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Mental Health Systems and Policy: Introduction to Part III
Gary S. Cuddeback, School of Social Work, Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill,
Joseph P. Morrissey, Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill
Obtaining care for severe and persistent mental illness has been a challenge because each service area has its own special purpose and funding mechanisms whereas those with severe and persistent mental illnesses need a broad array of services. Hence there has been much effort to produce service integration. Cuddeback and Morrissey review the experiences of service integration and consider four major innovations (Community Mental Health Centers; the Community Support Program and its spin-off, the Child and Adolescent Service System Program; the Program on Chronic Mental Illness; and efforts to introduce managed mental health care). Recent demonstration programs to integrate services have been subjected to comprehensive outcome evaluations. The research from two of these demonstrations produced similar findings; there was strong evidence for service system change and improvement, but little consistent evidence for improved client-level outcomes. The authors include a discussion of the evidence-based practice movement. The chapter concludes by describing opportunities for further research. Without a national policy for health and welfare programs, it is difficult to see how the various needs of those with severe and persistent mental illnesses will be met. Students may want to list the number of agencies in their own communities who provide services to those with severe and persistent mental illnesses, and question providers about gaps in such services as well as issues of coordination.
Over the past fifty years, the US mental health system has shifted from a centralized, institutional model based largely on state mental hospitals to a decentralized, community-based system involving several thousand public and private providers (Grob, 1991a). In this process of deinstitutionalization (Morrissey, 1982; Mechanic & Rochefort, 1992) many thousands of long-stay patients who had a severe and persistent mental illness (SPMI) were transferred to nursing homes or released directly to community settings. In addition, the growth of psychiatric services in community mental health centers attracted many more thousands of formerly unserved patients. As a result, the mental health services system expanded enormously and moved from a predominantly inpatient to a predominantly outpatient array of services (Goldman & Taube, 1989). These changes have benefited persons with acute care needs and those with milder conditions but, in a number of respects, they have disadvantaged persons with SPMI.
This chapter reviews the experiences with services integration (SI) in the broader U. S. health and welfare arena as a context for considering its applications in the mental health field over the past few decades. It then considers four major innovations as examples of SI in the mental health field-community mental health centers (CMHCs), the Community Support Program (CSP) and its spin-off, the Child and Adolescent Service System Program (CASSP), the Program on Chronic Mental Illness (PCMI) cosponsored by the Robert Wood Johnson Foundation (RWJF) and the U. S. Department of Housing and Urban Development; and the introduction of managed mental health care. The chapter then considers the effectiveness of SI with a focus on evaluation findings from the RWJF, PCMI and the Ft. Bragg children's mental health demonstration. It reviews the emergence of the evidence-based practice (EBP) movement and the interface between SI and EBP.
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