Community- and Program-Level Predictors of Funding Streams Used by Coordinated Specialty Care Programs.

OBJECTIVE: Although coordinated specialty care (CSC) is an effective service model to address first-episode psychosis, CSC is not widely accessible in the United States, and funding for this service model often remains challenging. The authors examined whether community- or program-level factors predict the use of public and private funding streams in a national sample of 34 CSC programs in 22 U.S. states and territories. METHODS: As part of a larger mixed-methods study, CSC program leaders completed a brief questionnaire regarding funding sources. Statistical modeling was used to examine program- and community-level predictors of the use of funding sources. RESULTS: Most CSC programs (20 of 34, 59%) reported that Mental Health Block Grant (MHBG) set-aside funds accounted for more than half of their total funding, and 11 of these programs reported that these funds contributed to >75% of their funding. Programs ≤5 years old were more likely to rely on MHBG set-aside funds. Programs in Medicaid expansion states were more likely to rely on Medicaid funding than programs in nonexpansion states. Programs in higher-income service catchment areas used more state funds than did those in lower-income areas, and among programs in lower-income service catchment areas, those that were >4 years old were more likely than those ≤4 years old to rely on state funds other than Medicaid. CONCLUSIONS: CSC programs remain largely dependent on MHBG set-aside funding. Some programs have diversified their funding streams, most notably by including more Medicaid and other state funding. A more comprehensive funding approach is needed to reduce reliance on the MHBG set-aside funds.

Cycles of reform in the history of psychosis treatment in the United States.

The history of psychosis treatment follows a series of four cycles of reform which provide a framework for understanding mental health services in the United States. The first three cycles of reform promoted the view that early treatment of mental disorders would reduce chronic impairment and disability. The Moral Treatment era (early 1800's to 1890) featured freestanding asylums, the Mental Hygiene movement (1890 to World War II) introduced psychiatric hospitals and clinics, and the Community Mental Health Reform period (World War II to late 1970's) produced community mental health centers. None of these approaches succeeded in achieving the disability-prevention goals of early treatment of psychosis. The fourth cycle, the Community Support Reform era (late 1970's to the present) shifted the focus to caring for those already disabled by a mental disorder within their communities and using natural support systems. This shift embraced a broader social welfare framework and included additional services and supports, such as housing, case management, and education. Psychosis became more central during the current Community Support Reform era partly because individuals with psychosis continued to have disabling life experiences despite efforts at reform. Some degree of recovery from psychosis is possible, and individuals with serious impairment may move towards social integration and community participation. Early intervention for young people with psychosis focuses on reducing the negative sequelae of psychosis and promotes recovery-oriented changes in service delivery. The role of social control, the involvement of service users and their families, and the balance between psychosocial and biomedical treatments play an important role in this history. This paper describes the reform cycles, their political and policy contexts, and what influenced its successes and shortcomings.

Growth of Coordinated Specialty Care in the United States With Changes in Federal Funding Policies: 2014-2018.

OBJECTIVE: In 2014, the number of coordinated specialty care (CSC) programs in the United States greatly expanded. The proliferation of CSC programs was likely due in part to the availability of Mental Health Block Grant (MHBG) set-aside funds for treatment of first-episode psychosis. This study aimed to explore the characteristics of CSC programs across 44 states, the District of Columbia, and three U.S. territories that received funding through the MHBG set-aside program in 2018. METHODS: Leadership at 88% (N=215) of the 244 MHBG-funded CSC programs identified through state mental health authorities participated in an online survey. RESULTS: Overall, 69% of the CSC programs were initiated after 2014. More than 90% of programs included services that were consistent with federal guidance. CSC programs showed variability in training received, program size, and enrollment criteria. CONCLUSIONS: The results of this study emphasize that clear federal guidance can help shape national CSC implementation efforts, although decisions at the state and local levels can influence how implementation occurs. The strategy of states administering federal funds for CSC may be adapted for the rollout of other behavioral health interventions. Future studies could investigate factors that may shape national dissemination efforts, such as leadership within the state, funding, availability of programs established before the influx of funding, and considerations about sustainability after the funding is no longer available.

Paths Toward Sustainable State and County Systems of Care.

The Substance Abuse and Mental Health Services Administration's Children's Mental Health Initiative (CMHI) Cooperative Agreements support the development of children's systems of care (SOCs). The National Evaluation of CMHI interviewed representatives from Mental Health Authorities (MHA) and Medicaid agencies in 25 state, county, and municipal jurisdictions in the FY13 and FY14 grant cohorts in grant years 2 and 4. This paper analyzes funding for five services (wraparound planning; intensive care coordination; family peer support; youth peer support; and flexible funding) that are a core part of SOCs, and grantee descriptions of sustainability strategies and challenges. The analysis found that, of the five pathways described in the literature: securing Medicaid coverage; obtaining state MH system funding; braiding funding with other child-serving systems; modifying payment structures to support workforce development; and redeploying funds from higher cost to lower cost services, grantees most frequently used Medicaid coverage, often combined with MHA funding.

Family Organizations in Children's Mental Health Systems of Care: the Challenge of Maintaining Financial Sustainability.

Family-run organizations are an important source of support for families of children with serious emotional disturbance, yet little work has explored how these organizations sustain their work. The National Evaluation Team (NET) for the Substance Abuse and Mental Health Services Administration's Children's Mental Health Initiative grant program interviewed 20 family organizations in Grant Year 2 and 22 organizations in Year 4 to assess their main funding sources, the adequacy of this funding to support the organization, and changes in their funding and financial sustainability over time. Family organizations were supported mainly by mental health authority and other state agency funding and were in early stages of accessing Medicaid funding for peer services. However, many did not have sufficient or sustainable funding to maintain their functions by the grant's end. This work discusses factors that may relate to sustainability and the development of more sustainable funding for these important organizations.

The demand side: uses of research in child and adolescent mental health services.

This special issue on child and adolescent mental health contains a thoughtful set of papers that address many of the challenges in bridging research and practice. These articles, however, focus predominantly on the supply side of producing research for use by a range of audiences, including practitioners, administrators and policymakers. This commentary emphasizes the importance of attending to, and better understanding, the demand side with regard to how research evidence is evaluated, understood,and utilized. Drawing from work underway at the William T. Grant Foundation, the authors argue for the need to understand three broad topics: user settings and perspectives, political, economic and social contexts, and the various uses of research. Furthermore, understanding the use of research evidence, or the demand side, is itself atopic for empirical investigation. The authors conclude that, when it comes to supplying evidence, don't forget the demand side.

If it walks like a duck and quacks like a duck then must it be a rabbit? Programs, systems and a cumulative science of children's mental health services.

The system of care approach as a strategy for serving children and adolescents with serious emotional disturbance (SED) is by any measure a success with one exception: there is controversy regarding the scientific evidence documenting that the services provided through systems of care improve the symptomatic and functional outcomes of the youth and their families served when compared to the services provided through more traditional service systems. This paper traces this essential problem to challenges in the definitions of systems of care, particularly the level at which systems of care are conceived to exist and the impact of these challenges on the collection of relevant and meaningful data that could otherwise create a cumulative science regarding systemic interventions for youth with SED. In many regards, systems of care are often viewed in the context of programs of care that are predominantly evaluated within program evaluation rather than system evaluation perspectives. This article elucidates the problems created by the varying definitions of systems of care for the development of a cumulative practice and policy relevant research base pertaining to children and adolescents with serious emotional disturbance. Alternative strategies for future research are discussed in the context of alternative definitions of the system of care concept.

Quality of publicly-funded outpatient specialty mental health care for common childhood psychiatric disorders in California.

OBJECTIVE: To describe the documented adherence to quality indicators for the outpatient care of attention-deficit/hyperactivity disorder, conduct disorder, and major depression for children in public mental health clinics and to explore how adherence varies by child and clinic characteristics. METHOD: A statewide, longitudinal cohort study of 813 children ages 6.0-16.9 years with at least 3 months of outpatient care, drawn from 4,958 patients in 62 mental health clinics in California from August 1, 1998, through May 31, 1999. The main outcome was documented adherence to quality indicators based on scientific evidence and clinical judgment, assessed by explicit medical record review. RESULTS: Relatively high adherence was recorded for clinical assessment (78%-95%), but documented adherence to quality indicators related to service linkage, parental involvement, use of evidence-based psychosocial treatment, and patient protection were moderate to poor (74.1%-8.0%). For children prescribed psychotropic medication, 28.3% of the records documented monitoring of at least one clinically indicated vital sign or laboratory study. Documented adherence to quality indicators varied little by child demographics or clinic factors. CONCLUSION: Efforts to improve care should be directed broadly across clinics, with documentation of safe practices, particularly for children prescribed psychotropic medication, being of highest priority.

Economic antecedents of foster care.

Individual and ecological research suggests that rising unemployment may affect the incidence of violence through two countervailing mechanisms suggested by frustration-aggression theory. The first, or provocation effect, assumes increased violence among persons who feel anger because they believe their job loss was arbitrary. The second, or inhibition effect, posits less violence among employed persons who attempt to reduce their chances of job loss by curtailing behavior objectionable to employers. The literature also reports that these mechanisms affect victimization measured as foster care sought by the state for abused children. The foster care finding, although consistent with theory and important for basic as well as applied reasons, arises from methods that cannot rule out several rival hypotheses. We revisit this research and apply improved methods to test the reported association in Los Angeles and San Francisco counties. We find that, as implied by the provocation and inhibition mechanisms, differences in monthly prevalence of foster care placements increase with modest increases in unemployment but decline when unemployment becomes much higher than usual levels.