The Vulnerable Populations core is concerned with access to and quality of care among those who fall to the public safety net, including most persons with severe and chronic mental illness (because private insurance limits are soon exceeded), the poor uninsured, and the Medicaid population. The underlying concern that motivates the research in this core is that supply-side cost control measures which are the hallmark of managed care reforms are most likely to have negative consequences for these populations. These are populations for whom access to appropriate care has long presented a challenge to public policy and the public systems charged with their care. How will these populations fare under public managed care reforms? The broad aims of the Vulnerable Populations core are: 1) TO study the effects of managed care financing reforms and technologies on populations that have historically had difficulty accessing appropriate care, and 2) To develop and evaluate ways within managed care models to improve service delivery for these populations. Four specific research projects are proposed. Project 1 looks broadly at the public mental health system and how provider organizations and patterns of care are changing for the poor. Projects 2, 3, and 4 focus on specific vulnerable populations (persons with schizophrenia, racial/ethnic minorities, and the dually diagnosed respectively), and represent efforts to build an empirical information base that can inform quality improvement efforts under managed care. For schizophrenia, where the empirical groundwork for quality improvement efforts is most well-developed, we propose refinement of instruments and methods to improve quality of care for schizophrenia under managed care, and build the groundwork for a quality improvement demonstration. For minority populations, where the goal of """"""""cultural competence"""""""" is widely parleyed but poorly defined or agreed upon, we focus on better understand patterns of access to mental health care for minorities under managed care, and work toward a longer- term agenda to study dimensions of cultural competence in managed care. For the dually diagnosed, where recent welfare reform legislation has dismantled a significant portion of the public safety net, we first examine patterns of care in a public mental health system undergoing managed care reform, and then investigate the extent to which integrated programs are operating under public managed care models.
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