Implementing publicly funded risk contracts with community mental health organizations

Social support and functional outcome in severe mental illness: the mediating role of proactive coping

Individuals with Severe Mental Illness (SMI) are faced with wide-spread social and occupational impairment, yet some are able to achieve a meaningful degree of functional improvement. A structural model based on Proactive Coping Theory was developed and tested in a longitudinal context to better understand: (1) the impact of proactive processes on functioning for people with SMI, and (2) the stability of the theoretical framework over time for this population. A latent path analysis examining social support, positive reappraisal, intrinsic motivation, and role functioning was tested with 148 severely mentally ill individuals receiving psychosocial rehabilitation treatment at baseline. An observed path analysis of the model was examined at six months post-baseline with 102 people. The baseline model displayed an excellent fit to the data and accounted for 54% of the variance in role functioning. Results at time 2 also suggest the empirical promise and potential longitudinal viability of the model. In line with Proactive Coping Theory and a social resources model of coping, social support may facilitate proactive coping processes to enhance role functioning, and these processes may be stable over time for people with SMI.

The causal relationships between neurocognition, social cognition and functional outcome over time in schizophrenia: a latent difference score approach

BACKGROUND

Social cognition has been identified as a significant construct for schizophrenia research with relevance to diagnosis, assessment, treatment and functional outcome. However, social cognition has not been clearly understood in terms of its relationships with neurocognition and functional outcomes. The present study sought to examine the empirical independence of social cognition and neurocognition; to investigate the possible causal structure among social cognition, neurocognition and psychosocial functioning.

METHOD

The sample consists of 130 individuals diagnosed with schizophrenia. All participants were recruited as they were admitted to four community-based psychosocial rehabilitation programs. Social cognition, neurocognition and psychosocial functioning were measured at baseline and 12 months. The empirical independence of social cognition and neurocognition was tested using confirmatory factor analysis (CFA) and the possible causal structure among social cognition, neurocognition and psychosocial functioning was investigated using latent difference score (LDS) analysis.

RESULTS

A two-factor model of social cognition and neurocognition fit the data very well, indicating the empirical independence of social cognition, whereas the longitudinal CFA results show that the empirical independence of neurocognition and social cognition is maintained over time. The results of the LDS analysis support a causal model that indicates that neurocognition underlies and is causally primary to social cognition, and that neurocognition and social cognition are causally primary to functional outcome.

CONCLUSIONS

Social cognition and neurocognition could have independent and distinct upward causal effects on functional outcome. It is also suggested that the approaches for remediation of neurocognition and social cognition might need to be distinct.

The prospective relationships among intrinsic motivation, neurocognition, and psychosocial functioning in schizophrenia

To address significant gaps in our understanding about how neurocognition, intrinsic motivation (IM), and psychosocial functioning are interrelated in schizophrenia, this study investigated the following questions: Is IM stable or dynamic over time? Does neurocognition predict change in IM over time? What is the association between change in neurocognition, change in IM, and change in psychosocial functioning? Finally, what is the causal structure of the relationships among neurocognition, IM, and psychosocial functioning over time? One hundred and thirty individuals diagnosed with schizophrenia or schizoaffective disorder were recruited from 4 community-based psychosocial rehabilitation programs in urban Los Angeles. Measures of neurocognition were taken at baseline and 12 months. Measures of IM, psychosocial functioning, and symptoms were taken at baseline, 6, and 12 months. Results of latent growth curve modeling analyses demonstrated that IM is dynamic over time. Baseline neurocognition was associated with the initial level of IM but did not predict the rate of change in motivation. However, baseline levels of IM predicted rates of subsequent improvement in neurocognition. Change in IM was strongly associated with change in psychosocial functioning, and change in neurocognition was associated with change in psychosocial functioning, but change in IM was not associated with change in neurocognition. Latent difference score analyses revealed that neurocognition caused changes in psychosocial functioning, and psychosocial functioning caused changes in IM. These findings improve our fundamental understanding of the relationships among these variables and contribute to intervention development for improving outcomes in schizophrenia.

Neurocognitive change, functional change and service intensity during community-based psychosocial rehabilitation for schizophrenia

BACKGROUND

This study examined the magnitude of neurocognitive change during 1 year of community-based psychosocial intervention, whether neurocognitive change and functional change were linked, and how neurocognitive change combined with service intensity to facilitate functional change.

METHOD

A total of 130 individuals diagnosed with schizophrenia were recruited upon admission to four community-based psychosocial rehabilitation programs. Subjects were assessed at baseline, 6 and 12 months on role functioning and symptom measures. Neurocognition was measured at baseline and 12 months. Service intensity was the number of days of treatment attendance during the study period. Latent mean difference tests and Latent Growth Curve Models (LCGMs) were used to examine the study hypotheses.

RESULTS

There was statistically and clinically significant functional improvement over 12 months. Neurocognition improved significantly over time. Seventy-six (58%) of the sample showed neurocognitive improvement and 54 (42%) did not. There was a significant rate of functional enhancement in the neurocognitive improver group. There was a non-significant rate of functional change in the neurocognitive non-improver group. Neurocognitive improvers showed functional improvement that was 350% greater than neurocognitive non-improvers. Service intensity did not vary between neurocognitive improvers and non-improvers but there was a strong interaction between neurocognitive improvement, service intensity and rate of functional improvement such that service intensity was strongly related to functional improvement for neurocognitive improvers but not for neurocognitive non-improvers. Medication usage and symptomatology did not confound these findings.

CONCLUSIONS

These findings suggest that neurocognitive improvement may be a foundation for functional change and treatment responsiveness during community-based psychosocial rehabilitation for individuals with schizophrenia.

Intrinsic motivation, neurocognition and psychosocial functioning in schizophrenia: testing mediator and moderator effects

BACKGROUND

This study examined the nature of the relationships among neurocognition, intrinsic motivation, and psychosocial functioning for persons with schizophrenia. Hypotheses concerning both mediator and moderator mechanisms were tested.

METHOD

120 individuals diagnosed with schizophrenia were recruited as they entered outpatient psychosocial rehabilitation programs. Measures of psychosocial functioning and intrinsic motivation were administered at baseline. Measures of neurocognition were administered at baseline by testers blind to scores on other study variables. Data were analyzed using latent construct modeling to test for mediator and moderator effects.

RESULTS

There were strong bivariate relationships between neurocognition, intrinsic motivation, and psychosocial functioning. The results demonstrated that intrinsic motivation strongly mediated the relationship between neurocognition and psychosocial functioning. This mediation was evidenced by: (i) the direct path from neurocognition to functional outcome no longer being statistically significant after the introduction of motivation into the model, (ii) the statistical significance of the indirect path from neurocognition through motivation to functional outcome. There was no support for the two moderation hypotheses: the level of neurocognition did not influence the relationship between intrinsic motivation and psychosocial functioning, nor did the level of intrinsic motivation influence the relationship between neurocognition and psychosocial functioning.

CONCLUSIONS

Neurocognition influences psychosocial functioning through its relationship with intrinsic motivation. Intrinsic motivation is a critical mechanism for explaining the relationship between neurocognition and psychosocial functioning. Implications for the theoretical understanding and psychosocial treatment of intrinsic motivation in schizophrenia are discussed.

How neurocognition and social cognition influence functional change during community-based psychosocial rehabilitation for individuals with schizophrenia

The purpose of this study was to assess how neurocognition and social cognition were associated with initial functional level and with rates of functional change in intensive community-based psychosocial rehabilitation interventions that have been shown to yield significant functional change for individuals diagnosed with schizophrenia. We also examined how service intensity was associated with rates of change and whether it served as a moderator of the relationship between functional change and both neurocognition and social cognition. The sample consisted of 125 individuals diagnosed with schizophrenia or schizoaffective disorder who were recruited upon admission to 1 of 4 community-based psychosocial rehabilitation facilities and were followed prospectively for 12 months. One hundred and two subjects completed the 12-month protocol. The findings suggested that (i) the initial level of psychosocial functioning was related to both social cognition and neurocognition at baseline, (ii) when significant rehabilitative change occurs, higher neurocognition and social cognition scores at baseline predicted higher rates of functional change over the subsequent 12 months, (iii) greater service intensity was related to higher rates of improvement in functional outcome over time, and (iv) service intensity moderated the relationship between neurocognition and initial functional level and moderated the relationship between social cognition and the rates of functional change at a trend level. These findings have relevance to our understanding of the heterogeneity in functional rehabilitative outcomes, to our understanding of the conditions of rehabilitative change and for the design of psychosocial interventions in the community.

Biosocial pathways to functional outcome in schizophrenia

Biosocial models are preeminent in the study of schizophrenia, yet there has been little empirical testing of these models.

OBJECTIVE

This study provided the first test of a biosocial causal model of functional outcome in schizophrenia, using neurocognition, social cognition, social competence and social support as predictors of both global and specific domains of functional outcome.

METHOD

The design used baseline variables to predict both concurrent functional status and prospective 12-month functional outcome. Subjects were recruited upon admission to outpatient community-based psychosocial rehabilitation programs shown in previous studies to be effective in improving functional outcomes. 139 individuals diagnosed with schizophrenia or schizoaffective disorder participated in the study; 100 participants completed the 12-month assessments. Face-to-face interviews assessed neurocognitive functioning (with five neuropsychological measures), social cognition (as perception of emotion), social competence, social support, and functional outcome which consisted of items covering the domains of social, independent living, and work functioning.

RESULTS

Path analysis modeling showed that the proposed biosocial models had strong fit with the data, for both concurrent and 12-month global functional outcomes, with fit indices ranging from .95 to .98. The model explained 21% of the variance in concurrent global functional outcome, and 14% of the variance in 12-month prospective outcome.

CONCLUSIONS

The support for this model was strong, and it has implications for understanding the causal factors related to functional outcome, as well as for intervention strategies for improving functional outcomes in schizophrenia.

Characteristics of individuals with severe mental illness who use emergency services

Emergency services are both a safety net and a locus for acute treatment. While the population with severe, persistent mental illness uses emergency services at a high rate, few studies have systematically examined the causes of this service use. This study examines a random sample of 179 people who were high uti- lizers of services from the Los Angeles County Department of Mental Health. Interviews were conducted and 5 years of service use data were studied. Greater use of emergency services was associated with male gender, minority race, severe illness, homelessness, and less family support. Efforts to reduce emergency services need to improve access to appropriate community services, particularly for people who are homeless or lack family support.

Ethnicity and treatment outcome variation in schizophrenia: a longitudinal study of community-based psychosocial rehabilitation interventions

The purpose of this study was to investigate cross-ethnic variations in prospective treatment outcomes over a period of 12 months from community-based psychosocial rehabilitation interventions for people with schizophrenia. Data were pooled from two similar studies of psychosocial rehabilitation for clients with schizophrenia conducted in the same urban settings. The final sample consisted of 226 people diagnosed with a schizophrenia spectrum disorder, consisting of 108 (48%) white subjects, 81 (36%) African American subjects, and 37 (16%) Latino subjects. Main analyses were performed using hierarchical linear modeling. Analyses indicated that both study groups demonstrated statistically significant rehabilitative improvement over a period of 12 months. Although African American subjects had a significantly slower rate of improvement (compared with white subjects) in social functioning, analyses in several other outcome domains generally revealed that all three ethnic groups showed similar change trajectories over time, with no additional ethnic-related differences reaching statistical significance. With the exception of slower social improvement for African Americans, the findings from this study suggest that community-based psychosocial rehabilitation interventions did not result in significantly poorer outcomes for the ethnic minority groups examined. Several important implications are discussed.

Managed care in the public sector: lessons learned from the Los Angeles PARTNERS program

PARTNERS is the Los Angeles County Department of Mental Health's capitated managed care treatment program. To explore the context in which public sector managed care reforms are occurring and to understand the obstacles to implementing such programs, qualitative data were collected from administrators, case managers, and clients. Administrators were found to need assistance in negotiating managed care contracts and in tracking costs. Case managers, although concerned about increased clinical demands, enjoyed the flexibility and creativity their new roles allowed. Clients were satisfied with their increased independence, even though many had to change their site of care. Beyond considering these concerns, the range of community stakeholders who may be affected by such interventions must be addressed.

Risk adjustment for high utilizers of public mental health care

BACKGROUND: Publicly funded mental health systems are increasingly implementing managed care systems, such as capitation, to control costs. Capitated contracts may increase the risk for disenrollment or adverse outcomes among high cost clients with severe mental illness. Risk-adjusted payments to providers are likely to reduce providers' incentives to avoid or under-treat these people. However, most research has focused on Medicare and private populations, and risk adjustment for individuals who are publicly funded and severely mentally ill has received far less attention. AIMS OF THE STUDY: Risk adjustment models for this population can be used to improve contracting for mental health care. Our objective is to develop risk adjustment models for individuals with severe mental illness and assess their performance in predicting future costs. We apply the risk adjustment model to predict costs for the first year of a pilot capitation program for the severely mentally ill that was not risk adjusted. We assess whether risk adjustment could have reduced disenrollment from this program. METHODS: This analysis uses longitudinal administrative data from the County of Los Angeles Department of Mental Health for the fiscal years 1991 to 1994. The sample consists of 1956 clients who have high costs and are severely mentally ill. We estimate several modified two part models of 1993 cost that use 1992 client-based variables such as demographics, living conditions, diagnoses and mental health costs (for 1992 and 1991) to explain the variation in mental health and substance abuse costs. RESULTS: We find that the model that incorporates demographic characteristics, diagnostic information and cost data from two previous years explains about 16 percent of the in-sample variation and 10 percent of the out-of-sample variation in costs. A model that excludes prior cost covariates explains only 5 percent of the variation in costs. Despite the relatively low predictive power, we find some evidence that the disenrollment from the pilot capitation initiative input have been reduced if risk adjustment had been used to set capitation rates. DISCUSSION: The evidence suggests that even though risk adjustment techniques have room to improve, they are still likely to be useful for reducing risk selection in capitation programs. Blended payment schemes that combine risk adjustment with risk corridors or partial fee-for-service payments should be explored. IMPLICATIONS FOR HEALTH CARE PROVISION, USE, AND POLICY: Our results suggest that risk adjustment methods, as developed to data, do not have the requisite predictive power to be used as the sole approach to adjusting capitation rates. Risk adjustment is informative and useful; however, payments to providers should not be fully capitated, and may need to involve some degree of risk sharing between providers and public mental health agencies. A blended contract design may further reduce incentives for risk selection by incorporating a partly risk-adjusted capitation payment, without relying completely on the accuracy of risk adjustment models. IMPLICATIONS FOR FURTHER RESEARCH: Risk adjustment models estimated using data sets containing better predictors of rehospitalization and more precise clinical information are likely to have higher predictive power. Further research should also focus on the effect of combination contract designs.

Tracking changes in behavioral health services: how have carve-outs changed care?

This special issue of the Journal of Behavioral Health Services & Research on mental health carve-outs brings together some of the latest research on recent policy and market changes affecting behavioral health services. This introductory article provides background information about carve-outs and the managed behavioral health care industry. This article also reviews prior research in the mental health carve-out field.

The economic impact of capitated care for high utilizers of public mental health services: the Los Angeles PARTNERS program experience

Los Angeles PARTNERS, or "people achieving rehabilitation together need empowering respectful support," is a treatment program that uses capitation to shift risk for treatment costs of high utilizers of public mental health services to private community-based treatment organizations. This analysis reveals two important findings from PARTNERS. First, the economic incentives created by capitation contributed to the dis-enrollment of PARTNERS clients; furthermore, factors such as not speaking English or Spanish or having schizophrenia increased the probability of dis-enrollment. Second, analyses of health costs for enrollees in the PARTNERS capitation program suggest that the program did not result in a change in total costs. However, the program increased the use of community-based care and increased treatment costs for clients with lower preprogram costs but decreased costs for the clients with high preprogram costs. These results suggest that future capitation programs for this severely ill population would benefit from using detailed clinical information to determine program eligibility and to set risk-adjusted capitation rates.