November 20, 1998

Less than a decade after its inception, the Village Integrated Services Agency in Long Beach, Calif., has become a model for the successful delivery of community mental health services.

The program grew from a task force convened in 1986 by consumers, mental health care providers, and business people concerned about what they saw as California's failing mental health system. The question that confronts those looking for a model is whether the unusual mix of personalities and philosophies at the Village can be replicated elsewhere.

"We definitely do not see ourselves as a cookie-cutter program to be replicated everywhere, but rather as an inspiration to help others form their own visions," said Mark Ragins, M.D., the agency's resident psychiatrist, in an overview of the program published by the Village. Ragins and program director Martha Long discussed the Village at APA's Institute on Psychiatric Services (IPS) in Los Angeles last month.

Village Director Martha Long explained that the program, which serves about 275 patients, is "an amalgam" of concepts designed to serve a cross-section of the seriously mentally ill in the Long Beach area. Patients are referred to as "members," and case managers are called "personal service coordinators." Observed Ragins: "People are not cases and do not want to be managed."

The underlying philosophy stresses "rehabilitation and recovery," said Long. "The glue that holds [the program] together is that philosophy," she added. "We focus on wellness rather than illness. We help people get a life."

The Village uses teams consisting of a psychiatrist, social worker, and personal service coordinators, Long explained. The program has no residential facilities, but can arrange hospitalization if necessary. Hospitalization, however, accounts for only 6 percent of the program's budget, compared with more than 40 percent of the Los Angeles County mental health budget, she noted.

The program's psychiatrists are on staff at a nearby hospital, which has improved continuity of care and resulted in a halving of the average length of stay as compared with the average in Los Angeles County, said Long. Although the Village provides most services directly, it contracts out if needed. For example, one very depressed woman with obsessive-compulsive disorder was interested only in the Bible, so the Village contracted for her admittance to a Christian psychiatric hospital.

Capitation, often derided by psychiatrists as imposing harmful constraints on patient care, has been "a wonderful tool for us" in promoting good case management, said Long. The Village agency was initially capitated at $15,000 per patient per year and has been in the black every year since the program's inception, she added. The Village is now pioneering a two-tiered capitation system in which 138 "moderate utilizers" are capitated at $4,950 a year and 138 "high utilizers" are capitated at $16,190 a year.

The greatest challenge in restraining expenses is the escalating cost of drugs, Long said. The agency policy is to use the "best drug first," rather than an economically oriented formulary.

"We do everything we can think of to help people go from patient to worker," said Long. The Village does not follow any one model other than aiming for rehabilitation and recovery, she noted. In addition to routine psychiatric services, the Village helps patients develop their own networks of contacts within in the community. Without such contacts, patients are unlikely to succeed in attaining a normal existence.

Many of the Village's clients "are making it," remarked Ragins. He recalled his astonishment at seeing a patient who suffered from multiple diagnoses working as a secretary and keeping both his work and home lives organized. "Every day things happen that are impossible," he said.

Employment is considered a cornerstone of the Village rehabilitation approach. The Village provides employment through its own café deli; minimart; bank; and maintenance, clerical, and data entry units, all staffed by patients. Members and staff often work side by side, and boundaries between staff and members are "intentionally and massively blurred," Ragins noted.

Continuity of care is one key to the program's success, Ragins said. This means not only making sure that their psychiatrists are on staff at a nearby hospital so that they understand the patients from the Village who may end up there, but also having staff keep in touch with the patients in a variety of unconventional ways both during active program participation and after formal participation is concluded.

This seamless approach has included getting a patient out of a state hospital and searching through the woods to find a patient who had become disoriented. In another instance a staff person kept in touch with a patient suffering from paranoia by dropping by and shouting up to the patient, who would not come out of his apartment. In that case, the patient eventually relented and let the staff worker come inside.

"We do whatever it takes to be in their life, not necessarily [adhering to] the doctor-patient relationship," Ragins explained. The emphasis is on establishing and nurturing a connection.

"We do not think our job is to scrub the world of mental illness," he added. Every effort is made to give patients a sense of being in a partnership with clinicians. This extends to medication management, he noted, in that clinicians discuss medication with patients and allow patients to try different medications if they are uncomfortable with the effects of a medication they receive.

Another part of the Village's success is attributable to the integration of substance abuse treatment into clinical services, since about 30 percent of their patients are comorbid for substance abuse, Ragins said.

The program is not residential, so in part it involves finding acceptable housing for patients. One informal rule the program follows is not referring anyone to housing where a staff person would not feel comfortable visiting in the middle of the night, Ragins said. Most of the patients live in independent apartments, although they are not fully independent, he observed. In addition to medication monitoring, patients get help with housekeeping, shopping, and budgeting. As patients improve, they are given increasing responsibility for their lives, Ragins said.

The program has been honored by the Mental Health America and has been visited by program administrators from around the world, according to Ragins. He was the corecipient of APA's 1995 Van Ameringen Award for his outstanding contribution to the field of psychiatric rehabilitation.