This proposal to examine the general physician's role in the mental health treatment of the seriously mentally ill (SMI) client population. The policy issue to be addressed in this study is to what degree do the SMI receive treatment for their psychiatric conditions following hospital discharge from primary care physicians and what system and client factors impede or support follow-up community care. Questions to be examined are the following: (l) Are SMI patients in capitated health care plans (HIO/HMOs) more likely than those in fee for service plans to have ambulatory mental health care provided by their primary care physician? (2) Has the implementation of Intensive Case Management programs for the SMI significantly decreased the proportion of clients using a general physician for mental health care and, if so, what are the cost effectiveness implications with respect to continuity and rehospitalization rates? (3) What is the impact of comorbidity on the probability and level of use of physicians for the treatment of mental disorders? How does the initial treatment setting; i.e. primary care versus specialty, effect subsequent patterns of care such as cross over between sectors? (4) How does involuntary commitment and forensic status effect the choice of provider and the level of service? Are their significant provider barriers to care for this population or are these clients simply treatment resistant, using only costly emergency and inpatient services during periods of crisis? These areas of investigation have significant policy implications given the large percent of public funds that are allocated to the mental health treatment of the SMI. Given the pressure on public systems to become more efficient and recognizing the possible economies of scope that are present in using a physician to provide both health and mental health care, it is important to investigate the effect that system and social case mix changes are having on the patterns of psychiatric care in the general health care sector. This will hopefully provide a richer knowledge base for the planning and delivery of public health and psychiatric services.
