A theory of social integration as quality of life.

OBJECTIVE: Quality of life, once a priority in caring for people with severe mental illness, has since been eclipsed by other concerns. This article returns attention to quality of life by offering a theory of social integration (as quality of life) for persons disabled by severe mental illness. METHODS: Data collection for this qualitative study consisted of 78 individual, unstructured interviews with 56 adults who have been psychiatrically disabled. Field observations and interviews with staff and service users were carried out during eight ethnographic visits to service sites working to promote social integration. Data were analyzed with an inductive strategy based on grounded theory methodology and framed theoretically by the capabilities approach to human development. Goals were to identify personal capacities needed for integration, characterize occasions for capacity development in mental health care, and develop a working theory. RESULTS: Six personal capacities were identified: responsibility, accountability, imagination, empathy, judgment, and advocacy. Occasions were characterized in terms of their defining mechanisms: contradiction, reinterpretation, rehearsal, raising expectations, and confrontation. A working theory was constructed to characterize the process of capacity development for social integration through exposure to increasingly challenging occasions for growth in the context of mental health care. CONCLUSIONS: Capacities for social integration can be effectively developed as part of the everyday routines of mental health care. Eventually, the process shifts from development to the exercise of capacities and to participation as full citizens in the social world beyond treatment.

Therapeutic communities and mental health system reform.

TOPIC: The contemporary relevance of therapeutic communities as a treatment modality in mental health is described. METHODS: This paper builds upon on a qualitative study to provide a case illustration of a working therapeutic community for persons with serious mental illness. SOURCES USED: The data are seventeen interviews conducted with staff and residents and observations carried out during four days of field work by the research team. CONCLUSIONS: Studies are needed to determine whether therapeutic communities strengthen consumer capacity for social integration and thus contribute to empowerment and the larger recovery agenda.

Connectedness and citizenship: redefining social integration.

OBJECTIVE: Despite decades of deinstitutionalization, individuals with psychiatric disabilities living outside the hospital may be described as in the community, but not of it. To effectively address the persisting problem of social exclusion of persons with psychiatric disabilities, new conceptual tools are needed. To address this need, a new definition of social integration is offered. METHODS: The definition is based on data from a qualitative study. Data collection consisted of individual, unstructured interviews with 56 adults who have been psychiatrically disabled (N=78 interviews) as well as ethnographic visits to five service sites working to promote social integration for their users (N=8 visits). An interpretive approach was used to analyze the data. RESULTS: Social integration is defined as a process, unfolding over time, through which individuals who have been psychiatrically disabled increasingly develop and exercise their capacities for connectedness and citizenship. Connectedness denotes the construction and successful maintenance of reciprocal interpersonal relationships. Social, moral, and emotional competencies are required to sustain connectedness. Citizenship refers to the rights and privileges enjoyed by members of a democratic society and to the responsibilities these rights engender. The definition calls for full rights and responsibilities of citizenship. CONCLUSIONS: The new definition sets an ideal, but not unrealistic, standard for social integration in the context of psychiatric disability. High standards encourage mental health professionals and policy makers to rethink what is possible for mental health services and to raise expectations for connectedness and citizenship among persons once disabled by mental illness.

Guideline recommendations for treatment of schizophrenia: the impact of managed care.

BACKGROUND: Medicaid-managed care has been shown to reduce the number and length of psychiatric hospitalizations, but little is known about the clinical and social consequences of such managed care programs. The purpose of this study was to compare the treatment of schizophrenia for disabled Medicaid beneficiaries who were and were not enrolled in managed care. METHODS: This was a prospective observational study of patients who sought care for a psychiatric crisis from June 7, 1997, to May 13, 1999. Patients were followed up for 6 months. Inpatient and outpatient mental health facilities in Massachusetts were studied. The participants included 420 adult Medicaid beneficiaries, aged 24 to 64 years, who were treated for schizophrenia; 784 eligible beneficiaries were originally contacted and invited to participate (53.6% response). A private managed behavioral health care organization administered the Medicaid mental health benefit for about half the patients in the study. The other half were enrolled in the dually insured fee-for-service Medicare/Medicaid plan. The main outcome measures were adherence to the Schizophrenia Patient Outcomes Research Team treatment recommendations from inpatient and outpatient medical records, self-reported quality of interpersonal interactions between patient and clinician, self-reported care experiences and outcomes, and clinician-reported outcomes. RESULTS: There were no differences between the managed care plan and the unmanaged fee-for-service plan in adherence to the schizophrenia treatment guidelines. However, much outpatient care in both programs was inconsistent with treatment guidelines. Inpatient treatment was far more likely to conform to guidelines than outpatient treatment. Patient ratings of their care were positive and not different between plans. Clinical outcome and health-related quality of life were not different between plans. CONCLUSIONS: A major change in Massachusetts in the way mental health care is organized and financed had neither a negative nor a positive effect on care quality. However, adherence to nationally accepted guidelines for care was only modest, suggesting a need to improve the delivery of treatment to the most disabled highest-risk adults with schizophrenia.

Risk is not a four letter word: social integration and developmental growth.

Individuals facing recovery from serious mental illness confront social challenges stemming from discrimination and the structure of our economic safety net. Although research has contributed to significant advances for individuals with the most serious mental illness, questions about the social nature of their world remain largely unasked. How can persons with mental illness move from community isolation to community integration? Building on earlier research, this paper uses qualitative data to address developmental challenges as impediments to community integration for young people with serious mental illness. Sixty transcripts from unstructured, in-depth interviews with psychiatrically disabled persons moving toward social integration were content analyzed to demonstrate possibilities for developmental growth in the context of living-learning communities. Data are organized and presented in three conceptual categories drawn from developmental theory: (1) risk-taking; (2) reciprocal relationships; and (3) self-determination. Based on the results, we suggest that attention to the challenges of developmental growth should complement current evidence-based and best program practices for young adults with mental illness.

Limiting inpatient substance use treatment: what are the consequences?

This study tested whether a managed care policy of substituting outpatient for inpatient treatment of substance use disorders shifted treatment costs to psychiatric providers. This was an observational study, based on administrative data of 25,450 adult disabled Medicaid beneficiaries treated for schizophrenia and major affective disorders. Eighteen percent had a diagnosis of substance use disorder. Multivariate regression was used to determine the odds of having a hospital admission and the relationship of managed care to hospital length of stay and total per person treatment expenditures. Hospital admissions and length of stay for both substance use disorder and psychiatric treatment were reduced, but adults with a dual diagnosis had higher annual expenditures compared to those with only a psychiatric diagnosis. There was no evidence of cost shifting. Although emphasis on outpatient treatment did not result in cost shifting, the combination of substance use disorder and psychiatric illness remains an expensive public health problem.

Practitioner relationships and quality of care for low-income persons with serious mental illness.

OBJECTIVE: Though central to experiences of mental health care for persons with serious mental illness, relationships with practitioners have been underemphasized in recent quality-of-care research. This qualitative study described concepts of good care in relationships with psychiatrists, therapists, and case managers from the perspectives of low-income persons with psychiatric disabilities. METHODS: In-person, semistructured interviews were conducted with 51 adult Medicaid enrollees with psychiatric disabilities and diagnoses of schizophrenia. Grounded theory techniques were used to analyze the data. RESULTS: Eight categories representing service users' priorities for care in practitioner relationships resulted from the analysis: getting "extra things," looking for common ground, feeling known, the importance of talk, feeling like "somebody," practitioner availability, practitioner flexibility, and opportunities for input into treatment. CONCLUSIONS: Quantitative and illness-centered formulations may miss much of what low-income service users with serious mental illness value in their relationships with practitioners. The opportunity to counter feelings of vulnerability and alienation with a sense of connection that is based on shared humanness may be a high priority for services for this group. Practitioner relationships that help service users feel cared about and connected to the social world address suffering in mental illness and are thus essential to the meaning of good care.

Medical morbidity, mental illness, and substance use disorders.

OBJECTIVE: Previous research on the prevalence of medical disorders among adults with mental illness has been inconclusive. In general, studies have found higher rates among persons with mental illness, but these studies did not account for comorbid substance use disorders. The authors examined whether certain medical disorders are more prevalent among adults with severe mental illness and whether a comorbid substance use disorder increases prevalence beyond the effect of severe mental illness alone. METHODS: Administrative data from the Massachusetts Division of Medical Assistance were used in a cross-sectional observational study design. The sample consisted of 26,332 Medicaid beneficiaries 18 to 64 years of age. Of these, 11,185 had been treated for severe mental illness. Twelve-month prevalence rates were computed, and logistic regression was used to estimate the effect of a substance use disorder or another mental illness on the risk of having a medical disorder. RESULTS: Compared with Medicaid beneficiaries who were not treated for severe mental illness, those with severe mental illness had a significantly higher age- and gender-adjusted risk of the medical disorders considered in the study. Those with a comorbid substance use disorder had the highest risk for five of the disorders. CONCLUSIONS: The higher treated prevalence of certain medical disorders among adults with severe mental illness has three implications: substance use disorder is an important risk factor and requires early detection; integration of the treatment of medical disorders and severe mental illness should receive higher priority; and efforts should be made to develop specialized disease self-management techniques.

Use of a state inpatient forensic system under managed mental health care.

OBJECTIVES: One of the goals of managed mental health care has been to lower the use of inpatient psychiatric treatment. In the past, interventions that have limited hospitalization for persons with severe mental illness have led to greater involvement of these individuals with the criminal justice and forensic mental health systems. The authors examined associations between Medicaid managed mental health care in Massachusetts and rates of admission to the inpatient forensic mental health service maintained by the state's mental health department. METHODS: A total of 7,996 persons who were receiving services from the department before and after the introduction of managed care were studied. A logistic regression model based on generalized estimating equations was used to identify associations between Medicaid beneficiary status and forensic hospitalization before and after the introduction of managed care. RESULTS: The overall rate of forensic hospitalization declined in the study cohort in both periods. However, no significant decline was observed in the risk of forensic hospitalization among Medicaid beneficiaries whose care had become managed. CONCLUSIONS: Although the results of this study warrant further exploration, the risk of forensic hospitalization among Medicaid beneficiaries should be considered by policy makers in the design of mental health system interventions.

Commentary: The benefits of collaboration in research: who will pay?

Collaboration between MCOs and researchers holds promise for benefiting consumers by working on quality-of-care-related research. There are at least three areas of collaboration that might benefit both researchers and MCOs: (1) the developing and validating of management and fiscal indicators, (2) developing and validating clinical indicators and (3) studying access to treatment for vulnerable populations. These three areas offer benefits to the MCO and unusual research opportunities for investigators. Barriers for both MCOs and researchers must be overcome before this work can be carried out, not the least of which is who will pay for the work to be done.

Toward a model for testing the relationship between quality of care and costs.

BACKGROUND: In mental health services research there is little empirical evidence to support speculation about the relationship between costs and quality. AIMS OF THE STUDY: The purpose of this paper is to provide a conceptual model and test its usefulness in determining the cost of care that meets evidence-based standards. METHODS: A case study of individuals treated for an acute episode of schizophrenia is described and a conceptual model for determining the costs of evidence-based care is presented. Statistical tests of difference were used to compare two groups, those with care that met guideline standards and those that did not. RESULTS: Compared to care that did not meet recommendations, evidence-based care was cheaper. Clinical benefits to patients were the same, but those with poor care (higher than recommended doses of anti-psychotic medication) had higher treatment costs as well as more side-effects. DISCUSSION: The conceptual model faces many challenges in application, but shows promise as one approach to determining the cost of evidenced based care. IMPLICATIONS FOR HEALTH CARE PROVISION AND USE: The results support efforts to encourage clinicians to follow practice guidelines. IMPLICATIONS FOR HEALTH POLICIES: The growth of evidence-based medicine must be matched by efforts to assess the costs of adherence to practice guidelines. The pressure of fiscal restraints needs to be balanced with information about what the cost will be to provide recommended treatment. IMPLICATIONS FOR FURTHER RESEARCH: The greatest effort needs to be in the conceptual development of the model so that we can confidently estimate the costs and effectiveness of evidence-based treatment recommendations.

Schizophrenia, substance use disorders and medical co-morbidity.

OBJECTIVES: This study compared medical treatment costs of adults with schizophrenia to adults with both substance use disorders and schizophrenia. METHODS: This cross-sectional observational study used a paid claims data base to identify 6884 adults treated for schizophrenia. Twenty percent of these also had substance use disorder. We report the costs and likelihood of hospitalization for eight common medical diseases, and the categories of injuries and poisoning, and ill defined conditions. Multivariate analyses were used to adjust rates of treatment for age and sex differences in the comparison groups. RESULTS: There were higher rates of treatment for five of the eight medical disorders, higher treatment costs for two of the medical disorders and much higher costs for psychiatric treatment among those with comorbid substance use disorders. Both groups had high rates of treatment in the categories of injury and poisoning and ill defined conditions. CONCLUSIONS: Closer working relationships among mental health and medical professionals are needed to care for those with schizophrenia and substance use disorders: first, greater attention to the treatment of substance use disorders may improve the health status of those with schizophrenia, reduce their costly medical and psychiatric care and stabilize their psychiatric condition, and second, continuity of care among professionals may promote willingness to seek medical attention or alleviate misunderstandings when adults with schizophrenia present with medical problems.

Externally caused deaths for adults with substance use and mental disorders.

For decades, there have been reports of shorter life expectancy among those with mental illness, especially those with more serious psychiatric disorders. The purpose of this study was to compare the risk of mortality among Medicaid beneficiaries, aged 18-64 years, treated for mental illness to a comparable group who were not mentally ill and to the general population. The data used were from the Massachusetts Division of Medical Assistance and records of deaths from the Department of Public Health in Massachusetts. Individuals treated for both psychiatric illness and substance use disorders (dual diagnoses) were compared separately from those whose treatment was only for a psychiatric disorder. For all Medicaid beneficiaries, the most common causes of death were attributed to heart disease and cancer. When compared to the general population, adjusted odds ratios estimated death by injury to be twice as likely among the mentally ill when compared to the general population. Medicaid beneficiaries with dual diagnoses are 6-8 times more likely to die of injury, primarily poisoning, than their counterparts treated for medical conditions only.

Ethnography and measurement in mental health: qualitative validation of a measure of continuity of care (CONNECT).

Ethnography contributes to measure development by enhancing validity and providing a basis for qualitative validation. Validating research measures means making cases for their "trustworthiness." The authors argue for the trustworthiness of CONNECT, a measure of continuity of care, by presenting the interpretive logic through which they elaborated continuity for measure construction purposes. They used category construction methods to identify mechanisms of continuity in ethnographic data. Mechanisms suggested five measurement domains: (a) knowledge, (b) flexibility, (c) availability, (d) coordination, and (e) transitions. Validation rationales summarize the ethnographic evidence and explain how the domain relates to continuity. In making explicit the data and the reasoning used, the authors argue for the trustworthiness of their interpretation. The arguments for trustworthiness demonstrate a qualitative validation process.

Associations between adherence to guidelines for antipsychotic dose and health status, side effects, and patient care experiences.

BACKGROUND: One approach to improving quality of care is to encourage physicians to follow evidence-based practice guidelines. Examples of evidence-based guidelines are the PORT recommendations for the treatment of schizophrenia. However, few studies have examined the relationship between adherence to guidelines and patient outcomes in clinical settings. OBJECTIVE: The purpose of this article is to report the relationship between guideline adherence to antipsychotic medication dose and self-reported health status, side effects, and perceptions of care. RESEARCH DESIGN: This report is based on a subsample of patients from a larger prospective observational study of disabled Massachusetts Medicaid beneficiaries treated for schizophrenia. SUBJECTS: Participants were 329 acutely ill, vulnerable, high-risk Medicaid adult beneficiaries enrolled after visiting any 1 of 8 psychiatric emergency screening teams for hospital admission evaluation. MEASURES: Dose levels, symptoms, and functioning from medical records; self-reports as data collected from BASIS-32, SF-12, and CABHS; and paid health benefit claims for psychiatric treatment were measured. RESULTS: Approximately 40% of the patients in this study had daily antipsychotic doses well above the recommended range, but there was no evidence that their health status was better than those on doses below 1000 CPZ units recommended for acute episodes. High-dose levels had no relationship to baseline symptom profile or referral source. CONCLUSIONS: There was no evidence that health status was better on higher-than-recommended doses, but we cannot conclude that lower doses for some would have led to poorer outcomes. Physicians who believe that higher doses are more therapeutic for patients need to demand rigorous effectiveness research that tests whether there are benefits of higher doses and determine the ratio of those benefits to the clinical costs, including the risk of side effects.

CONNECT: a measure of continuity of care in mental health services.

This paper introduces a measure of continuity of care (CONNECT) developed for mental health services research. CONNECT addresses qualities of interpersonal interaction in service-user/practitioner relationships through 13 scales and one single-item indicator. The scales are grouped into five domains: knowledge, flexibility, availability, coordination, and transitions. Domains were derived from ethnographic data. Service users rate responses to items using 5-point scales The measure is administered in interview format. CONNECT was developed for use with persons who have serious mental illness. Preliminary testing included cognitive interviews and two pilot studies. The results of a field test in which 400 persons with serious mental illness completed CONNECT indicate that the measure is easily administered and produces well-distributed responses. Five scales meet the .80 criterion for internal-consistency reliability for group-level research. Estimates of 2-week test-retest reliability indicate fair-to-good agreement. A broad initial validation strategy including known groups and convergent validity assessments produced results that will inform and focus future efforts. Next steps in the measure development process are discussed.

Assessing consumer perceptions of inpatient psychiatric treatment: the perceptions of care survey.

BACKGROUND: Consumer perceptions of behavioral health care are widely recognized as important quality indicators. This article reports the development and use of the Perceptions of Care (PoC) survey, a standardized public domain measure of consumer perceptions of the quality of inpatient mental health or substance abuse care. The goals were to develop a low-cost, low-burden survey that would address important quality domains, allow for interprogram comparisons and national benchmarks, be useful for quality improvement purposes, and meet accreditation and payer requirements. METHODS: The sample was composed of 6,972 patients treated in 14 inpatient behavioral health or substance abuse treatment programs. The PoC survey was given to patients by program staff in the 24-hour period before discharge. RESULTS: Aggregate reports and ratings of care identified areas that are highly evaluated by consumers, as well as areas that provide opportunities for quality improvement. Factor analysis identified four domains of care, and a 100-point score was developed for each domain. Regression analyses identified significant predictors of perceptions of care for use in computing risk-adjusted scores. Unadjusted and adjusted scores were presented to demonstrate the impact of risk adjustment on quality of care scores and relative ranking of programs. Examples were given of how programs used survey results to improve the quality of care. DISCUSSION: Results demonstrated that the PoC survey is sensitive to detecting differences among inpatient behavioral health programs and can be useful in guiding quality improvement efforts. However, risk adjustment is important for appropriate interpretation of results.

Does prospective payment reduce inpatient length of stay?

A change in payment mechanism for inpatient care from per diem to per episode creates two incentives - a marginal and an average price effect - to change length of stay. The decrease in marginal price per day to zero should reduce the length of stay, while an increase in average price per inpatient stay should increase the length of stay. This study uses data from a natural experiment to estimate both marginal and average price elasticities, and to test whether the length of stay falls after the introduction of prospective payment in a sample of 8509 severely mentally ill patients. We estimate that the marginal price elasticity is zero, but the average price elasticity is between 0.16 and 0.20. The results were generally robust for short- and long stayers, and for persons admitted early and late after the change in payment mechanism. The model controlled for hospital fixed effects and individual random effects.