Characterization of rural mental health service systems

This paper explores two mental health systems in rural North Carolina that provide services to people with severe mental disorders. Recent findings show rural people with mental disorders receive less mental health care than their urban counterparts. This study asks whether rural service systems differ from urban systems in the way that their services are coordinated and structured. A popular conception is that public mental health systems in the United States are uncoordinated with many services provided outside the mental health sector. Rural service providers are seen as even more dependent on nonspecialized mental health providers than their urban counterparts. While many rural service barriers are attributed to the rural environment, little is known about rural service systems and how their organization might contribute to or negate barriers to care. Social network methods were used in this study to compare two rural with four urban systems of care. Findings confirm that mental health systems fit the de facto hypothesis, but that rural systems differ in ways not anticipated by the hypothesis. Rather than being more dependent on nonmental health agencies, rural mental health agencies are more interdependent.

Service delivery and community: social capital, service systems integration, and outcomes among homeless persons with severe mental illness

OBJECTIVES

This study evaluated the influence of features of community social environment and service system integration on service use, housing, and clinical outcomes among homeless people with serious mental illness.

STUDY SETTING

A one-year observational outcome study was conducted of homeless people with serious mental illness at 18 sites.

DATA SOURCES

Measures of community social environment (e.g., social capital) were based on local surveys and voting records. Housing affordability was assessed with housing survey data. Service system integration was assessed through interviews with key informants at each site to document interorganizational transactions. Standardized clinical measures were used to assess clinical and housing outcomes in face-to-face interviews.

RESEARCH DESIGN

Structural equation modeling was used to determine the relationship between (1) characteristics of the social environment (social capital, housing affordability); (2) the level of integration of the service system for persons who are homeless in each community; (3) access to and use of services by individual clients; and (4) successful exit from homelessness or clinical improvement.

PRINCIPAL FINDINGS

Social capital was associated with greater service systems integration, which was associated in turn with greater access to assistance from a public housing agency and to a greater probability of exiting from homelessness at 12 months. Housing affordability also predicted exit from homelessness. Neither environmental factors nor systems integration predicted outcomes for psychiatric problems, substance abuse, employment, physical health, or income support.

CONCLUSION

Community social capital and service system integration are related through a series of direct and indirect pathways with better housing outcomes but not with superior clinical outcomes for homeless people with mental illness. Implications for designing improved service systems are discussed.

Service system integration, access to services, and housing outcomes in a program for homeless persons with severe mental illness

OBJECTIVES

This study evaluated the hypothesis that greater integration and coordination between agencies within service systems is associated with greater accessibility of services and improved client housing outcomes.

METHODS

As part of the Access to Community Care and Effective Services and Supports program, data were obtained on baseline client characteristics, service use, and 3-month and 12-month outcomes from 1832 clients seen at 18 sites during the first year of program operation. Data on interorganizational relationships were obtained from structured interviews with key informants from relevant organizations in each community (n = 32-82 at each site).

RESULTS

Complete follow-up data were obtained from 1340 clients (73%). After control for baseline characteristics, service system integration was associated with superior housing outcomes at 12 months, and this relationship was mediated through greater access to housing agencies.

CONCLUSIONS

Service system integration is related to improved access to housing services and better housing outcomes among homeless people with mental illness.

Service system performance and integration: a baseline profile of the ACCESS demonstration sites. Access to Community Care and Effective Services and Supports

OBJECTIVE

Networks of agencies at the 18 demonstration sites in the Access to Community Care and Effective Services and Supports (ACCESS) program for homeless persons with serious mental illness were surveyed to profile baseline levels of systems performance and integration as part of a longitudinal evaluation of systems change and client outcomes.

METHODS

Interviews were conducted with a representative from each of 875 agencies in the 18 service networks. Information was obtained about the perceived performance of the service system and the extent of systems integration as measured by client referrals, funds exchanges, and information sharing between agencies. Measures consisted of two multi-item scales assessing the accessibility and coordination of services for the target population in each community and four indexes of interagency relationships.

RESULTS

Services at baseline for homeless mentally ill persons at the program sites were rated as relatively inaccessible, and the coordination of services between agencies was rated as even more problematic. Interagency ties were largely based on client referrals and information exchanges, with very few instances of funding transfers in the form of contracts or grants. On average, at baseline agencies that had received an ACCESS grant were better connected to their local service network than were other agencies.

CONCLUSIONS

Consistent with the premise of the ACCESS demonstration, services for persons who are homeless and mentally ill in urban America are fragmented and not very accessible. The longitudinal design of the evaluation will allow for an assessment of efforts to improve services and systems integration and of the effects of these improvements on client outcomes.

Involvement of the inferior vena cava by adrenal phaeochromocytoma--MRI findings

Involvement of the inferior vena cava (IVC) by adrenal phaeochromocytoma is rare. Only angiographic and sonographic features have been described previously. We present a case with magnetic resonance demonstration of the IVC invasion.