A chapter outlining processes related to planning and implementation of a long-term care and rehabilitation system was included in a book edited by Ken Minkoff, MD and David Pollack, MD in 1997 (Hawthorne, W., & Hough, R., (1997). Integrated services for the long-term care. In K. Minkoff & D. Pollack (Eds.). Managed Mental Health Care in the Public Sector: A Survival Manual (pp. 205-216). Amsterdam: Harwood Academic Publishers.) The chapter outlines the basic conceptual framework for a comprehensive, multi-level, integrated services system (ISS) designed to provide long-term treatment and rehabilitation services within a managed-care environment to the seriously and persistently mentally ill (SPMI) population.
Recent advances in psychiatric and psychosocial rehabilitation technology suggest that the SPMI population can benefit from specialized treatment systems designed to optimize the potential for improved functional and quality of life outcomes. While the specific mechanisms that produce improved outcomes remain elusive, community-based psychosocial programs have been demonstrated to be more effective than traditional methods of treatment (Brekke, 1988). The ISS described relies on fundamental psychosocial concepts (Bachrach, 1992), which were implemented in community-based programs involving residential treatment, supported housing, clubhouses, case management, and the integrated services agency model.
The discussion presents a basic managed-care system comprised of an array of flexible and integrated services. The ISS can be successfully designed into an existing case management system or can be used in conjunction with contracting private services. However, designing an effective system to produce improved outcomes will likely require more than augmented case management and/or a central authority (Reed & Babigian, 1994; Talbot, 1995). Accordingly, certain system components, which are considered important to the effective functioning of the system, are presented. Although, as Bachrach (1992) has pointed out, the underlying psychosocial principles are the most important aspect. The discussion is therefore not intended to present the "right" or only way to design and operate a capitation-based system for the SPMI, but rather to present some basic guidelines and ideas that we hope will be useful in designing a system customized to the local needs of a community.
The process of planning, designing, and implementing a system for the SPMI population may best be undertaken in cooperation and collaboration with representatives of local providers, client advocacy groups, and family members. Involving these groups at the planning level will add important and useful perspectives to the design of the system. It will also help to insure a higher level of cooperation and may help overcome resistance from some, such as hospital providers, who may not benefit financially as much as under the traditional reimbursement system. Involving other providers at the planning stage can help to align system goals and facilitate system integration. This planning process will also help ensure that the system is customized to local needs. As Bachrach (1992) has pointed out, a system cannot be "canned" and simply exported to different communities without carefully evaluating and addressing the cultural, social, and economic aspects as well as the unique needs of each community.
Bachrach, L. (1982). Assessment of outcomes in community support systems: Results, problems, and limitations. Schizophrenia Bulletin, 8, 39-61.
Bachrach, L. (1992). Psychosocial rehabilitation and psychiatry in the care of long-term patients. American Journal of Psychiatry, 149, 1455-1463.
Brekke, J. (1988). What do we really know about community support programs? Strategies for better monitoring? Hospital and Community Psychiatry, 39, 946-952.
Reed, S. & Babigian, (1994). Postmortem of the Rochester capitation experiment. Hospital and Community Psychiatry, 45, 761-764.
Talbott, J. (1995). Evaluating the Johnson Foundation program on chronic mental illness. Hospital and Community Psychiatry, 46, 501-503.