The State of New Mexico will implement a major reform in managed mental health service delivery for low-income populations in July 2005. Seventeen state agencies will contract with a single behavioral health organization to oversee the delivery of all public mental health services. This reform is designed to decrease administrative costs and service fragmentation while improving access to culturally relevant, evidence-based mental health services, particularly in rural areas. However, concerns linger that managed mental health care programs may adversely affect access and services for vulnerable populations and may overly burden rural safety-net institutions. The 5-year R01 research project proposed in this application will use a multi-method ethnographic approach to examine: (1) the process of introducing the reform in a rural and multiethnic state and (2) the degree to which the reform results in improved access and quality of care for low-income seriously mentally ill (SMI) patients in public mental health programs and other safety-net institutions. This longitudinal study has three specific aims: (1) To examine changes in help-seeking behavior, access, and utilization of services by American Indian, Hispanic, and White SMI patients and their social supports (e.g., family and close peers) in three rural and three urban settings before, during, and after the reform. (2) To investigate changes in the work environment, attitudes, and behavior of frontline service providers and staff members of safety-net institutions in the targeted settings before, during, and after the reform. (3) To assess the impacts of the reform on the organization and financial condition of safety-net institutions in the targeted settings and statewide. Our multi-method ethnographic research strategy will employ both qualitative and quantitative methods in two sets of studies, conducted prior to and after the reform is implemented. The first set, consisting of administrative database reviews and ethnographic interviews and observations with SMI patients and frontline service providers, will describe changes in patterns of mental health care utilization and provider behavior. These studies will occur in three rural counties and three comparison urban counties. The second set, consisting of ethnographic interviews with state policymakers and structured surveys with clinical directors of rural and urban safety-net institutions, will identify changes in service provision for the SMI statewide. This latter statewide component will facilitate linking of the community-level ethnographic data with broader system change. The proposed ethnographic assessment of New Mexico's reform will offer new practical knowledge, grounded in the actual experiences of diverse stakeholders, that may improve state mental health policy for rural and minority SMI populations. In collaboration with the State of New Mexico, we will assess whether the reform decreases barriers to care for these underserved groups and how it affects the viability of existing services rendered in safety-net institutions. This research will fill a gap in research on statewide assessments of public health care initiatives, which do not typically focus on patient help-seeking behavior and the unique access and utilization problems faced by rural, racial and ethnic minorities. Since rural states may turn to the New Mexico reform as a model to reduce administrative costs and service fragmentation and to increase access for the SMI, this research is of great national relevance.
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