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This is the conclusion of a two-part series begun in the September 4 issue. Part 1 covered the experience of Ventura County, California, in merging behavioral health and welfare services to create a new Human Services Agency. Part 2 looks at other counties that have integrated services and at the role of psychiatrists within the new organizations.
By Lynda McCullough
As an increasing number of states and counties across the country integrate their mental health and welfare services, many psychiatrists see the change as one more area where the professional role of psychiatrists is being eroded and the medical model will be replaced by a social one. They point to the fact that more and more social workers are serving as top administrators while psychiatrists participate on teams of mental health professionals rather than calling the shots themselves. Others, though, say that these changes may not be as bad as they first seem.
The idea of combining agencies emerged about a century ago, said Pat Jordan, L.C.S.W., a mental health consultant who is studying integrated services. The author of a recent report for the California Institute of Mental Health titled "Integrated Services for Children and Families," Jordan said integrated services become popular at various times. She believes they are popular now because "everything has become extremely complex. It has become very difficult for families to negotiate the public system."
Part of the reason for the complexity is that as service professionals specialize in particular areas, each group develops its own rules, said Jordan. At the same time, parents are becoming more vocal, and they are advocating for systems that are easier to use.
Other factors for the increasing interest in integrated services right now, said Jordan, are changes in the welfare system and the relative strength of the economy. Welfare is a multiproblem situation that requires collaborative answers, she said. In times when the economy is good, such as now, she added, there is more money to use to create fiscal incentives for departments and professionals to work together.
Changes in Medicaid funding are also affecting mental health coverage, sometimes making it necessary for mental health services to integrate with other departments. "The blending of Medicaid dollars into the mental health budget in order to be able to globally manage inpatient as well as outpatient care is probably something that needs to happen. Right now they are managed, at least in Maine, by the departments of human services and mental health, respectively," said Gordon Clark, M.D., founding president of the American Association of Community Psychiatrists (AACP) and president-elect of the American Association of Psychiatric Administrators (AAPA). "Management of patient Medicaid is hard to get your hands around if you don't have them around the whole pot of money."
According to Jordan, there are perceptible differences in the ways services are integrated based upon where the leadership and decision making about integration are occurring and what the local needs are. Several counties around the country have integrated mental health and human services, while some have combined agencies in other ways.
In her report, Jordan described how counties like Napa in California combined the administration of the departments of social services and behavioral health. It describes how Placer County, Calif., drew up a Memorandum of Understanding (MOU) in 1988 among leaders from the county in the juvenile court, probation, mental health, education, and child welfare services divisions in which they agreed to share responsibility for providing services for children and families through comprehensive assessment, unified case planning, and coordinated multisystem services. The Family Council coordinates services for Stark County, Ohio, and the North Carolina Pitt Edgecombe Nash Public Academic Liaison Program, an integrated service delivery program that serves children and their families in three North Carolina counties. Jordan noted that it is too early to evaluate the outcomes of any of these systems.
Service integration is also going on at the state level, said psychiatrist Richard Lippincott, M.D., Louisiana's assistant secretary for mental health. He noted that "umbrella agencies come and go in the state system." Five years ago, said Lippincott, welfare was part of the Department of Health and Human Resources, but the arrangement didn't work and the departments were made independent again.
Changes in service agencies are just part of a current milieu in which the role of the psychiatrist in the public sector seems to be increasingly relegated to the sidelines. Many psychiatrist administrators have been lured away from the public sector to managed care. At the same time, the practice of psychiatry is becoming more neurobiological and specialized. In addition, said Lippincott, emphasis and respect for administration has gradually diminished in the profession. Finally, there is very little training within psychiatric residencies for administrative skills.
Many psychiatrists facing these challenges to their profession have been alarmed, some angered. They are concerned about the need for medical leadership in the newly forming agencies.
"We have to look at what we're angry at," said Roy Wilson, M.D, director of the Department of Mental Health for the state of Missouri. "What existed before? We did a poor job before seeing to it that patients on welfare were getting the mental health services that they needed."
Wilson said the overall quality of services was poor in the past and that integration can be productive if it is done right and administrators pay attention to political and human service issues such as housing, day care, and education.
William Reid, M.D., chair of APA's Committee on Psychiatric Administration and Management, said that "sometimes the upset of local psychiatrists is reasonable and sometimes it's not. Change makes us nervous." When it comes to the indigent, he said, Medicaid payments apply to general health and mental health, and the administration of mental health is usually different from that of welfare, but each service needs to know what the others are doing. He said that integration can sometimes be an effective way to provide services.
Another difficulty arising for psychiatrists in the changing public health system is the "turf wars" between different mental health professions. Animosity between social workers and psychiatrists sometimes arises, and it has to be worked through, said Lippincott. "If we understand the different roles, it can be a partnership, and it works best that way."
Most psychiatrists would like to see psychiatrists in charge of mental health and human service agencies, but in reality social workers have been moving into that role in increasing numbers. The reactions to this change, which has occurred gradually in the last 40 years, vary.
"There has been an erosion in psychiatric leadership at the CEO level, and it's become imperative to have the position of psychiatrist as the medical director required in organizations," said Clark. It's not absolutely necessary to have psychiatrists as overall administrators of a system of care, said Clark, but it is important for there to be psychiatric clinical leadership and for psychiatrists and other administrators to collaborate effectively.
"My friends know me as a strong spokesman for medical issues," said Reid, but "social workers have been running county agencies for years. It has been that way and it should stay that way." There are not enough doctors properly trained and experienced in administration to take these roles, he said, and small counties that don't have a lot of funding are going to find it easier to pay a social worker's salary. In addition, he added, psychiatrists may not be willing to work in administration because the work does not pay as well as they might like.
Reid believes that a medical director can work in partnership with a social worker-manager. A social worker who is trained and experienced, with the "appropriate" view of administration and respect for medical and clinical issues and for the psychiatrist's role, can be a fine administrator, he said.
Wilson said the state of Missouri is currently putting together a program to provide mental health and substance abuse services to children in custody of its welfare group in the division of family services.
"I believe a clinical background is important for that integration and to help identify outcomes, but you need more than a clinical background to be successful," said Wilson. If psychiatrists have the kind of experience and background to understand what the program and political issues and players are, they have an advantage over social workers as administrators, he said, but if they don't, they may have to work closely with, rather than as, managers.
As a psychiatrist who has worked as both a staff psychiatrist and medical director at a community mental health center, Clark said he believed he had medical-legal responsibility without authority. There needed to be guidelines for psychiatric practice and for mental health centers, state hospitals, and state offices of mental health, he said.
"We needed model job descriptions for each level clearly spelled out. Authority should be commensurate with medical-legal responsibility, and the principles should be applicable to all systems of care at all levels-program, organization, and system."
Clark said the AACP and APA collaborated in developing these guidelines and that the AACP has been promulgating them as much as possible.
In addition, said Clark, "I think it is very important that we as clinical leaders develop the administrative skills in order to be able to talk the same language administrative types talk and advance ourselves in that arena to promote optimal clinical system design and management.
Clifton Tennison Jr., M.D., the AACP liaison to APA, said the AACP walks a fine line between insisting on psychiatric leadership and the need to be effective team players respectful of multidisciplinary efforts. Still, said Tennison, the AACP thinks psychiatrists with administrative training can be the best people for administrative roles.
"The person with the broadest, most comprehensive training should be the person who oversees quality of care. We think psychiatrists should get out there and develop administrative skills so that they can lead organizations."