Douglas A. Bigelow

Complementary and Alternative Medicine Use in Canada and the United States

Use of complementary and alternative medicine (CAM) has stimulated discussion in both Canada1–4 and the United States5–12 on topics such as who might benefit from CAM insurance coverage and the role of CAM as a substitute for use of conventional medical treatment vs a supplement to such treatment. In the United States, members of racial or ethnic minority groups are less likely to use CAM than are White people, and elevated income is a strong predictor of CAM use.5,6,8 In the United States (unlike in Canada), race and ethnicity are related closely to health insurance status.13 In both Canada4 and the United States,5,6,8 CAM use appears higher in western regions than in other areas. In Canada, western provinces are much more likely than those in the east to cover CAM in their health programs.1 In the United States, some 42 states mandate coverage of chiropractic care in private insurance,9 whereas federal legislation mandates coverage for all people older than 65 years (in the Medicare program) as well as for individuals whose health insurance is provided by large employers regulated under the Employee Retirement Income Security Act.14 This study examined relationships between race, geography, and conventional medical care and the use of acupuncture, chiropractic, homeopathy/naturopathy, and massage therapy.

THE CONCEPT AND MEASUREMENT OF QUALITY OF LIFE AS A DEPENDENT VARIABLE IN EVALUATION OF MENTAL HEALTH SERVICES

Publisher Summary This chapter describes the theory that is used to formulate mental health system goals and performance measures and evaluate mental health programs. There has been an increasing emphasis on evaluation of community mental health programs (CMHPs) in the last couple of decades. Much effort has been dedicated to the pursuit of a simple, economical, powerful means of assessing treatment effectiveness. The sought-after assessment is presumed to lead directly to program improvement and choices among alternative, competing programs. There is a lack of a common language or universal theory describing mental illness and the impact of treatment in a way that is readily amenable to the evaluation and management of clinical programs. Quality of life is a concept of an individual participating in an environment. The environment offers opportunities to satisfy the individuals needs. In return, the environment places performance requirements upon the individual that the individual should meet by the use of his or her abilities. Quality of life consists of a state of satisfaction for the individual and his or her meeting of the performance requirements of his or her environment. Client problems presented in mental health practice include dissatisfaction or performance aberrations. Treatment strategies can be aimed at disabilities, insufficient opportunities, or excessive performance requirements that underlie problems in satisfaction or performance.

Implementation and Effectiveness of a Bed Reduction Project

A legislative mandate to shift a cohort of patients from the state hospital into intensive community treatment created an opportunity to explore questions about the impact of intensive community treatment on hospital utilization and quality of life. Information on prior and subsequent hospital utilization was taken from the state client information system. Information on community services and quality of life was obtained by interviewing clients in their homes, interviewing others who knew the clients, and by making direct observations of the clients circumstances. Twenty-five of the intensively served clients were interviewed two to three months after discharge, as were 17 comparable clients who did not receive the intensive services. Clients did, in fact, receive more and better community services, their quality of life was better, and hospital utilization was dramatically reduced for both the targeted clients and the entire county catchment area.

Organization and Financing of Alcohol and Substance Abuse Programs for American Indians and Alaska Natives

OBJECTIVES Although American Indians and Alaska Natives have high rates of substance abuse, few data about treatment services for this population are available. We used national data from 1997-2002 to describe recent trends in organizational and financial arrangements. METHODS Using data from the Indian Health Service (IHS), the Substance Abuse and Mental Health Services Administration, the National Institute on Alcohol Abuse and Alcoholism, the Henry J. Kaiser Family Foundation, and the Census Bureau, we estimated the number of American Indians served by substance abuse treatment programs that apparently are unaffiliated with either the IHS or tribal governments. We compared expected and observed IHS expenditures. RESULTS Half of the American Indians and Alaska Natives treated for substance abuse were served by programs (chiefly in urban areas) apparently unaffiliated with the IHS or tribal governments. IHS substance abuse expenditures were roughly what we expected. Medicaid participation by tribal programs was not universal. CONCLUSIONS Many Native people with substance abuse problems are served by programs unaffiliated with the IHS. Medicaid may be key to expanding needed resources.

Outcomes for medicaid clients with substance abuse problems before and after managed care

Medicaid conversion from fee for service to managed care raised numerous questions about outcomes for substance abuse treatment clients. For example, managed care criticisms include concerns that clients will be undertreated (with too short and/or insufficiently intense services). Also of interest are potential variations in outcome for clients served by organizations with assorted financial arrangements such as for-profit status versus not-for-profit status. In addition, little information is available about the impact of state Medicaid managed care policies (including client eligibility) on treatment outcomes. Subjects of this project were Medicaid clients aged 18–64 years enrolled in the Oregon Health Plan during 1994 (before substance abuse treatment managed care, N=1751) or 1996–1997 (after managed care, N=14,813), who were admitted to outpatient non-methadone chemical dependency treatment services. Outcome measures were retention in treatment for 90 days or more, completion of a treatment program, abstinence at discharge, and readmission to treatment. With the exception of readmission, there were no notable differences in outcomes between the fee for service era clients versus those in capitated chemical dependency treatment. There were at most minor differences among various managed care systems (such as for-profit vs not-for-profit). However, duration of Medicaid eligibility was a powerful predictor of positive outcomes. Medicaid managed care does not appear to have had an adverse impact on outcomes for clients with substance abuse problems. On the other hand, state policies influencing Medicaid enrollment may have substantial impact on chemical dependency treatment outcomes.

Community mental health program efficiency

Six urban community mental health centers participated in a capitated payment system designed for persons with severe mental illness who frequently used the state hospital. The centers and their funding agency agreed that a chief outcome measure would be the length of time clients were able to remain enrolled in the outpatient program. Clients of the six agencies were quite similar to one another. During the 18-month study length of enrollment in the outpatient program did not vary among the agencies whereas agency expenditures varied by more than three-fold. Although some of this expenditure variation was due to economies of scale at larger agencies, different practice styles also contributed to variable efficiency.

Supportive homes for life versus treatment way-stations : An introduction to TAPS project 41

Patients, providers, planners, and funders are struggling with major policy options for the design of mental health service systems for patients with serious and persistent mental illnesses. For this purpose, we need a better knowledge of whole systems examined cross-sectionally (e.g., Andrews, 1991, 1992), and we need a better knowledge of the life course and long-term outcomes for patients receiving different forms of care (e.g., Harding et al., 1987). Other components of whole systems are important for long term outcomes. However, housing is arguably the most important. It is even demonstrable that, without adequate housing, other components, including medication, are not effective (cf. Baker & Douglas, 1990). For some time, one of the specific housing issues has been whether we create homes to support and maintain patients with serious mental illness for lengthy periods of time, or whether we seek quick recovery and restoration of function by means of rehabilitation-oriented residential programs from which patients are expected to graduate in a matter of months. Despite the obvious fact that we need a range of residential services (Talbott, 1987) the question remains about emphasis. At times during the last two or three decades, the notion seemed to prevail that most, if not all, patients have the potential to quickly re-

Unit costs of community mental health services

The unit (hourly) costs of delivering services for six community mental health agencies in the greater Portland, Oregon area were computed. The calculations include an explicit methodology for allocating indirect costs associated with clinical services and with administrative overhead. Substantial variation among the six agencies in their unit costs was found and is explained by agency differences in: use of high cost (chiefly medical) personnel, the fraction of time staff spend in direct face-to-face client contact, and numbers of clients in treatment groups. The methodology as well as the results are increasingly important for community mental health programs in the era of managed mental health care.

Demonstrating the Process of Community Innovation: The Indian Country Methamphetamine Initiative

Abstract In 2007 the federal Department of Health and Human Services, Office for Minority Health, collaborating with other federal agencies, sponsored the Indian Country Methamphetamine Initiative (ICMI). ICMI was undertaken to create community-driven, culture-based best practices in methamphetamine prevention and treatment which could then be disseminated throughout Indian Country. The ICMI ultimately involved ten tribes and five national organizations. Each tribe established a coalition of community government, nongovernment agencies, and elements of civic society to develop a comprehensive assessment, plan, and then to implement the plan. Each tribal coalition planned a complex array of activities including treatment programs, public education and mobilization, law enforcement strategies, and other intervention strategies, each intervention described within a logic model. These interventions focused on logic modeling; coalitions; capacity development and service system optimization; law enforcement and justice; individual and family treatment; public information, awareness, and education; community mobilization; and a very popular ICMI strategy, cultural renaissance. It was concluded that worthwhile activities were conducted under ICMI sponsorship, but that the specific aim of demonstrating community-driven, culture-based innovations in a manner suitable for dissemination was achieved only to a limited extent. Based on this outcome together with similar experiences, recommendations for future initiatives are suggested.

The Greater Vancouver Mental Health Service Society: 20 years' experience in urban community mental health.

Caring for people in the community with persistent and disabling mental illnesses presents a major challenge to government, planners and mental health professionals. The success with which mentally disabled people are integrated into community life says much about the society in which we live. This article describes the experience of the Greater Vancouver Mental Health Service Society in offering community-based mental health services to persons with schizophrenia and other major mental disorders over the past 20 years. The key to its success lies in a decentralized, relatively non hierarchical organizational structure which allows committed and skilled multidisciplinary teams to work with patients and their families in their community. The resulting services are fully integrated within the fabric of the community and are responsive to local needs. Partnerships among professionals, patients, families and community agencies result in work that is creative, productive and effective.