Personal health budgets and the role of nursing.

A personal health budget is an allocation of NHS resources that is given to an eligible individual to meet an identified set of health needs in lieu of commissioned services. Personal health budgets were introduced into the NHS in England in 2009 to give individuals more control of the care they receive. This article describes personal health budgets and presents some early findings from pilots in England and the United States.

International development in self-directed care.

Self-directed care is an alternative way of delivering services that seeks to empower participants by expanding their degree of choice and control in selecting services. Over the last decade, it has been widely adopted internationally in home and community-based long-term care for people with physical and cognitive disabilities and for seniors. It has been shown to improve satisfaction with services, improve quality of life, and reduce costs compared with services from an agency. A small number of pilot programs are now experimenting with self-directed care in other areas; for example in the management of serious mental illness and other chronic conditions. If positive findings from long-term care can be replicated, self-directed care can make an important contribution to improving health care quality and effectiveness. This issue brief examines a range of innovative self-directed care programs in England, Germany, the Netherlands, and the United States.

Self-directed care for adults with serious mental illness: the barriers to progress.

The President's New Freedom Commission on Mental Health identified self-directed care as one service innovation that could create a more consumer- and family oriented mental health system. Four years later, there are still fewer than 400 consumers in five states accessing self-directed care in the public mental health system. This Open Forum identifies three main barriers to explain this lack of progress: the absence of a strong evidence base to support the effectiveness of self-directed care for serious mental illness, uncertainty over the appropriate scope of self-directed care, and the absence of a sustainable source of funding. The introduction of the 1915(i) provision of the Social Security Act in 2007 appears to partly address the funding barrier to self-directed care. There is also a strong case for a large-scale evaluation of self-directed care for persons with serious mental illness to address the two remaining barriers to progress.

Debating personal health budgets.

Personal health budgets (PHBs) were piloted in the National Health Service (NHS) in England between 2009 and 2012 and were found to have greater positive effects on quality of life and psychological well-being for those with mental health problems than commissioned service, as well as reducing their use of unplanned care. The government intends to extend PHBs in England for long-term conditions, including mental health, from April 2015. Given the importance of engaging clinicians in the next phase of PHB development, we provide an overview of the approach, synthesise the evidence from the national pilot and debate some of the opportunities and challenges. Balancing individual choice and recovery with concerns for risk, equity and the sustainability of existing community services is the central tension underpinning this innovation in mental health service delivery.

A plan to reduce emergency room 'boarding' of psychiatric patients.

Overcrowded U.S. emergency rooms have become a place of last resort for psychiatric patients. Psychiatric boarding, defined as psychiatric patients' waiting in hallways or other emergency room areas for inpatient beds, is a serious problem nationwide. Boarding consumes scarce emergency room resources and prolongs the amount of time that all patients must spend waiting for services. It is often the result of an inability to gain timely access to community-based care. As policy makers implement the new health reform law, improving access and continuity of community mental health care through health homes must be a priority. We present a seven-point plan to address psychiatric boarding.

Specialty care medical homes for people with severe, persistent mental disorders.

The patient-centered medical home concept is central to discussions about the reform of the health care delivery system. Most descriptions of the concept assume that a primary care practice would serve as the hub of the medical home. However, for people with severe and persistent mental disorders, specialty health care settings serve as the principal point of contact with the health care system. For them, a patient-centered medical home in a specialty setting would be the most expedient way to address their urgent health care needs. Among other issues, implementing this idea would mean reimbursement strategies to support the integration and coordination of primary care in specialty settings.