Rural mental health leaders' perceptions of stigma and community issues.

This paper provides a description of the attitudes of rural leaders toward mental health issues using data collected in two rural counties (one in Virginia and one in North Carolina). Study participants (N = 63) are individuals identified as leaders making a significant positive contribution to mental health issues in each county. While the counties were matched on a number of demographic characteristics, the counties had one difference believed important: one had a county mental health center located within the county boundary while the other had no in-county mental health center. The study found that rural leaders believed that other community members held attitudes toward mentally ill persons that were more discriminatory than their own. In addition, rural leaders expressed that mental health was a more important concern to them than it was to the community as a whole. Finally, the importance placed on issues of importance to the community and the resulting issue of priority of relevance varied in response to the occupation of respondents. The study presents an approach to understanding how occupational structures affect community issue priorities among rural leaders.

Comparing provider perceptions of access and utilization management in full-risk and no-risk Medicaid programs for adults with serious mental illness.

This article compares provider perceptions of access to services and utilization management (UM) procedures in two Medicaid programs in the same state: a full-risk capitated managed care (MC) program and a no-risk, fee-for-service (FFS) program. Survey data were obtained from 198 mental health clinicians and administrators. The only difference found between respondents in the FFS and MC sites was that outpatient providers in the MC site reported significantly lower levels of access to high-intensity services than did providers in the FFS site (p < .001). Respondents in the two sites reported similar attitudes toward UM procedures, including a strong preference for internal over external UM procedures. These findings support the conclusion that through diffusion of UM procedures, all care in the Medicaid program for persons with a serious mental illness is managed, regardless of risk arrangement. Implications for mental health services and further research are discussed.

Corporatization and deprivatization of health services in Canada.

Canada's system of health services has been shaped by the forces and values in the Canadian political, cultural, social, and economic environment; these forces continue to place constraints on future changes. We distinguish between "corporatization" and "privatization", and the implications of each for improved efficiency of the system. Although the organization of health services is, in certain provinces, undergoing significant structural changes, there is evidence that rather than privatizing, the system may actually be continuing to experience what we have termed deprivatization, as the scope of government involvement expands to include a more comprehensive definition of health care. Trends in Canada differ considerably from those in the United States; universal health insurance has curbed the ability and desire of institutions to exclude members of some socioeconomic groups from receiving care. U.S.-based models, if applied to Canada, could lead to both higher costs and lower quality of care. Considerable efficiencies can be realized within Canada's current system.

The nature and extent of hospital competition in a government-funded health system.

A national study of Canadian hospitals assessed the perceived level and types of competition and the strategies pursued by these hospitals. Questionnaire data were obtained from chief executive officers in 715 hospitals, yielding a national response rate of 68%. Respondents indicated the perceived level of competition in the environment, the content of competition, and stated hospital strategies. Additional data were obtained on market share and hospital type. Close to half of the respondents indicated little or no competition in their environment, while 30% indicated substantial levels of competition. This represents a significant deviation from conventional wisdom about the Canadian health services environment. Respondents in hospitals with more than 75% of the market share were less likely to perceive competition than those with a smaller market share. CEOs in teaching hospitals and in hospitals located in larger communities reported higher levels of competition. Hospitals competed mostly for capital, programs, and staff; about a third of hospitals competed for patients and no differences were found by type of institution. Those hospitals in more competitive environments were more likely to indicate the use of diversification and horizontal integration as organizational strategies.

Implementation dilemmas in North Carolina's Willie M. program.

The state of North Carolina entered into a consent agreement in response to a class-action lawsuit initiated by a class of emotionally or neurologically impaired children who had exhibited assaultive or violent behavior and who had been denied appropriate care and education. The consent agreement stipulates in detail a full range of services appropriate to each child's ability. The Willie M. program represents a dramatic shift in state-level child welfare services, but dilemmas deter the full realization of its potential. These dilemmas are discussed and illustrated.

Multidisciplinary teams in health care: lessons from oncology and renal teams.

An indepth study conducted on units treating renal disease and cancer clinics determined that multidisciplinary teams are relatively commonplace in these areas. Developing four team organizational structures--sequential, primary, nucleus and dynamic--the authors hypothesize that each varies on a continuum in terms of how highly structured they are. The framework suggests that the ideology of equal participation on the team is the most difficult to sustain, and that difficulties typically arise as organization requirements become more complex. More research seems to be indicated to develop a comprehensive organizational framework, and the probable effect of organizational form on team performance. One of the key issues addressed is team leadership.

New patterns of community care: coordinated services for dually diagnosed adults in North Carolina.

North Carolina has developed coordinated care systems for people dually diagnosed with both a mental retardation and a different major mental illness. In response to a class action lawsuit, the state has become a leader in treatment of this form of dual diagnosis. Systems of care for this "Thomas S class" operate in each of 41 area programs for mental health, developmental disabilities, and substance abuse. Networks of care among leaders in mental health and developmental disability promote the coordination of health, housing, social, and vocational services. A survey of 100 area program leaders finds extensive cooperation and a variety of services provided and contracted for, both within and beyond each area program, particularly among developmental disability specialists. Cooperation among leaders is associated with service variety and inter-organizational linkages. The extent of relationships among provider organizations is associated with better access to care. Best practice includes a single portal of entry and inter-agency councils.

Performing public health functions: the perceived contribution of public health and other community agencies.

As public health struggles to define its role within health care reform, the need to examine carefully the component organizations providing and/or supporting health care for the public appears critical. This article identifies the nature and extent of involvement by agencies other than the official local public health department in performing public health practices and functions within 63 local public health jurisdictions. Adequacy of overall public health performance is significantly related to the extent of participation of outside agencies. Outside agencies contribute over 26 percent to the total public health performance for the jurisdictions surveyed. Other agencies of government, both at the state and local level, are the predominant outside contributors to public health practice. Private and voluntary agencies are perceived as minor contributors. Little variation exists among communities in which outside agencies tend to perform particular public health activities. Findings suggest that local public health departments can maximize their impact by understanding better the nature of working relationships within multi-institutional arrangements, encouraging greater levels of collaboration and integration and acting as catalysts for increased support of public health activities.

Future directions for AUPHA (Association of University Programs in Health Administration)? Results of a survey of faculty members.

As part of its strategic planning process, the Association of University Programs in Health Administration (AUPHA) conducted a survey of individual faculty members in health administration programs. The objective of the survey was to assess the faculty development needs of individual faculty members in terms of their professional association affiliations, and to identify what, if any, additional roles might be filled by AUPHA. The findings supported a role for AUPHA beyond its historical role of serving the needs of health administration programs primarily through program directors. Of particular importance to faculty members were exchanges with faculty in other health administration programs around research and teaching issues. While these views were held by those of all academic ranks and educational levels, the importance of these activities was judged higher by those respondents with doctorates and those of assistant professor rank. A specific role indicated for AUPHA is one of creating opportunities for exchange among individual faculty members in health administration programs. Furthermore, the data suggest that those faculty members of assistant professor rank should be a major focus for AUPHA faculty development activities. Roles for AUPHA in the areas of revising curricula and exploring new methods of instruction, developing closer linkages with management practitioners and discussions of ways to facilitate multidisciplinary exchange and research were outlined in this study.

Managing health services organizations with an educational mission: the case of Canada.

Teaching hospitals represent a major segment of the Canadian health system, accounting for a disproportionate number of beds, patient days, and separations. Thus, although only six percent of hospitals are classified as teaching hospitals, they are responsible for about 36 percent of total hospital operating expenses. While affiliation with a medical school presents unique opportunities for the teaching hospital and increases its prestige, there are clear costs associated with affiliation. Administrators have less control over resource allocation decisions, including the types of teaching programs offered. Teaching hospitals cannot unilaterally design their own teaching programs around specialties and subspecialties of their own choosing; decisions related to teaching programs have a direct impact on the services provided by the hospital and may negatively affect the hospital's ability to fulfill its patient care mission. As education budgets are constrained, teaching hospitals are expected to assume outstanding teaching-related expenses. Teaching hospitals are also expected to shift some of their teaching to alternative settings, such as the community. Thus, teaching hospital administrators will require a strong background in finance as well as negotiation and political skills.

The multiconstituency approach to organizational performance assessment: a Canadian mental health system application.

This papers applies a multiconstituency approach to assessing organizational performance in Canadian general hospital psychiatric units and provincial psychiatric hospitals. In the absence of reliable and valid outcome measures, researchers and administrators have increasingly considered the views of external constituencies as a means of both defining the criteria for effective performance and actually assessing organizational performance. Key constituencies included psychiatric unit staff, psychiatric hospital administrators, and directors of community agencies providing mental health and related services. Opinions about organizational roles were found to exist among constituencies and among professional groups. Perceptions of organizational performance were highest for primary roles and substantially lowest for roles of secondary importance to the constituency. Future analyses of this type could help to validate the use of both constituency measures and more traditional performance measures. While constituency views may be seen as subjective, they are nevertheless key to building effective mental health service delivery systems.

Economic evaluations in the Canadian Mental Health System. I: Theory behind economic evaluation.

Economic evaluation is becoming an increasingly important part of the evaluation of health and mental health services. Current models for conducting economic evaluation, including cost-effectiveness analysis, cost-benefit analysis, and cost-utility analysis, have great potential for improving the quality of decision-making and for making mental health programs more effective and efficient. This paper presents the basic economic theory underlying the various forms of economic evaluation and provides general guidelines for developing and conducting an economic analysis of a health program.

Economic evaluations in the Canadian Mental Health System. II: From theory to practice in mental health care.

This paper follows from a previous paper which described the basic approaches to economic evaluation of health programs. The discussion in this paper builds and discusses the theoretical and practical concerns felt by practitioners and analysts about economic evaluations in mental health care. Two examples of economic evaluations that compare the costs of hospital care and community-based care are presented to illustrate some of the limitations of economic evaluation. Discussion also focuses on the difficulties involved in developing and conducting economic analyses in the mental health field, as well as problems faced in trying to generalize from one study setting to others.

A method for achieving consensus on rheumatoid arthritis outcome measures: the OMERACT conference process.

We describe the process used during the international Conference on Outcome Measures in Rheumatoid Arthritis Clinical Trials (OMERACT). The objectives of the conference were (1) to broaden consensus on the minimum number of outcome measures to be included in all RA clinical trials in rheumatoid arthritis (RA); (2) to achieve consensus on criteria for (a) minimum clinically important improvement in patients with RA and (b) minimum important differences between treatment groups in RA clinical trials; and (3) to decide whether aggregate outcome measures (indices) are useful in the assessment of patients and trials. A combination of plenary sessions and structured nominal groups were employed during the conference. Simulated patient profiles and clinical trial profiles were used to generate discussion. The objective of the nominal group exercises was to capture each participant's judgments of the relative importance of each outcome measure and the degree of change required to indicate clinical improvement. Considerable discussion ensued on the content of the core set of outcome measures. An electronic interactive voting machine was used to obtain participants' views on a core set of outcome measures and methodological issues. To permit further discussion of outcome measures, the group explored the use of aggregate outcome measures (indices) in patient care and trials only in a preliminary way. A final plenary session dealt with patient perceptions of minimum important differences, a new classification of antirheumatic drugs, and a repeat of part of the preconference questionnaire. Concluding statements and future plans were developed at the conclusion of the meeting.

An empirical assessment of rural community support networks for individuals with severe mental disorders.

The community support network has been well-established as a requirement for community treatment of individuals with severe mental disorders. This network generally consists of a multidisciplinary set of organizations that interrelate in some manner with individuals in the community. The question of coordination within this network has been much discussed; however little published research has empirically examined the types and extent of coordination among network organizations. In particular, little attention has been given to community support networks in rural communities. In each of seven rural counties, information was obtained on inter-actions among organizations in the community support network. These networks were analyzed to yield information on network density and centralization. Using measures of centrality, the most central organizations in each network were identified. Exchanges of information were the most common type of interaction among organizations in each network. Client referrals occurred less frequently, and sharing of resources was an even rarer phenomenon. Network analysis of community support networks provides an objective perspective on the structure of community support networks. An understanding of exchange among organizations within these networks is of value to administrators, clinicians, and planners interested in achieving greater effectiveness, as well as to patients, their families, and advocacy groups concerned with access and quality of care.