Mental health social work and nursing in the USA and the UK: divergent paths coming together?

BACKGROUND: When the mental health systems of the UK and the USA are compared, one of the most striking differences is that social workers are the largest professional group in the USA and community nurses the largest in the UK. AIM AND METHOD: This paper examines the history of the development of both professional groups in both countries, and their education and training. RESULTS: Demand, supply and economic factors are important influences and reasons for these differences. CONCLUSIONS: Both professions have critical future workforce roles, but further consideration needs to be given to the extent to which their skills and values overlap in order to inform future workforce planning, and to reduce the extent to which the workforce pattern in both countries risks being over-determined by supply issues.

Mental health and addictions services in resort communities: the case of Martha's Vineyard.

Resort communities face many behavioral health problems and challenges in service delivery. However, few discussions of these issues are present in the literature. Unique needs of rural and resort areas are described using Martha's Vineyard, MA, as a case example. Community strengths and barriers to care are reviewed, and approaches to providing better services offer opportunities for improved care giving.

Managed care and the quality of substance abuse treatment.

BACKGROUND: In the US, the spiraling costs of substance abuse and mental health treatment caused many state Medicaid agencies to adopt managed behavioral health care (MBHC) plans during the 1990s. Although research suggests that these plans have successfully reduced public sector spending, their impact on the quality of substance abuse treatment has not been established. AIMS OF THE STUDY: The Massachusetts Medicaid program started a risk-sharing contract with MHMA, a private, for-profit specialty managed behavioral health care (MBHC) carve-out vendor on July 1, 1992. This paper evaluates the carve-out s impact on spending per inpatient episode and three proxy measures of quality: (i) access to inpatient treatment (ii) 30-day re-admissions and (iii) continuity of care. METHODS: Medicaid claims for inpatient treatment were collapsed into episodes. Clients were tracked across the five-year period and an interrupted time series design was used to compare the three quality outcomes and spending in the year prior to (FY1992) and the four years during MHMA (FY1993-FY1996). Logistic and linear regression models were used to control for race, disability status, age, gender and primary diagnosis. RESULTS: Despite a 99% reduction in the use of hospital-based settings, access to 24-hour services overall increased by 38%, largely due to an expansion in the use of freestanding detoxification and acute residential services. Continuity improved by 73%. Nevertheless, rates of 7-day (58%) and 30-day (24%) readmission increased significantly, even after controlling for increases in disability status. Per episode spending decreased by 76% ($2,773), characterized by a dramatic spending reduction in FY1993 that was maintained but not augmented in subsequent years. DISCUSSION: The carve-out had mixed effects on the quality of substance abuse treatment. While one of the three measures (readmission rates) deteriorated, two improved (access and continuity). IMPLICATIONS FOR HEALTH CARE PROVISION AND USE: Rapid re-admissions were strongly associated with shorter lengths of stay, suggesting that strengthening discharge planning may preserve the benefits of MBHC while avoiding its risks. IMPLICATIONS FOR HEALTH POLICIES: Since reductions in Medicaid spending were impressive but finite, MBHC may not be the permanent solution to inflation in behavioral health care. MBHC firms should implement quality-monitoring programs to ensure that aggressive utilization management strategies do not compromise quality of care. IMPLICATIONS FOR FURTHER RESEARCH: The impact of managed behavioral health care should ideally be evaluated in randomized controlled studies. In addition, research is needed to establish that the quality measures employed in this evaluation - improved access, enhanced continuity and fewer rapid re-admissions actually correspond to reductions in drug or alcohol use and other favorable outcomes obtained through client self-report or urinalysis.

Guest editors' introduction: implementing evidence-based mental health practices and performance measures in Massachusetts.

In September 2005, a one day educational forum on implementing evidence-based mental health practices and performance measures in Massachusetts was held at Brandeis University. Factors for successful implementation are reviewed. Papers in this issue cover theory, concrete actions, and best practices that will aid policy makers, providers, and consumers in improving their behavioral health services.

Stakeholder perspectives on public managed behavioral care in Massachusetts.

The 2003 survey of Massachusetts behavioral health providers, as well as conference presentations by other key stakeholders, demonstrate continuing high ratings for the Massachusetts Behavioral Health Program. Key issues facing the program include improving integration, state funding cutbacks, movement into performance and outcomes measurement, and concerns about continuing stigma of mental illness. These issues are prevalent in other states that can benefit from the studies and perspectives of the Massachusetts experience.

Assessing consumer satisfaction in the Massachusetts Behavioral Health Partnership.

From 1999 to 2003, Consumer Quality Initiatives, Inc. (CQI) conducted peer interviews with 226 inpatient, 433 day treatment, and 822 outpatient clients of programs within the network of the Massachusetts Behavioral Health Partnership. Ninety-two percent of day treatment, 93% of the outpatient clients, and 79% of inpatient clients rated their care as satisfactory. Clients' views of access, appropriateness of services, outcomes of services, what clients liked most, and recommendations are summarized. Predictors of satisfaction (e.g., being treated with respect and dignity) and outcomes are also shown.

Managed behavioral health care: lessons from Massachusetts.

Since implementing the first statewide carve-out for behavioral health care in 1992, Massachusetts has achieved sustained reductions in cost, increases in access, and improvements in major quality measures. This introduction to a special issue describes the context, linkages with primary care, consumer satisfaction, unmet need, performance incentives (a key component of the success), stakeholder perspectives, and impacts on special populations.

Evaluation of the Massachusetts Behavioral Health Program: Year 8.

The eight-year provider evaluation of the Massachusetts Behavioral Health Program showed positive assessments of care provision, continuing problems in integration of care, high assessments of the clinical review process, high evaluations for administration, and positive ratings compared with other managed care organizations. Changes in provider organizations continue. Substance abuse and mental health providers gave similar ratings, while inpatient providers were more critical than outpatient providers. Ratings in Year 8 were higher generally than in Year 7. The program continues to be a success; however, improvement in several areas continues to be difficult.