Julienne Giard

Florida's medicaid mental health carve-out: Lessons from the first years of implementation

Florida, like many other states, has embarked on an experiment with managed mental health care for Medicaid enrollees. Under a 1915(b) waiver, the states Medicaid agency began a mental health carve-out demonstration in March 1996 in the Tampa Bay area. This qualitative case study seeks to ascertain the impact of the carve-out (and, by comparison, HMO arrangements) on the public mental health sector. Findings suggest that the carve-out demonstration has succeeded in creating a fully integrated mental health delivery system with financial and administrative mechanisms that support a shared clinical model. However, other findings raise concerns about the HMO model in terms of stability, access to care, efficiency, and more generally about the shifting of risk and public responsibility “downstream” to private organizations without sufficient governmental oversight. These findings may offer guidance for other states implementing major managed care policy initiatives for disabled Medicaid enrollees.

Poor and Depressed, The Tip of the Iceberg: The Unmet Needs of Enrollees in an Indigent Health Care Plan

Depression is a leading cause of disability [World Health Organization (WHO), 2001] with economic costs exceeding

The role of coercion in the treatment of women with co-occurring disorders and histories of abuse

63 billion per year in the US [U.S. Department of Health and Human Services (DHHS), 1999]. The challenges of treating depression among the poor are compounded by broader social needs. This study examined the prevalence of depression and psychosocial needs among enrollees in an indigent health care plan. Results indicated clinical levels of depression were present in 28.6% of respondents (n=1,405). Depressed respondents were significantly more likely (p<0.001) to have co-occurring alcohol (OR=1.78; CI95=1.32–2.40), drug (OR=2.67; CI95=1.80–3.98), and health (OR=5.44; CI95 = 4.12–7.19) problems compared to non-depressed respondents. Significantly more social needs were also associated with depression. Depressed respondents averaged 7.8 needs compared to 3.6 among non-depressed respondents. Needs included a significantly increased likelihood (p<0.001) of lacking sufficient food (OR=2.56; CI95=1.97–3.34), shelter (OR=3.67; CI95=2.23–6.05), or money (OR=3.18; CI95= 2.39–4.23) and having more legal (OR=2.95; CI95=2.22–3.92) and family (OR=3.00; CI95=2.32–3.86) problems. The high rates of co-occurring social needs among individuals with clinical depression underscores the need for comprehensive, coordinated care in order to improve their quality of life and also reduce high utilization of crisis management services.

Creating Alcohol and Other Drug, Trauma, And Mental Health Services For Women in Rural Florida: The Triad Women's Project

Debate continues on issues of involuntary treatment for individuals with behavioral healthcare problems. Women with co-occurring disorders and histories of abuse are an especially vulnerable population. This study seeks to increase our knowledge about the experiences of coercion for women in the behavioral healthcare system. Patterns of coercion are explored. This study did not find the predicted relationship between high levels of interpersonal violence and frequent involuntary treatment experiences. The results do offer support for the hypothesis that women are more likely to be currently mandated to treatment if they have been recently arrested, and that being mandated to treatment does not appear to be related to clinical issues such as recidivism and acute symptoms. As expected, women currently required to be in treatment report having less choice in other aspects of their care. Implications for future research in the current climate of increasingly coercive policies are presented.

Characteristics of women engaged in treatment for trauma and co‐occurring disorders: Findings from a national multisite study

SUMMARY Located in central Florida, the Triad Womens Project is a comprehensive system of care developed to respond to the needs of women and children living in a three-county semi-rural area. The women have histories of abuse or violence, co-occurring alcoholism and other drug (AOD) and mental health disorders, and have been high utililizers of behavioral healthcare services. This paper will describe the efforts of collaborating providers, the women themselves, services researchers, and concerned community members to develop services to assist these women in their AOD recovery, their healing from abuse, and their empowerment in dealing with mental illnesses. Practical information on establishing consensus, dealing with barriers and filling service gaps will be presented.