Rebecca Wells

Coordination between Child Welfare Agencies and Mental Health Service Providers, Children's Service Use, and Outcomes.

OBJECTIVE Interorganizational relationships (IORs) between child welfare agencies and mental health service providers may facilitate mental health treatment access for vulnerable children. This study investigates whether IORs are associated with greater use of mental health services and improvement in mental health status for children served by the child welfare system. METHODS This was a longitudinal analysis of data from a 36-month period in the National Survey of Child and Adolescent Well-Being (NSCAW). The sample consisted of 1,613 children within 75 child welfare agencies who were 2 years or older and had mental health problems at baseline. IOR intensity was measured as the number of coordination approaches between each child welfare agency and mental health service providers. Separate weighted multilevel logistic regression models tested associations between IORs and service use and outcomes, respectively. RESULTS Agency-level factors accounted for 9% of the variance in the probability of service use and 12% of mental health improvement. Greater intensity of IORs was associated with higher likelihood of both service use and mental health improvement. CONCLUSIONS Having greater numbers of ties with mental health providers may help child welfare agencies improve childrens mental health service access and outcomes. PRACTICE IMPLICATIONS Policymakers should develop policies and initiatives to encourage a combination of different types of organizational ties between child welfare and mental health systems. For instance, information sharing at the agency level in addition to coordination at the case level may improve the coordination necessary to serve these vulnerable children.

Sustainable network advantages: A game theoretic approach to community-based health care coalitions

Abstract: Health care organizations often enter into a cooperative arrangement to create safety-net programs and coordinate care. Maintaining effective cooperation in such alliances poses special problems that can be examined using network analysis and explained in game theory terms. A mental health coalition case study is presented using network analysis and game theory interpretations. Had a positive-sum game approach been applied to the coalitions initial design, its subsequent suboptimal performance might have been averted. The application of network analysis plus a game theoretic paradigm has significant implications for improving both the design and the coordination of such coalitions.

Community-Based Coalitions’ Capacity for Sustainable Action: The Role of Relationships:

Given both the importance and difficulty of promoting community-based public health coalitions, their capacity for sustainable action merits systematic examination. The current study addresses this need, focusing specifically on the relational dimension of capacity, that is, how relationships both among members and with external actors affect coalition-level activity. The context is a multimethod comparative case study of two rural cancer control coalitions. The authors began by using quantitative and qualitative data to characterize relational capacity in each coalition and then assessed the association between coalition-level relational capacity and level of subsequent interventions. The more active coalition had a more inclusive relational structure than did its less active counterpart but also placed less emphasis on personal friendships. The authors conclude that coalitions’ relational structures are measurable and that this dimension of capacity may affect sustainable capacity for health promotion.

What Motivates People to Participate More in Community-based Coalitions?

The purpose of this study was to identify potential opportunities for improving member participation in community-based coalitions. We hypothesized that opportunities for influence and process competence would each foster higher levels of individual member participation. We tested these hypotheses in a sample of 818 members within 79 youth-oriented coalitions. Opportunities for influence were measured as members’ perceptions of an inclusive board leadership style and members’ reported committee roles. Coalition process competence was measured through member perceptions of strategic board directedness and meeting effectiveness. Members reported three types of participation within meetings as well as how much time they devoted to coalition business beyond meetings. Generalized linear models accommodated clustering of individuals within coalitions. Opportunities for influence were associated with individuals’ participation both within and beyond meetings. Coalition process competence was not associated with participation. These results suggest that leadership inclusivity rather than process competence may best facilitate member participation.

Tailoring of outpatient substance abuse treatment to women, 1995-2005

Background:Tailoring substance abuse treatment to women often leads to better outcomes. Previous evidence, however, suggests limited availability of such options. Objectives:This investigation sought to depict recent changes in outpatient substance abuse treatment (OSAT) tailoring to women and to identify unit and contextual factors associated with these practices. Research Design:Data were from 2 waves of a national OSAT unit survey (N = 618 in 1995, N = 566 in 2005). Comparisons of weighted means between waves indicate which practices changed over time. Multiple logistic regressions with generalized estimating equations test associations between unit and contextual attributes and tailoring to women. Measures:Tailoring to women was measured as availability of prenatal care, child care, single sex therapy, and same sex therapists, and the percentage of staff trained to meet female clients’ needs. Results:Two measures of tailoring to women declined significantly between 1995 and 2005: availability of single sex therapy (from 66% to 44% of units) and percent of staff trained to work with women (from 42% to 32% of units). No aspect of tailoring to women became more common. Proportion of female clients, total number of clients, methadone status, and private and government managed care were associated with higher odds of tailoring to women. For-profit facilities, which became more prevalent during the study period, had lower odds than other units of tailoring treatment to women. Conclusions:Some key aspects of OSAT tailoring to women decreased significantly in the last decade. Managed care contracts may offer 1 mechanism for counteracting these trends.

Serving Persons With Severe Mental Illness in Primary Care–Based Medical Homes

OBJECTIVE Primary care-based medical homes are rapidly disseminating through populations with chronic illnesses. Little is known about how these models affect the patterns of care for persons with severe mental illness who typically receive much of their care from mental health specialists. This study examined whether enrollment in a primary care medical home alters the patterns of care for Medicaid enrollees with severe mental illness. METHODS The authors conducted a retrospective secondary data analysis of medication adherence, outpatient and emergency department visits, and screening services used by adult Medicaid enrollees with diagnoses of schizophrenia (N=7,228), bipolar disorder (N=13,406), or major depression (N=45,000) as recorded in North Carolina Medicaid claims from 2004-2007. Participants not enrolled in a medical home (control group) were matched by propensity score to medical home participants on the basis of demographic characteristics and comorbidities. Those dually enrolled in Medicare were excluded. RESULTS Results indicate that medical home enrollees had greater use of both primary and specialty mental health care, better medication adherence, and reduced use of the emergency department. Better rates of preventive lipid and cancer screening were found only for persons with major depression. CONCLUSIONS Enrollment in a medical home was associated with substantial changes in patterns of care among persons with severe mental illness. These changes were associated with only a modest set of incentives, suggesting that medical homes can have large multiplier effects in primary care of persons with severe mental illness.

Organizational Survival in the Outpatient Substance Abuse Treatment Sector, 1988-2000

Substance abuse remains one of the most pressing health issues in the United States today, yet treatment supply continues to lag far behind need. Given the hostile environments treatment facilities face, their survival is a matter of pressing policy concern. Results from analyses of National Drug Abuse Treatment System Survey (NDATSS) data from 1988 through 2000 suggest that organizational attributes such as age, size, and client severity and resource dependencies such as reliance on government revenue affect survival, but their effects change over time. By the mid-1990s, director involvement in state and local policy making was positively associated with subsequent survival; later that decade, directors’ professional credentials affected survival as well. Results also show that serving clients with multiple substance abuse problems became a survival liability by the late 1990s. Facilities that treat clients with multiple addictions may need additional financial support to serve these particularly vulnerable clients.

Using the balanced scorecard to characterize benefits of integration in the safety net

The purpose of this study was to develop a comprehensive framework depicting the potential benefits of integration among health-care providers that serve vulnerable populations. Research teams interviewed participants in 12 integrated functions across seven community health-centre-led networks. Functions included clinical processes; managed care contracting; and administrative services such as human resources, finance, and information systems. Using a Balanced Scorecard framework, benefits were identified across financial, customer, internal business, and learning and growth perspectives. Financial benefits were more frequently cited relative to managed care and administrative functions than relative to clinical functions. Clinical functions were frequently characterized by perceived improvements in patient care quality, while managed-care functions appeared to yield most benefits in access. Administrative functions were most often associated with improvements in internal business operations. There were substantial findings in learning and growth across all three types of integration, in keeping with the early stages of the integrated functions in the study. Findings imply that integration among health-care providers yields a wide range of benefits, but not necessarily quickly or financial in nature.

Adapting a Dynamic Model of Interorganizational Cooperation to the Health Care Sector

Despite a recent proliferation of interorganizational networks in health care, there is very little empirical guidance about how to facilitate their success over time. The current study tests a theory of cooperative evolution in the context of five matched pairs of successful versus “challenging” initiatives within six community health center-led networks. Researchers collected initial data in 2000/2001 and conducted follow-up interviews with key informants two years later. Analyses included semi-inductive coding of interview transcripts and systematic comparisons between successful and challenging cooperative efforts. As theory predicts, both initial conditions and subsequent adaptation affected project evolution, with successful and challenging projects following distinct trajectories. The external environment and momentum, however, played more salient roles in these health care safety net networks than they had in corporate ventures. These findings indicate the utility of qualitative techniques to adapt theories developed in other sectors to health care contexts.

Why Do Some Health Centers Provide More Enabling Services Than Others

Enabling services (such as outreach, transportation, case management, and discharge planning) play a critical role in improving care for vulnerable populations. However, these services are generally not covered by third party payers, making them a challenge for safety net providers that are themselves often financially strained. The study reported here identified organizational and patient population characteristics associated with enabling services provided by community health centers funded by the Health Resources and Services Administration (HRSA). Lagged regressions on 2003–2004 data from HRSA’s Uniform Data System (n=841) indicated that health centers with more managed care contracts and larger staffs provided both broader scopes of enabling services and higher volumes of these services. Grant revenue was negatively associated with the volume of enabling services; however, net revenue was positively associated with service volume. There were several positive associations between indicators of patient need and the scope and volume of enabling services.