Perspectives - Vol. 5, No. 1 - The Program on Chronic Mental Illness

Despite a narrow interpretation of the findings of its evaluation, the Program on Chronic Mental Illness demonstrated the feasibility and the utility of Local Mental Health Authorities in promoting the integration of service systems. The program also demonstrated that integration could have a positive impact on continuity of care, family burden, and housing status for individuals with severe mental illness. In addition, the Mental Health Services Program for Youth illustrated several models of integrating services for children with severe emotional disorders. Together with the Mental Health Services Development Program, the Program on Chronic Mental Illness underscored the importance of attending to the need for high-quality services, even in well-integrated service systems.

When the evaluators of the program concluded that integration of the service system was necessary but not sufficient to improve individual outcomes, they set in motion a series of activities in the development of mental health services--activities that influenced the design of subsequent government projects. They also influenced a new generation of mental health service activities funded by The Robert Wood Johnson Foundation.

Along with other trends in health services--managed care and a growing concern about outcomes, for instance--the findings from the Program on Chronic Mental Illness and other demonstration programs intensified interest in measuring the quality of care. This interest included attention to using services whose effectiveness has been demonstrated, the development of evidence-based treatment recommendations, and attention to the quality of clinical and social services in programs devoted to systems reform. The evaluators of the Program on Chronic Mental Illness themselves became involved in two federal projects extending their work into the new areas: the Access to Community Care and Effective Services and Supports project (ACCESS), and the Schizophrenia Patient Outcomes Research Team (PORT).

During the waning days of the Program on Chronic Mental Illness in 1992, a federal task force on homelessness and mental illness released a report; among the recommendations was a call for a service systems demonstration project to further test the systems integration hypothesis.²² The demonstration was to determine whether a small grant of resources to promote the integration of systems would result in better coordination among mental health providers and other human services providers and would promote residential stability and improved quality of life for individuals who were homeless and had a mental illness. ACCESS was designed with the Program on Chronic Mental Illness in mind.²³

Some members of the task force and the staff at the Center for Mental Health Services, the federal agency given responsibility for the new demonstration, were aware of the more nuanced view of the findings of the Program on Chronic Mental Illness. They encouraged ACCESS to provide substantial resources to the demonstration sites to develop clinical and social services, in addition to grants and technical assistance for promoting systems integration. Service grants of between $600,000 and $800,000 a year were made to each of the sites to develop Assertive Community Treatment outreach teams--the service viewed as missing in the Program on Chronic Mental Illness and presumed to be responsible for the no-difference findings. In this fashion, ACCESS became a demonstration of the integration of systems combined with improvement of services.

It was no accident that the Program on Chronic Mental Illness influenced the federal ACCESS program. In spite of a sense of competition between the federal mental health agencies and The Robert Wood Johnson Foundation, Foundation staff members had coordinated their efforts in the program with those of the government. Furthermore, the Foundation coordinated the funding and oversight of the evaluation with the National Institute of Mental Health and other federal agencies. Federal and state governments knew about the program, and were aware of its findings. Additionally, participants in the program and its evaluation served as consultants to the government on the design of ACCESS. Many of the evaluators of the program ultimately worked on its evaluation.

As ACCESS rolled out in 1993, the findings of the Program on Chronic Mental Illness were held out as lessons--particularly the need to develop state-of-the-art services at each site. This was critical to the design of ACCESS and its evaluation that compared the nine sites in each state receiving both additional resources for services integration and enhanced clinical services in the form of intensive case management--that is, ACT services--and the nine sites that received only resources to enhance clinical services. This strategy assesses whether the quality of services alone, or in concert with systems integration, leads to improvement in clinical and social outcomes.

Preliminary results indicate that, twelve months after first receiving services, previously homeless service recipients in sites with better integration of services are more likely to be independently housed than those in sites with less well-integrated services.²⁴ Studies of the impact of changes in integration over time, however, are not complete.

When the Agency for Health Care Policy and Research and the National Institute of Mental Health announced their intent to fund a Schizophrenia Patient Outcomes Research Team (PORT), a group of the evaluators for the Program on Chronic Mental Illness seized the opportunity and, with some new colleagues, successfully bid on the contract. This gave them the chance to apply the lessons learned from the evaluation of the Program on Chronic Mental Illness to treatment recommendations. Now in its sixth year, the team has reviewed the literature on the effectiveness of treatment, conducted field studies, and published treatment recommendations on schizophrenia. It has almost completed an assessment of the impact of efforts to disseminate the recommendations.²⁵

The PORT treatment recommendations coincided with a broader initiative within the mental health field to develop treatment guidelines and medication algorithms for use by psychiatrists and other practitioners. Several efforts at disseminating them have been initiated, among them the Texas Medication Algorithm Project (TMAP), that is supported by The Robert Wood Johnson Foundation and other funders.

ACCESS and PORT, as well as the original Program on Chronic Mental Illness, have underscored the importance of technical assistance in facilitating the implementation of a program; technical assistance in the design of Local Mental Health Authorities and on housing development were essential in the program. This lesson was relearned in ACCESS, in which the adoption of systems change was hampered by a lack of understanding of the central concept of service systems integration. After almost two years of a stuttering start, special resources were allocated to ACCESS project implementation. As a result, each of the ACCESS sites developed strategic plans for services integration and increased its level of integration activities. New demonstrations and efforts at disseminating treatment guidelines have made similar discoveries.

The emphasis on the content and quality of services has extended from ACCESS and the Schizophrenia PORT to a number of federal mental health demonstration projects. Programs focusing on employment services, supportive housing, treatment of simultaneously occurring mental illness and substance abuse, and diversion of individuals with mental illness from jail into treatment all underscore the importance of quality of care and the development of services. This emphasis is traceable to the lessons learned from the Mental Health Services Program for Youth, the Mental Health Services Development Program, and the Program on Chronic Mental Illness. Models of systems integration and service innovation, developed in these Foundation-supported programs, have been replicated in newer demonstration programs and have had a far-reaching impact.

1. G. Grob. The Mad Among Us. New York: Free Press, 1994; H. Goldman and J. Morrissey. "The Alchemy of Mental Health Policy: Homelessness and the Fourth Cycle of Reform," American Journal of Public Health, 1985, 75, 727-731.

2. L. Aiken, S. Somers, and M. Shore. "Private Foundations in Health Affairs: A Case Study of a National Initiative for the Chronically Mentally Ill." American Psychologist, 1986, 41, 1,290-1,295.

3. R. C. Tessler and H. H. Goldman. The Chronically Mentally Ill: Assessing Community Support Programs. Cambridge, Mass.: Ballinger, 1982.

4. M. J. England and R. F. Cole. "Broad Continuum of Care Needed to Serve Mentally Ill Children," Psychiatric Times, 1990, 7(11); R. F. Cole, "Financing Policy and Administrative Mechanisms for Child and Adolescent Mental Health Services." The Child, Youth, and Family Service Quarterly, 1990, 13(2); R. F. Cole and S. Poe. Partnerships for Care. Washington, D.C.: Washington Business Group on Health, 1993; Final Progress Report, "Evaluation of the Mental Health Services Program for Youth Phase III," RWJF Grant #13613 Grant Period-February 1, 1991-June 30, 1995. RWJF: Princeton, N.J.

5. M. Shore and M. Cohen. "The Robert Wood Johnson Program on Chronic Mental Illness: An Overview." Hospital and Community Psychiatry, 1990, 41, 1,212-1,216; M. Shore and M. Cohen. "Introduction." Milbank Quarterly, 1994, 72, 31-35.

6. L. I. Stein and M. A. Test. Alternatives to Mental Hospital Treatment. New York: Plenum, 1975; L. I. Stein, "The Robert Wood Johnson Foundation Mental Health Services Development Program," New Directions for Mental Health Services 45, 1990, 75-89; Final Report: "Mental Health Services Development Program January 1, 1987-August 31, 1991." Grant I.D. #16485. RWJF: Princeton, N.J. (File); L. I. Stein. "Innovative Community Mental Health Programs." New Directions for Mental Health Services 56, 1992, entire issue.

7. H. Goldman, J. Morrissey, and M. S. Ridgely. "Form and Function of Mental Health Authorities at RWJ Foundation Program Sites: Preliminary Observations." Hospital and Community Psychiatry, 1990, 41, 1,222-1,230.

9. H. Goldman, A. Lehman, J. Morrissey, S. Newman, R. Frank, and D. Steinwachs. "Design for the National Evaluation of the Robert Wood Johnson Foundation Program on Chronic Mental Illness." Hospital and Community Psychiatry, 1990, 41, 1,217-1,221.

10. H. Goldman, J. Morrissey, and M. S. Ridgely. "Form and Function of Mental Health Authorities at RWJ Foundation Program Sites: Preliminary Observations." Hospital and Community Psychiatry, 1990, 41, 1,222-1,230; H. Goldman, J. P. Morrissey, M. S. Ridgely, and others. "Lessons from the Program on Chronic Mental Illness." Health Affairs, 1992, 11, 51-68; H. Goldman, J. Morrissey, and M. S. Ridgely. "Evaluating the Program on Chronic Mental Illness" (RWJ PCMI). Milbank Quarterly, 1994, 72(1), 37-48; J. Morrissey, M. Calloway, T. Bartko, M. S. Ridgely, H. Goldman, and R. Paulson. "Mental Health Authorities and Service System Change from the RWJ PCMI." Milbank Quarterly, 1994, 72(1), 49-80; A. Lehman, L. Postrado, D. Roth, S. McNary, and H. Goldman. "An Evaluation of Continuity of Care, Case Management, and Client Outcomes in The RWJ PCMI." Milbank Quarterly, 1994, 72(1), 105-122; M. S. Ridgely, J. Morrissey, R. Paulson, H. Goldman, and M. Calloway. "Case Management and Client Outcomes in the Robert Wood Johnson Foundation Program on Chronic Mental Illness." Psychiatric Services, 1996, 4(7), 737-743; J. A. Talbott. "Evaluating the Johnson Foundation Program on Chronic Mental Illness: An Interview with Howard Goldman." Psychiatric Services, 1995, 46(5), 501-503.

11. H. Goldman, J. Morrissey, and M. S. Ridgely. "Form and Function of Mental Health Authorities at RWJ Foundation Program Sites: Preliminary Observations." Hospital and Community Psychiatry, 1990, 41, 1,222-1,230; H. H. Goldman, J. P. Morrissey, M. S. Ridgely and others, "Lessons from the Program on Chronic Mental Illness." Health Affairs, 1992, 11, 51-68; H. Goldman, J. Morrissey, and M. S. Ridgely. "Evaluating the Program on Chronic Mental Illness (RWJ PCMI)." Milbank Quarterly, 1994, 72(1), 37-48.

12. J. Morrissey, M. Calloway, T. Bartko, M. S. Ridgely, H. Goldman, and R. Paulson. "Mental Health Authorities and Service System Change from the RWJ PCMI." Milbank Quarterly, 1994, 72(1), 49-80.

13. A. Lehman, L. Postrado, D. Roth, S. McNary, and H. Goldman. "An Evaluation of Continuity of Care, Case Management, and Client Outcomes in the RWJ PCMI." Milbank Quarterly, 1994, 72(1), 105-122.

15. R. Tessler and G. Gamache. "Continuity of Care, Residence, and Family Burden in Ohio." Milbank Quarterly, 1994, 72, 149-170.

16. S. Newman, J. Rechovsky, K. Kaneda, and A. Hendrick. "The Effects of Independent Living on Persons with Chronic Mental Illness: An Assessment of the Section 8 Certificate Program." Milbank Quarterly, 1994, 72, 171-198.

17. M. S. Ridgely, J. Morrissey, R. Paulson, H. Goldman, and M. Calloway. "Case Management and Client Outcomes in The Robert Wood Johnson Foundation Program on Chronic Mental Illness." Psychiatric Services, 1996, 4(7), 737-743.

18. M. Shore and M. Cohen. "The Robert Wood Johnson Program on Chronic Mental Illness: An Overview." Hospital and Community Psychiatry 41, 1990, 1,212-1,216; M. Shore and M. Cohen. "Introduction." Milbank Quarterly, 1994, 72, 31-35; H. Goldman, J. Morrissey, and M. S. Ridgeley. "Form and Function of Mental Health Authorities at RWJ Foundation Program Sites: Preliminary Observations." Hospital and Community Psychiatry, 1990, 41, 1,222-1,230; H. Goldman, A. Lehman, J. Morrissey, S. Newman, R. Frank, and D. Steinwachs. "Design for the National Evaluation of The Robert Wood Johnson Foundation Program on Chronic Mental Illness." Hospital and Community Psychiatry, 1990, 41, 1,217-1,221.

19. J. Rosenberger. "Central Mental Health Authorities: Politically Flawed?" Hospital and Community Psychiatry, 1990, 41, 1,171.

20. D. Shern, N. Wilson, A. Coen, D. Patrick, M. Foster, D. Bartsch, and J. Demmler. "Client Outcomes II: Longitudinal Data from the Colorado Treatment Outcome Study." Milbank Quarterly, 1994, 72, 123-148.

21. L. Bickman. "A Continuum of Care: More Is Not Always Better." American Psychologist, 1996, 51, 689-701.

22. Federal Task Force on Homelessness and Mental Illness. Outcasts on Main Street (ADM 92-1904). Washington, D.C.: Interagency Council on the Homeless, 1992.

23. F. Randolph, M. Blasinsky, W. Leginski, L. Parker, and H. Goldman. "Creating Integrated Service Systems for Homeless Persons With Mental Illness: The ACCESS Program." Psychiatric Services, 1997, 48, 369-373.

24. R. Rosenheck, J. Morrissey, J. Lam, M. Calloway, M. Johnsen, H. Goldman, F. Randolph, M. Blasinsky, A. Fontana, R. Calsyn, and G. Teague. "Service System Integration, Access to Services, and Housing Outcomes in a Program for Homeless Persons with S evere Mental Illness." American Journal of Public Health, 1998, 88(11), 1,610-1,615.

25. See Schizophrenia Bulletin, 1995, 21(4), for a series of articles on the issue; and A. Lehman, D. Steinwachs, and others. "Translating Research Into Practice: The Schizophrenia Patient Outcomes Research Team (PORT) Treatment Recommendations." Schizophrenia Bulletin, 1998, 24(1), 11-19.

Reference:
Goldman, Howard H. (2000). The Program on Chronic Mental Illness. [Online]. Perspectives. [2000, February 1].

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