Managed care approaches are rapidly being developed and implemented in public mental health systems. While somewhat more is known about managed care effects in the private sector, relatively little is known about managed care in the public sector, in terms of its use to contain costs rather than increase service integration or coordination. Further, implementation of the managed care in the public sector is particularly challenging because of the special needs of the client population (sick disabled, and often socially disadvantaged), as well as relatively limited public resources for managing or monitoring care. We propose a Public Sector Research Core. The broad aim of the public sector core is to develop an interdisciplinary team focused on understanding the goals and processes of managed care in the public mental health sector and the relationship of these to goals and processes in the private sector. By studying variations in implementation and processes of managed care across public sector settings we will better understand the consequences of managed care for quality of care and outcomes. The Core will sponsor three specific projects. One is an evaluation of a pilot program of capitated care for high-utilizers of care in Los Angeles County Department of Mental Health, examining (a) obstacles to implementation of managed care, (b) """"""""dumping"""""""" (disenrollment of high cost clients) and pre-post service use patterns, and (c) differences and similarities in needs and clinical characteristics among those who enrolled in the program, refused enrollment, and received care-as-usual. This project expands a previously funded pilot evaluation sponsored by Los Angeles County. The second project intends to """"""""open the black box"""""""" of public sector managed care by developing conceptual framework and method for studying the structure and function of case management treatment teams and for describing the costs and outcomes associated with various team structures. This project will result in an improved understanding the process of management in public sector mental health, using Ventura County as an example, and will provide a baseline for observing changes in team structure with implementation of managed care. The third project will use a well-established method for developing measures of the appropriateness of care to develop criteria and measures of quality of psychotropic medication management for individuals in community mental health treatment programs with psychotic symptoms. This approach will then be tested across a range of managed care treatment settings, including those studied in the first two projects. The ultimate goal of the Core is to use the research to form a basis from which we can develop new studies of the effects of a range of public sector managed care models on clinical effectiveness, quality of care, costs, and cost- effectiveness. To achieve this end, the Public Sector Core will work closely throughout the Center funding period to develop a new demonstration of capitated managed care in Los Angeles County, integrating the approaches developed in the specific projects. The Public Sector Core includes an interdisciplinary research team including psychiatrists, sociologists, anthropologists, and consultation from statisticians and economists in the Administrative Core.
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