Eri Kuno

The Effect of Income and Race on Quality of Psychiatric Care in Community Mental Health Centers

This study examined the relationship between quality of mental health care provided by community mental health centers (CMHCs) and the poverty and racial mix of neighborhoods. Indicators of quality of care were constructed by examining service mix and prescription patterns for adult patients with schizophrenia during fiscal year 1996. CMHCs in high income, Caucasian areas were found to have higher quality of care indicators than those in low income, African American areas; i.e., higher percentage of patients on atypical antpsychotic prescriptions (47% vs. 33%) and higher percentage using intensive case management (ICM) services (67% vs. 29%). Questions arise regarding the factors underlying this phenomena and the extent to which they are provider-driven or due to patient preferences.

Implementing the Illness Management and Recovery Program in Japan

OBJECTIVE This study investigated the feasibility and outcomes of the illness management and recovery program in Japan. METHODS Thirty-five patients with schizophrenia were recruited. Participants were assigned (not randomly) to the intervention and wait-list comparison groups. Symptom severity, functioning, activation level in self-management, quality of life, satisfaction, self-efficacy in community living, and satisfaction with services were measured before and after the intervention. RESULTS Over two years 25 patients completed the intervention (some after being wait-listed). In the pre-post comparison, they showed significant improvement in symptoms and functioning, self-reported activation in self-management, quality of life, satisfaction, and self-efficacy in community living. Compared with the ten participants in a wait-list comparison group, the eight participants in the first intervention group showed an increased quality of life in social functioning, satisfaction in living, and self-efficacy for social relationships in community living. CONCLUSIONS Findings suggest that the program is effective for participants with severe mental illness in Japan.

Psychiatric service utilization and cost for persons with schizophrenia in a Medicaid managed care program.

A pre-post study design was used to look at changes in behavioral health care services and costs for Medicaid-eligible individuals with schizophrenia in a managed care (MC) carve-out compared to a fee-for-service (FFS) program in Pennsylvania between 1995 and 1998. Statistically significant reductions of 59% were found in hospital expenditures in the MC program compared to 18.3% in the FFS program. The decline in hospital costs was due to dramatic fee reductions in the MC site. No significant differences in overall ambulatory utilization were found in either program; however, ambulatory expenditures rose 57% in the MC program versus a decline of 11% in fee for service. The ambulatory cost increase resulted from a cost shift between county block grant funds, and Medicaid funds, with no additional revenues provided to outpatient providers. Study implications are that cost reductions from MC are mainly due to reducing utilization and payments to hospitals, similar to the findings for private sector programs.

Service Components of Case Management Which Reduce Inpatient Care Use for Persons with Serious Mental Illness

This is a study of two types of case management:case management (CM) which provided the servicecoordination functions, and Intensive Case Management(ICM) which consisted of both the coordination function and the provision of direct support to theclient. Using secondary data on public clients,characteristics of mental health service use wereanalyzed for 80 ICM and 84 CM clients. The ICM clientshad significantly fewer episodes per patient and less inpatientdays per year than the CM clients. These findingssuggest that direct support services make a significantdifference in reducing annual hospital care.

Distance Matters in Choice of Mental Health Program: Policy Implications for Reducing Racial Disparities in Public Mental Health Care

The purpose of this study is to examine the influence of race, geographic distance and quality on the choice of community mental health programs. The study population was comprised of adult Medicaid recipients who received outpatient treatment for serious mental illness in FY 2001. A discrete choice model was employed to examine the likelihood of choosing one program over another. Quality was measured based on follow-up after hospital discharge and continuity of care in outpatient services. Maps showing the relationship between race and the quality of care were prepared to visually confirm the results of the statistical analysis. African American and Hispanic clients were less likely to travel further for treatment, while no significant difference was found between the Caucasian and other race groups. Caucasian subjects were more likely to choose programs with a higher quality of care compared to Hispanic or African American clients. Higher income clients were, on average, traveling longer and receiving better quality of care after controlling for race. The results suggested that clients living in higher income White neighborhoods are more likely to travel longer distances for mental health treatment. Special attention must be paid to improve the quality of care in lower income minority neighborhoods to insure equity of treatment in publicly funded programs.

Long-term effectiveness of the ACCESS program in linking community mental health services to homeless persons with serious mental illness.

This study examined the long-term effectiveness of the ACCESS (Access to Community Care and Effective Services and Supports) project on service utilization and continuity of care among homeless persons with serious mental illness. A 3-year longitudinal analysis, using Medicaid claims data, tracked behavioral health service utilization among 146 Medicaid-eligible participants in the Pennsylvania ACCESS program. Utilization patterns of inpatient, outpatient, and emergency department services for psychiatric and substance abuse treatment were examined during the year prior to, during, and one year after the implementation of the ACCESS project. Use of psychiatric ambulatory care significantly increased among intervention participants and remained greater following ACCESS intervention. Better continuity of care following hospitalization was achieved during and after the intervention. The number of days spent hospitalized significantly decreased during the intervention. These results suggest that the ACCESS intervention was effective in linking hard-to-reach homeless persons with serious mental illness to the community mental health service system, and that this effect was maintained after termination of the intervention.

Initiative to Build a Community-Based Mental Health System Including Assertive Community Treatment for People With Severe Mental Illness in Japan

In Japan, although the locus of care is still predominantly in psychiatric hospitals, a growing number of mental health service providers have become engaged in promoting community integration of people with severe mental illness. This paper describes an ongoing initiative to build a mental health and social services system, which is viewed as a model for other Japanese communities in creating support for people with severe mental illness. This initiative consists of two projects: development and evaluation of an assertive community treatment (ACT) team located in a suburb of Tokyo and a broader community support project in this same community. A pilot evaluation of consumer outcomes for the ACT team demonstrated that ACT is feasible and effective in the Japanese social and cultural context. The community support project was successful in start-up demonstration programs of case management, residential, and supported employment services. Challenges to the expansion of ACT and other community-based services in Japan are discussed.

Living Arrangements of Individuals with Schizophrenia in Japan: Impact of Community-Based Mental Health Services

Aims: In Japan psychiatric hospitals and family play the predominant roles in caring for people with serious mental illness. This study explored how the introduction of community-based care has changed this situation by examining living arrangements of individuals with schizophrenia who were treated in one of the most progressive systems in Japan (Kawasaki) compared with national norms. Methods: The proportion of clients with schizophrenia in the community versus hospital and living arrangements for those in the community were compared between the Kawasaki and national treated population, using data from the Kawasaki psychiatric service users survey in 1993 and two national surveys in 1993 and 1983. The variation in living arrangements was examined across five different age cohorts. Results: The estimated national population was 36.7, which was similar to 32.7 clients per 10,000 population in Kawasaki. Some 71% of the Kawasaki clients were treated in the community compared with 55% nationally. The difference between the Kawasaki and national populations was the largest among clients aged 40 to 59. The Kawasaki community clients had a higher proportion of clients living alone. Conclusions: The community mental health services available in Kawasaki appeared to reduce hospitalisation and help clients to live alone in the community.