Handbook of Mental Health Administration and Management

William H. Reid, Stuart B. Silver, William H. Reid, Stuart B. Silver

• Publisher: Routledge
• Year: 2013
• ISBN:
  9781134941018
• Edition: 1
• Topic: Psicología
• Subtopic: Historia y teoría en psicología

Clinicians who understand mental health care administration in addition to their clinical fields are likely to be valuable to the organizations in which they work. This handbook is an accessible source of information for professionals coming from either clinical or management backgrounds. Sections offer coverage in: mental health administrative principles, mental health care management, business, finance and funding of care, information technology, human resources and legal issues.

Part One

MENTAL HEALTH MANAGEMENT PRINCIPLES

INTRODUCTION

Bruce Lubotsky Levin

Clinicians and administrators have a significant interest in the successful operation of mental health care facilities. Furthermore, social accountability demands that attention be paid to the measuring and reporting of the efficiency, effectiveness, and quality of their operation. In the first chapter of this section, “Critical Issues in Mental Health Administration and Leadership,” Ardis Hanson and Bruce Lubotsky Levin examine some of the fundamental issues facing the mental health administration and management field, including evidence-based practice, diversity, comorbidity, insurance and financing, informatics, and policy.

The leadership function within mental health organizations continues to demand that professionals must understand and deal with current multidimensional problems within the internal and external organizational environment. In chapter 2, “Leadership and Training in Mental Health,” Levin, Hanson, and Sara Kuppin discuss the obstacles and challenges that leaders face within mental health organizations. They also examine the importance of curriculum changes in graduate and continuing education programs that prepare both clinical and administrative mental health practitioners.

The current conglomerate of mental health providers, agencies, services, institutions, and managed care/insurance entities, operating rather independently of one another, creates complex problems in the organization, financing, and delivery of mental health services. In chapter 3 of this section, “Mental Health Services Delivery,” Levin and Hanson emphasize the need for mental health administrators to understand the external health care environment and the resulting impact environmental changes have on the functioning of their mental health organization.

In chapter 4, “Administrative Theory,” L. Mark Russakoff suggests that different kinds of leaders may be needed during differing phases of a mental health organization's development. He emphasizes that there is no one complete, satisfactory model of administrative theory for mental health organizations. The complexity of human behavior in mental health organizations requires a model that integrates the individual, group, contextual, hierarchical, social, political, and economic parameters.

In the last chapter of this section, “The Dynamics of Organizational Change in Mental Health Administration,” Sharon Topping explores change and its many consequences for mental health organizations. Strategies designed to achieve new forms of management need to be developed with an awareness of existing organizational culture, particularly within public-sector mental health organizations. She briefly reviews the history, nature, and implementation of change, identifying forces that resist and promote organizational change within mental health facilities.

Chapter One

Critical Issues in Mental Health Administration and Leadership

Ardis Hanson
Bruce Lubotsky Levin

In 1999, the first Surgeon General's report on mental health was published by the U.S. Department of Health and Human Services. This landmark report summarized the epidemiology, treatment, financing, and service delivery issues in mental health. Organizationally, it also presented an in-depth examination of populations at risk, that is, children with severe emotional disorders, adults with severe mental disorders, and older adults with co-occurring disorders, as well as individuals with addiction disorders. Even though the report did not make formal policy recommendations, it focused primarily toward overcoming the gaps in what is known, discussed removing the barriers that keep people from seeking and obtaining mental health treatment, and offered a vision that may provide the basis for future policy development.

Although the report focused on the major issues in the organization, financing, and provision of mental health services, there remain additional issues of importance for mental health administrators. This chapter discusses issues critical to mental health administrators at all levels of management, including evidence-based practice, policy impact on treatment, diversity, immigrant populations, comorbidity, financing of care, parity, stigma, and information technology. Several of these are addressed in more detail in other chapters of this book.

It is crucial for all mental health administrators to keep pace with issues, trends, and continuing changes within their internal and external organizational environments. Ideally, while this process should start in graduate school, continuing education has become a vital component for mental health administrators. This chapter introduces the reader to selected issues of importance, including evidence-based practice, policy's impact on treatment, diversity, comorbidity, financing, policy, and informatics.

FROM RESEARCH TO PRACTICE

There have been over 50 years of research on mental illness. The field has made great strides over the years in psychopharmacology and the integration of biological, neurological, and behavioral sciences. New medications and psychosocial interventions have provided new treatment opportunities for mental disorders, requiring new approaches in evaluating their effectiveness. Some of these new approaches may come from the evaluation of somatic health care interventions. As somatic delivery systems have evolved, there has been a historical tendency to overlay these organization, financing, and delivery models on mental health care. These changes have not been successfully adapted to the unique characteristics of mental health care. Therefore, mental health administrators must carefully examine the impact of the somatic health care models on services delivery, as well as any additional impacts on organizational effectiveness (Schlesinger & Gray, 1999; Wolfe, 1999) (also see chapter 5 on organizational change, this volume).

Evidence-Based Practice

Evidence-based practice distinguishes between research that is of direct clinical significance and that which is not. Using a set of simple rules for evaluating research evidence, it provides a framework for making clinical decisions on the basis of research findings and for applying research findings to individual patients. It consists of five explicit steps: (1) The clinician constructs a specific clinical question concerning the care of a patient or group of patients; (2) the clinician finds the best evidence to answer the question; (3) the clinician evaluates the evidence for validity and usefulness; (4) the results are applied to the specific patient or group of patients; and (5) the outcome of the intervention is evaluated (Reynolds, 2000). Evidence-based practice increases accountability and also increases access to resources and dissemination.

There has been much discussion of the role of evidence-based practice in mental health. Barkham and Mellor-Clark (2000) suggested that practice-based evidence should help determine evidence-based practice, along with the contributions of random clinical trials and qualitative methods. Practice research networks should collaborate to collect and analyze large bodies of effectiveness data rather than efficacy data, particularly because observational or audit data may be more clinically relevant than data gathered under experimental conditions.

Cost-effectiveness data differ from cost-efficacy data. Cost-effectiveness studies evaluate a heterogeneous population, patients who are often less compliant with their treatment, and protocols where the researchers have less control over specific treatment interventions. Cost-effectiveness analyses show the relationship between the resources used (costs) and the health benefits achieved (effects) for an intervention compared with alternative strategies. These studies focus on specific treatments, specific dosages or units of service, and duration of treatment. Cost-effectiveness data can support the inclusion of mental health services such as the appropriateness of antipsychotic drug therapy, assertive community treatment, home-based therapies, partial hospitalization, or residential treatment (Goldman, 1996).

Cost-efficacy studies evaluate the impact of treatment on a very selective, homogeneous population using a specific study protocol. These studies often examine patient functioning, patient compliance with the treatment regimen, outcomes, relapse rates, and symptoms. Barkham and Mellor-Clark (2000) further suggested that there should be a greater emphasis on the interface between efficacy and effectiveness studies.

Beutler (2000) observed that the contemporary practice of psychotherapy is not strongly guided by empirical evidence but is moving in that direction. In his opinion, empirically informed change principles are an optimal way of proceeding toward evidence-based practice. As managed mental/behavioral health care systems continue to call for evidence-based interventions, there will be a discernible impact on clinical practice (Goldman, McCulloch, Cuffel, & Kozma, 1999). Because the goal of evidence-based medicine is to improve the quality of clinical judgments, it encourages decisions based on clinically relevant research and minimizes decisions based on outdated information, local practice patterns, product marketing literature, or subjective and conflicting opinions of medical experts (Bilsker, 2000; Sullivan, 2000). If evidence-based treatments are to be effective in clinical practice, administrators must start with the assumption that these treatments have much to offer practitioners in clinical settings. This would lead to qualitative and quantitative research questions involving all parties with an interest in evidence-based practice (Addis, Wade, & Hatgis, 1999).

Rubenstein et al. (1999) predicted three basic directions that administrators will follow as they move toward evidence-based practice. First, they will increasingly rely on external expert intervention design, based on previously tested strategies and premarket assessment of potential service delivery organizations. Second, these interventions will be disseminated to managed care organizations, including but not restricted to clinical care, through marketing, negotiation, and training. Finally, continuing education for staff at all levels will be critical, not only in the implementation of the interventions by trained clinical staff but also for administrators to determine outcomes and impacts (see chapter 2 on leadership and training, this volume).

Policy's Impact on Treatment

One of the main areas of emphasis in the Surgeon General's report was in the area of prevention (U.S. Department of Health and Human Services, 1999). Coupled with the release of prevention goals in Healthy People 2010 (U.S. Department of Health and Human Services, 2000), prevention is becoming a predominant theme when discussing the costs and treatment of mental illness. Unfortunately, prevention often appears contradictory to the current trend in managed care toward cost reduction. Despite evidence of effective preventive measures in mental health, funding is often inadequate. Preventive measures carry a cost, reflected in the budget and revenues, which in turn may create difficulties in their approval and application (Eisenberg, 1999), even though they may actually reduce costs within a managed care environment. If managed care organizations experience frequent enrollee turnover, they may need the incentive of short-term savings to provide preventive mental health care. However, when managed care organizations offer fewer mental health promotion options, they do experience higher voluntary disenrollment rates. The availability of prevention and promotion options may increase enrollee satisfaction and retention, as well as effective marketing tools to consumers (Dorfman, 2000).

The possibility that managing mental health care might reduce the use of other medical care services and thus lower total health care costs has important implications. Cuffel, Goldman, and Schlesinger (1999); Huskamp (1998); and Goldman, McCulloch, and Sturm (1998) indicated that managing mental health care reduced other medical (somatic) care costs and eased access to these services. If subsequent research supports these findings, health care purchasers and national and state legislators should take into account the influence of mental health care on the cost and utilization of general medical care services.

In the absence of empirical data, public-sector planners have little basis for understanding the economic consequences of managed care for mental health and substance abuse programs (Cuffel et al., 1999). Public-sector administrators need to be informed about the relationship between the organization and financing of mental health programs in the private sector and the cost of publicly funded medical care.

Partnerships between health care organizations and researchers can have successful impacts on health care. A study on depression suggests that support for increased care will require either new resources or shifting of resources (Rubenstein et al., 1999). Because primary care clinics typically do not provide the type of service reviewed in their study, the authors suggested that managed care organizations would find it easier to shift resources toward improved depression care if their competitors were doing the same. In addition, they suggested that resource shifts were more likely to improve care with careful design and evaluation. Achieving this depends on researchers, health care organizations, and other players in mental health service systems fostering collaborations among each other. There are a number of policy incentives that could aid these collaborations: financial, educational, and mandated (Rubenstein et al., 1999). Among financing incentives are tax breaks for implementing mental health—oriented primary care improvements and funding opportunities that encourage the collaboration of health services researchers and health care organizations. Increased public education on treatment of mental disorders and, more importantly, the success of treatment, through the use of national media campaigns would destigmatize mental illness. Finally, legislative mandates for states to more effectively track rates of detection, care, and outcomes for mental illness and substance abuse disorders ...