Health Center of the Finnish Student Health Service from January 1, 1980 to August 31, 1980. The group consisted of 16,174 students. The characteristics of the groups of patients who used only the mental health care service and of those who used all three services were also studied. Within each sector, there were fewer patients than expected who did not use the services of other sectors. The number of patients visiting dental and health care services, mental health and health care services, and all three services were greater than expected. The groups of patients who used only the mental health care service and those who used all three services were surprisingly similar. The greatest difference between the groups probably lay in their need for somatic and dental care. The organization, which incorporates mental health, dental, and health care services in the same building offers improved possibilities for care of the patient as a whole. On the basis of this study, there is no reason to think that such an organization leads to misuse of the various services.     

From Fragmentation to Integration

Abstract

Within the mental health field, there is an increased attention to issues of diversity. However, this awareness has not yet been applied to racially and culturally diverse gays and lesbians who are chronically mentally ill. Some of the reasons for this include the long history of homogeneity of American institutions; the underutilization of mental health services by minority groups; the stigmatization of the mentally ill; and homophobia, within both the psychiatric community and society at large. As a result, there is a need for mental health professionals to acknowledge minority gays and lesbians with chronic mental illness, and begin to provide programs that affirm their sexual orientation, race, and cultural identities.     

Working across borders to promote positive mental health and well‐being

World health reports highlight the increasing prevalence of mental health problems and the need to recognize that mental well‐being is a fundamental aspect of any health policy. The scale and cost of mental health problems mean that appropriate policies and strategies must be developed and implemented. In Ireland this is a period of substantial review and reflection on mental health policy and practice, but to date little consideration has been given to the development of a cross‐border strategy. Cooperation and collaboration has been largely dependent on the leadership of a number of individuals supported by short‐term European Union funding. This paper is informed by a study which was concerned with examining the issues associated with promoting mental health across the Irish border. Insights were provided by 38 individuals who were involved in the delivery of cross‐border mental health services in the North West region. The article argues that there is substantial support for working across borders and developing sustainable cross‐border health strategies. In the absence of a statutory all‐Ireland coordinated policy overseeing the development of mental health promotion, the sustainability of projects emerged as a key issue. The results suggest that whilst much innovative and creative work has been undertaken by committed individuals, what is now required is a strategic response from both the British and Irish governments which will ensure the needs of service users in these deprived border regions can be effectively addressed. Also, at a policy level this strategic development would be seen as a reflection of the value placed on promoting mental health and well‐being.     

Lost in transition: Illicit substance use and services receipt among at-risk youth in the child welfare system

This study examined the use of mental health and substance abuse services among adolescents in the child welfare system (CWS) who reported use of illicit substances. 1004 adolescents age 11–15 years at baseline were followed for 5–7 years, over five waves of data collection. Shortly after the investigation for maltreatment (baseline), 69.1% of youths using illicit substances received mental health and/or substance abuse outpatient specialty services. By the last follow-up, during the transition to adulthood, only 21.5% of young adults using illicit substances received outpatient specialty services. Youth who used illicit substances were more likely to receive outpatient and inpatient specialty services than non-users at the time of contact with the CWS (mostly baseline), but this difference faded over the follow-up period. By 5–7 years follow-up, there was no significant difference in specialty services receipt for illicit substances users versus non-users. Predictors of outpatient service use at most waves were having Medicaid, mental health needs, and having recently seen a school counselor or primary care physician. Among illicit substance users transitioning to adulthood, African American youths were less likely to receive outpatient specialty services than White youths. These findings reveal a need for more attention to illicit substances use among youth in the CWS, better cross agency integration, and special attention to the needs of transition-age youth to better connect them with services as they age out of the CWS.