Evaluation in a down-loaded mental health system.

Speculation that policy and funding shifts in the nation's mental health system would negatively impact program evaluation services in community mental health centers (CMHC) is substantiated. Performance of program evaluation activities was investigated in 71 CMHCs in 15 states over a two-year period. Twenty-five percent of the centers reported cutbacks, including staff attrition and diminished funding devoted to evaluation functions. The majority of centers reported no changes, but many directors representing these centers also indicated that they had never fully developed a capacity for performing evaluations and would cease to devote attention to these activities without available funding. In some centers evaluation functions are being transferred to clinical administrators; integrated into quality assurance activities; performed "as needed' by external consultants; or ignored altogether. Many centers are developing or enhancing a computerized information system to improve internal efficiency and to meet state accountability requirements. The professional issues raised to these trends as well as their implications for federal and state policy are discussed.     

The Federal GPRA Evaluation Mandate

Abstract

The Government Performance and Results Act (GPRA) mandates inclusion of evaluation in federal agency strategic plans, impacting human service programs receiving federal support. Recommended evaluation methods include flexible ongoing and participatory approaches. Yet social work may not be prepared to appropriately respond to the government's demands for accountability. This paper reviews GPRA and its implications for social work practice, evaluation, and research, offering response strategies. The paper suggests that the creation of a National Center for Social Work Research (S. 70/H.R. 663) could help bridge evaluation gaps, offering a centralized mechanism for monitoring evaluation activities and maximizing federal research resources.     

Accountability revisited: the arrival of client outcome evaluation

In the past few years, "accountability" for public mental health programs has become differentiated in the minds of not only program evaluators, but also program managers and funders, including state and local-level legislators. Increasingly, these officials are becoming concerned with more than just the numbers and targets of services delivered, and the cost involved, and are looking for evidence of positive outcome or impact on clients to justify program implementation and maintenance. This represents a significant move beyond the two accountability models that most recently seemed to be the focus of most formal accountability efforts--performance measurement and quality assurance. Pressures for implementing these two alternatives seem to have been reduced somewhat by the new federal Administration, but even prior to its advent there had been a rapid escalation in awareness of and concern for client outcome measurement among important audiences, including state and local mental health policy-makers and the U.S. Congress. This presents a major new opportunity and challenge for program evaluators at this new accountability focus continues to gather momentum.     

Passing a Mental Health Levy

ABSTRACT

The “devolution revolution” has decreased federal and state roles in the funding of social services and increased the burden on local sources, both public and private. This article describes how a community passed an initially unpopular property tax levy earmarked to support local drug, alcohol and mental health services. The article illustrates how social workers employing specific community practice knowledge provided leadership to the successful campaign. This example of community practice leadership includes building and maintaining coalitions, managing group tension and conflict and demonstrating fundamental social work values.     

Naturally Occurring Retirement Community-Supportive Service Program: an example of devolution

Devolution is defined as the transfer of power or authority from a central government to a local government. This article addresses federal policies on housing for the elderly and the devolution of funding for federal senior housing and describes two aspects of devolution of federal housing policy for the elderly. One, it points out the decreasing interest in senior housing by federal authorities as indicated by the decreased amount of funds allocated for this purpose. Two, it emphasizes the need for supportive, assistive services for residents of senior housing and how federal funds have not addressed this need adequately or sufficiently. As a consequence, there have emerged Naturally Occurring Retirement Communities (NORCs) in New York State, a housing arrangement that provides supportive and health services to all eligible residents. The article concludes with a discussion of policy implications and the need for additional research before replicating this model.     

Dilemmas in provision of urban mental health services for latency age children

Urban mental health facilities are increasingly overwhelmed by the sheer number of cases, at a time when federal, state and local funding cutbacks are greater than ever before. Additional to the numbers of cases needing care, is a growing number of cases presenting overwhelming social problems, i.e., emotional and medical pathology, economic deprivation, and substance abuse, with resultant family violence and child abuse. The case-loads in mental health agencies have become almost indistinguishable from those on the roles of child protection, juvenile justice, and child welfare agencies. Mental health service is near to impossible to provide, prior to major environmental manipulation, via educational planning, and frequent placement of children in day treatment programs, day care, or securing of in-home assistance, via home-maker services. These needed referrals take inordinate time, given the unresponsive, poorly coordinated bureaucracies providing such services. Many of the families seen are burdened by overwhelming social pathology, e.g., poverty, huge numbers of children per family, single-parenthood, drugs, and neighborhood violence. Treatment is increasingly difficult to provide, given the poor access to child serving systems, by parents and professionals, alike. Token services and worker burn-out in response to overwhelming difficult cases and excessive assignments, suggest a situation of crisis proportion. Clearly coalitions must be formed by over-burdened professionals, to better educate governing bodies, politicians, boards and administrators, and parents regarding this growing crisis. Professionals, battle-weary, are retreating from agency practice, simultaneous with agency cut-backs of staff and service. Agency administrators are cowed by local and state directives regarding budgetary cuts, and the situation worsens daily, as overburdened line staff struggle with an impossible challenge. Some sort of advocacy and social action must be taken by leaders in the field, to better inform and educate those responsible for budgetary allocations. Latency age children are among the most vulnerable, caught in deteriorating schools and neighborhoods, living with incredible daily violence, and pressures from drug dealers, pushers, adolescent gangs, and inadequate supports in their homes. This group of children is being pushed to become the violent adolescents of tomorrow. Major innovations and changes in delivery of services is necessary in health and mental health agencies serving this at-risk population. Proposed is a school based model of practice to provide access, coordination and collaboration of needed services.This paper was presented at the National Health Policy Forum, National Academies of Practice, April 1992.Ph.D. Specialization in the treatment of Children and Adolescents, Ph.D. Program.     

Naturally Occurring Retirement Community-Supportive Service Program

Summary

Devolution is defined as the transfer of power or authority from a central government to a local government. This article addresses federal policies on housing for the elderly and the devolution of funding for federal senior housing and describes two aspects of devolution of federal housing policy for the elderly. One, it points out the decreasing interest in senior housing by federal authorities as indicated by the decreased amount of funds allocated for this purpose. Two, it emphasizes the need for supportive, assistive services for residents of senior housing and how federal funds have not addressed this need adequately or sufficiently. As a consequence, there have emerged Naturally Occurring Retirement Communities (NORCs) in New York State, a housing arrangement that provides supportive and health services to all eligible residents. The article concludes with a discussion of policy implications and the need for additional research before replicating this model.     

Long-term care funding in Canada: a policy mosaic

When Canada was founded, health care was delegated as a provincial responsibility. Although the federal government shares a portion of health care costs, it is not directly responsible for the planning, delivery, and governance of health services. The 1984 Canada Health Act set national standards for the provision of physician and hospital services, but it does not apply to home care and long-term care facilities. Consequently, each province has established a unique approach to long-term care, resulting in a health policy mosaic. This paper examines different approaches to funding long-term care with a particular emphasis on the impacts of regionalization and of the implementation of case-mix-based funding systems.     

From tragedy to triumph: a segue to community building for children and families

In 2000, more than 60 nonprofit agencies, health care providers, government officials, and community advocates in Tarrant County, Texas, came together to work for systemic change in the mental health care system. The coalition, known as the Mental Health Connection, began working toward a "No Wrong Door" approach to mental health services, which required aggressive coordination between federal, private, and nonprofit resources. The result is a five- to six-year plan for implementation of a new systems of care model for children with severe emotional disturbances and their families. The Mental Health Connection also focuses on legislative advocacy to bring about necessary policy changes at the local, state, and federal levels. Finally, the coalition focuses on developing sustainable revenue streams that will allow the new systems to remain in place once the group accomplishes the initial mission of the Mental Health Connection.     

Long-Term Care Funding in Canada

Summary

When Canada was founded, health care was delegated as a provincial responsibility. Although the federal government shares a portion of health care costs, it is not directly responsible for the planning, delivery, and governance of health services. The 1984 Canada Health Act set national standards for the provision of physician and hospital services, but it does not apply to home care and long-term care facilities. Consequently, each province has established a unique approach to long-term care, resulting in a health policy mosaic. This paper examines different approaches to funding long-term care with a particular emphasis on the impacts of regionalization and of the implementation of case-mix-based funding systems.     

Civil society,social accountability and service delivery in Zimbabwe

Post‐2000, the deterioration of Zimbabwe's socioeconomic and political conditions is widely acknowledged as phenomenal and unprecedented. Consequently, government and local authorities are struggling to provide basic services. At the same time, civil society initiatives are promoting transparency and accountability in service delivery. The article explains how civil society coalitions and citizens are promoting and demanding accountability in the delivery of public services by local authorities. In particular, it focuses on four critical issues; namely local authority–citizen engagement, social accountability focus areas, social accountability tools and emerging social accountability issues. The article concludes that civil society‐led social accountability initiatives are effective under conditions of civil society capacity, institutionalization of social accountability by local authorities, and negotiating local political dynamics.     

Improving mental health assessments in child protection through audit

Existing agency records, together with questionnaires completed by social services referrers and mental health providers, were used to identify problems in current arrangements for obtaining specialist mental health assessments in child protection cases. Standards were set and implemented through a multi‐agency steering group. The practice of referrers and providers was then reaudited. Sixty‐nine social workers, six mental health specialists and 27 child protection initial case conferences (involving 31 children) were involved in the reaudit over a 4‐month period. Initially, main problems concerned communications, unclear referral and access arrangements, waiting times and disagreements over prioritization. Standards concerned consultation and decision‐making arrangements within the child mental health service, the format of referral and reply letters, the sharing of information and the attendance of mental health professionals at child protection case conferences. There appeared to be improvements in all these areas at reaudit. In conclusion, some shared views of problems, additional support funding and the audit process appear to have helped to improve inter‐agency collaboration and develop more efficient referral and care arrangements. There is a need to maintain and further develop this work, and audit would again be a useful means. Copyright © 1999 John Wiley & Sons, Ltd.     

An integrative approach to threat assessment and management: security and mental health response to a threatening client

Workplace violence threat assessment and management practices represent an interdisciplinary approach to the diversion of potentially dangerous employees and clients. This case study illustrates such an intervention in a complex situation involving a social service agency and its client. Following a curtailment of services and an arrest, the client developed an escalating homicidal anger toward the agency administrator. Once a Tarasoff warning was received, the agency contacted a security company who organized a threat assessment and management plan involving interdisciplinary collaboration. Information developed in the course of the assessment was presented to prosecutors, who facilitated the client's arrest and involuntary psychiatric commitment until he was judged to be no longer dangerous. This case ultimately involved an integration of the services of security, law enforcement, mental health professionals, prosecutors, the courts and the state mental health system in leading to a successful diversion of the client from a path of intended violence.     

Resolving conflicting demands on evaluation: A test demonstration of videotex for farmers

Evaluating an innovation for federal, state, and local policymakers and program managers alike entails conflicting demands on the evaluation study. Policymakers at federal, state, and local levels are best assisted by impact evaluations, whereas state and local program managers are best assisted by process evaluations. In-house evaluators often have an advantage in conducting process evaluations; external evaluators generally have an advantage in conducting impact evaluations. A cost-effective approach may be to combine in-house process evaluation and external impact evaluation. This dual approach was found to reduce conflicting demands on the evaluation of an experimental videotex system for agricultural producers.     

Motivations to Pursue Accreditation in Children's Mental Health Care: A Multiple Case Study

Accreditation is a growing, worldwide phenomenon that has spread to a range of industries and fields, including nonprofit social services and mental health care. Thousands of organizations are accredited, but it is not known what is driving the growth of this phenomenon. Using a multiple case study design, this exploratory study aimed to understand children's mental health agencies' motivations to pursue accreditation. In‐depth interviews, focus groups, document reviews, and limited observations were conducted at five children's mental health agencies that had recently undergone or were undergoing the Council on Accreditation process. Agencies were influenced by external factors, such as policies that require accreditation, wanting to assert their positions in the field, and the need to increase funding opportunities. Other factors were internal, related to agency leadership using accreditation as a platform for change and agencies' genuine intent to improve services. Implications for agencies, accreditors, and future research are offered.     

Evaluation of a system designed to link people living with HIV/AIDS with mental health services at an AIDS-service organization

This study evaluated the Rapid Response System, an initiative designed to link people living with HIV/AIDS with mental health services at an AIDS service organization. Data were extracted from agency records for 314 clients who had contact with the Rapid Response System over a 6-month period. Of the 281 clients who scheduled an appointment for an evaluation to initiate mental health services, 64% completed the evaluation. In the multivariate analysis, Latinos were significantly less likely than whites to complete the mental health evaluation. Further, there was a significant decrease in the likelihood of completing the mental health evaluation as the number of days between the Rapid Response System contact and the date of the evaluation appointment increased.Strategies that reduce the period of time between the initial referral and initiation of services may facilitate linkage with mental health treatment, particularly in the context of larger multi-service organizations.     

Testing Faith

Abstract

The U.S. federal government, through Charitable Choice, has opened public funding for the delivery of social services to faith-based organizations (FBOs) more than ever before. This increased access to governmental funding at all levels has led to a closer examination of the evidence base on the effectiveness of the services provided by FBOs, and the capacity of FBOs to respond to data needs for accountability and program improvement efforts. This paper discusses the current status of evaluation research on FBO services and the emerging data needs among faith-based providers. Promising avenues for enhancing the current understanding of outcomes of FBO services are explored such as (1) adopting outcome measurement practices in use within the current nonprofit sector, and (2) developing more rigorous research designs tailored to the special contexts of faith-based services. The paper suggests an agenda in which FBO operators, funders, and evaluators work together to move forward in improving the evidence base on faith-based services.     

Case Studies of Federal Occupational Health's EAP Responses to Natural Disasters

Summary

Employee assistance professionals have increasingly been called upon to address the emotional and mental health needs of customer organizations and their employees in response to large-scale natural or man-made disasters. In doing so, employee assistance program (EAP) professionals must use a repertoire of responses that encompasses a broad range of interventions, generally anchored in an understanding of and focus on the organization and its culture, mission, management and labor concerns, and other critical characteristics. The EAP's fallback response to a crisis affecting the workplace is often a critical incident stress debriefing or close variant of it. However, EAPs can best serve their customers at all levels with interventions attuned to an understanding of the workplace culture gained through a consultative relationship with management, while factoring in the nature of the disaster, the length of time and characteristics of the disaster's aftermath, and the nuances of the employees' physical and emotional needs throughout the entire disaster response and recovery process.

This article highlights these issues through the presentation of two case studies, gained from the hurricane response activities of the Federal Occupational Health (FOH) EAP. FOH, a service unit within the U.S. Department of Health and Human Services' Program Support Center, has 60 years of experience working in partnership with its federal agency customers to deliver comprehensive occupational health services to improve the health, safety, and productivity of the federal workforce. FOH's EAP contracts with vendor organizations to provide direct employee assistance, work/life, and related services to more than 1.3 million federal employees. The first case study describes (from the first person perspective) an on-site, multi-focused EAP intervention at a federal facility. The second case study describes management consultation with the U.S. Postal Service in response to major hurricane activity.     

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.