Community mental health resources, funds, staff, and expertise are limited and must compete with other

community needs. Within the mental health services themselves, consultation competes with direct services for

funding. How can and do community mental health agencies decide how to allocate their resources-and how

are those decisions handicapped or helped by the way funds are allocated?

mental health consultation programs:

priority setting and funding

beryce w. maclennan

Mental health consultation is a means for increasing the mental health resources in a community and the community’s capacity to understand, manage, and solve its mental health problems. Consultation may serve to: increase the communication between human service agencies; de- velop cooperative programs between community mental health and other human service agencies serving the mentally disturbed; increase the capacity of an agency to deal with the everyday mental health prob- lems of staff and clients; help business, institutions, and agencies im- prove the mental health climate of their organizations, and reduce stress and conflict in their operations. Consultations may provide a forum for problem solving; for training staff and administrators; and for increas- ing their capacity to communicate and to plan and develop programs.

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Consultation is used for all levels of prevention, but it is also the back-up for treatment undertaken by others. It is a critical component of an agency’s services for the treatment of the chronically ill in the com- munity, as well as for the maintenance of a mentally healthy population.

This chapter addresses the development of mental health consul- tation programs by health and mental health agencies. T h e methods that mental health agencies use in setting their priorities are examined and the resources for funding programs are explored. The agencies that are considered in this discussion generally have responsibility for the mental health of populations in specific geographic locations such as catchment areas, cities, or counties and include local government health and mental health departments, community hospital centers, mental health clinks, and formally incorporated community mental health centers (CMHCS).

Community mental health enthusiasts have been accused of grandiosity in attempting to include too many functions within their scope, and yet there are mental health (psychosocial and psychody- namic) dimensions to all human activities. Mental health problems are everywhere and mentally disturbed people are found in all walks of lie. TO improve their interpersonal effectiveness, city planners, business administrators, radio station managers, trucking operators, barmen, and beauticians have sought mental health consultation as well as policemen, jail wardens, school principals, nursing home operators, probation offi- cers, social service and child day care workers. There is no end to the indirect assistance which can be offered, accepted, and valued if mental health competencies and the means to fund services are available.

However, community mental health resources, funds, staff, and expertise are limited and compete with other community needs. Within the mental health services themselves, consultation competes with direct services for funds. How can and do community mental health agencies decide on how to allocate their resources-and how are these decisions handicapped or helped by the way funds are allocated?

needs assessment and priority setting

Two elements in setting consultation priorities today are the usc of needs assessments and the establishment of specific goals and strategies in relation to targeted populations. In addition, we must con- sider in the development of priorities whether and how consultations can be funded. While a needs assessment is required in order to obtain community mental health centers and other federal health service

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grants, all too frequently, their findings have been ignored; instead, consultation and education efforts have been developed as a result of ease of access or the special predilections of a particular mental health professional.

To obtain a staffing or operations grant, CMHCs are mandated by law (Public Law 94-63) to undertake a needs assessment and to base their program development on the findings. This usually includes a demo- graphic analysis; review of all available epidemiological data; and discus- sions of major needs with community planners and agency adminis- trators, citizens groups, and consumers of services. Existing resources and how they can be increased and adapted to meet identified needs must also be delineated.

As described in “The Practice of Mental Health Consultation’’ (Mannino and others, 1975), many centers develop a demographic pro- file of their area which shows the distribution of population across the area according to a number of factors-age, sex, socioeconomic status, ethnic and racial origin, transience, family composition. They examine where and how these subpopulations are living and how they are being served. This requires a knowledge of the geography and physical setting, the amenities of the subareas, and the human services that are provided. I t is necessary to know the extent to which the existing services are being used, how government, employers, and service agencies see their needs and problems, and to obtain an idea of the viewpoints of consumers and the general public.

Some centers have attempted formal citizen and consumer sur- veys. However, these are expensive and in poorer areas, where people are frequently less educated, they must involve face-to-face contact. Those who cannot read well will not respond to mail survey question- naires. It is easier, and probably at least as reliable, to attend meetings of organized groups and to take whatever opportunities are available to talk with users of services and with key neighborhood informants.

The demographic profile system (Rosen, 1974) may be helpful in identifying program defects. For instance, in one program providing patient education for low income mothers it was found that the majority of mothers in that census tract worked and were not able to attend any programs during the day. Parent education groups were then changed to the evenings.

To obtain a special consultation and education grant funded under Public Law 94-63 and its continuing legislation, the selection of target populations must be justified by a demonstrated high level of

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need and the strategies and goals of the program must be related to nature of the problems perceived and the spectrum of services ahead# provided.

or many existing resources. Some jail systems have their own psyc services; some schools a complete child guidance department. institutions may need no outside indirect service to assist trators, staff, and clients. Some communities have many el may in fact be well-to-do financially and served by privat family, or community support services. Another area may population of ex-institutionalized patients; or a high inci dalism or drug abuse; or many low-income, young, families where, almost unsupported, young women are strugg earn a living and bring up their children. Another area may neighborhoods rent by interethnic or interracial strife.

A major principle in setting priorities is to concentrate on t and on the method where the most can be achieved for the least Once a problem is identified there may be many ways of solving it instance, teenage vandalism may be the result of boredom. Many ad cents may be living in subdevelopments where recreational resources are minimal and where there is a lack of transportation to other areas. Tt may be the result of conflict between teenagers and their working ents because the former feel neglected. It may be that there is an in of strangers into the area; or a few youths, who are disturbed and in trouble, may be responsible. Before any intervention can be planned, the situation must be explored and analyzed with the participation of thr relevant actors, including the youth. Action will depend on the values o the community and the philosophy and skills of the center.

Taylor and others (1978), in attempting to determine how educators and mental health professionals could work well together, developed a school demographic profile instrument and q u e s t i o n n a h from which it was possible to identify how faculty and students assessed the strengths and weaknesses of their schools. In some situations, it WPg

possible to trace mental health and behavioral problems to frictions b tween students or staff or administrative mismanagement rather than individual psychopathology; thus it became possible to provide app p ia te consultation or training.

The Safe Schools Study Report to the Congress (National I n tute of Education, 1978) demonstrated the critical importance of the quality of school principals in creating an effective climate for learning

Needs vary greatly from place to place. There are places with

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and human development in the school. Mental health consultants can assist principals in understanding and dealing with the complex interre- lationships of their institutions. The impact can be great on both staff and students.

For example, a few years ago one community mental health center consultant staff met with the twelve elementary school principals (Quinn and Wagner, 1972) in the area at their monthly meeting to discuss their needs. Based on this experience, workshops were de- veloped in each school to focus on the management of different kinds of behavior problems experienced by principals and staff. These work- shops were also designed to train the principals to improve their capacity to counsel and supervise their staffs in these areas. Mismanagement of minor behavior problems may well lead to more serious and chronic mental health difficulties as children are distracted, fail to concentrate and learn, or are truant from the school. While consultation with indi- viduals or groups of teachers can be useful, if the principals can learn to assist their staffs in regular supervision, it adds additional skills to the community and reduces the need for the continuing involvement of mental health personnel.

integration of direct and indirect services for target populations

The trend today is to combine direct and indirect services that are directed toward a particular target population into a mutually support- ive system of care and treatment.

For instance, if a catchment area contains a large number of deinstitutionalized patients, a network of consultation connected to di- rect services needs to be developed. There will be a need to consult with and perhaps to provide training for those who house and care for these chronically handicapped individuals, such as nursing home staffs, group home and apartment house managers; for those who provide sheltered employment; for community support groups and for those who may have to deal with the occasional crisis; the police, welfare workers, clergy, hospital emergency room staff, and hot-line operators. While these are likely targets for consultation, ultimate selection can differ considerably. Some of these care givers may already be very competent in the man- agement of mental health problems and need no consultation. There may be reasons why others may be unwilling to accept a liaison. Some may already have their own paid consultations and liaison may be the most needed element; or the training of one or two key members coming

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together from each group may be the most economical method of achieving the desired goal. The concept of training trainers and super- visors may be helpful. A nursing home, run on mental health concepts, where supervisors train their own staff to manage day-to-day mental health problems of their emotionally and physically handicapped pa- tients, will require fewer direct mental health services. It will also be a happier place for patients and staff to live. It will be cost-effective for the community if mental health consultation and training are available to these supervisors.

A community’s most critical need may be to develop such profes- sional services. However, if a supportive community group can be formed through which capable volunteers or exconsumers may be able to move out, support each other, and substitute for professional com- munity care or crisis intervention, this may be even more effective and economical. Sometimes it may be most effective to locate and support key neighborhood residents with whom those in trouble normally con- sult. It has become clear, however, that without a system of community support services of which consultation and education form a part, p- tients cannot be kept out of the hospital (Turner and others, 1977). In deciding what service to provide and for whom, factors such as staff or volunteer turnover have to be taken into consideration. It is manifestIy extravagant to spend much staff time for the training of care givers W h o are planning to leave a program.

In planning to develop consultation and education services as part of an integrated program for any target group, it is important to ensure that the pieces fit together and that problems are well understood. Indi- viduals may be returning to the hospital because they do not know how to budget for inflation and cannot make ends meet; because there is r ~ )

transportation for low income patients to come for medication; or be- cause they feel so lonely that the hospital seems preferable to a dreary hotel room. Solutions for each of these problems are obviously different.

Not everything can be achieved at once, and a specific plan should be developed showing the steps needed to effect change. In some in- stances the frequency of consultations will be high initially and then may taper off, only to rise again when there is a turnover of supervisors or staff, or when new problems occur to upset the equilibrium.

It may be costly to prove that such efforts reduce the cost of day-to-day operations, but the recording of critical incidents and the need to return patients to hospitals can show the difference when nurs- ing staff are well or poorly trained in mental health concepts. This may

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well affect the availability of funding. In this age of accountability, legis- lators, state planners, agency administrators, and even the general public are requiring evidence that the services paid for are delivered and are effective.

alternative strategies and cost benefits

Although the evaluation of indirect services is still in a relatively primitive state, community mental health consultants and planners are becoming more sophisticated in examining and costing-out different strategies for dealing with the same problem.

For instance, there has recently been much concern about the high incidence of teenage pregnancy, which is costly in human misery and in money to individuals and communities, Financial costs can be estimated, such as: costs incurred because mothers drop out of school and require welfare support for themselves and their children; long- term projections of the costs related to the troubled careers of many unwanted children; and costs incurred because early pregnancy is asso- ciated with a high incidence of premature and low weight babies that need special care. Many different consultation and education strategies are being tried to prevent unwanted teenage pregnancy: through human relations and sex education in the schools; through neighbor- hood seminars; through media programs and articles in the press; through premarital counseling; and after the fact in pregnancy and well-baby public health clinics. Sometimes, girls are the target, some- times boys are included; sometimes the whole family or the parents are the ones advised. The cost of these efforts can be calculated. If we could show their differential effectiveness with this target group, we would be in a much better position to decide where consultations should be made available and we could justify the funding of these services. Unfortu- nately, very few attempts are made to compare either costs or results.

funding of consultation and education

Program development and problem solving consultation, staff development, continuing education, mental health education, and pub- lic information are all activities that are included under the term “consul- tation and education.” Several factors determine the extent to which they must be paid for by the community mental health service agency and the degree to which funds can be obtained from other sources.

Community mental health center and operations grants require a con- sultation and education component that will extend the communities* mental health knowledge and resources through working indirectly with other agencies and the general public.

Most centers have devoted only a small amount of their funds to indirect services and they decrease these amounts as federal funds di- minish (Naierman and others, 1977). However, the older centers that have qualified for the special consultation and education grants under Public Law 94-63 have shown a considerable increase in these services (Bass, 1978). This law provides for the funding of consultation and education programs through a complicated formula of per capita allow- ances and matching funds. It is designed not only to provide a w&- planned and well-organized distinct service but also to encourage centers to obtain reimbursement for their services. Unfortunately, only a s m d amount of money has been appropriated for these grants (National In- stitute of Mental Health Survey and Reports Branch, 1977).

Some states provide specific funds for consultation. For exampk, Colorado includes indirect services in its schedule of reimbursements and pays a specific fee for each consultation. Massachusetts now permits mental health clinics to retain third party funding to pay for consultation and education. The Harry Solomon Center in Lowell takes advantage Of this mechanism in providing the resources for a special consultation and education grant. The center also negotiates contracts with other human services and with industry and it delivers training and mental health education through seminars and workshops accredited by the l w d university.

The Lowell center's target groups are the deinstitutionalized, tk elderly, young children, and families in which violence occurs. con- sequently, many of its contracts are with centers for the elderly; nursing homes, foster homes, and housing for the elderly; and police and h* pita1 emergency centers through which consultation and training ar'6 provided.

Primary prevention related to young children is ptovidcd through its accredited college courses and through working with com- munity groups, day care centers, and through radio spots. Contracts with industry concentrate on the improvement of human relations at the work site.

Opportunities for paid consultation can be developed through the exploration of community needs and interests and by initially offer- ing free service. A few years ago a young psychiatrist (Bernstein and

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MacLennan, 1971) interested in having a say in radio and television programming obtained entry in the field by providing free administra- tive consultation. This led to the opportunity to influence programs and the chance to be paid for services rendered.

Some mental health facilities have been very successful in obtain- ing contracts for consultation or staff development from other human service agencies, from local governments, or from industry. A center in Nashville with a small staff of organizational psychologists developed a flourishing business in affecting the human relations climate at the work site of local firms. Other centers relating to industry have, as part of staff development programs, concentrated on sensitization of supervisors to the needs of workers, and still others have provided case consultation to assist managers and supervisors in coping with employees who have chronic or acute mental health problems.

Because of the recent development of requirements for profes- sional certification and licensing, mental health agencies have found it possible to charge for workshops, courses, institutes, and seminars that carry continuing education credit. Thus, they become attractive to social workers, teachers, health professionals, or are seen as providers of growth experiences for ministers, volunteers, court and correctional staffs. Under these circumstances individuals are willing to pay for their own training. Many human services agencies such as the schools and the police grant inservice credits, which are necessary for promotions for approved courses. Mental health agencies can take advantage of these requirements to arrange for their workshops, seminars, institutes, and even demonstration consultations to carry credit.

Mental health education to the general public can also sometimes be paid for when it is incorporated in school or college curriculums or when it is sponsored by citizen groups such as the Federation of PTAs, the Jaycees, day care associations, or alumni groups, although they are likely to expect that the mental health facility should provide speakers as a public service. If the facility has exceptionally talented staff, it may be possible to obtain payment for radio and television programs, or news- paper and magazine articles, although the most that can usually be ar- ranged is free time or space. Mental health services can also expand their programs by the use of talented professional volunteers.

It seems just as useful to encourage a consultee agency to employ an in-house mental health consultant as staff or on contract as to furnish a consultant from the mental health facility itself, so long as activities are well coordinated. Recently, federal emphasis has been placed on forming

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relationships between health and mental health systems and on increas- ing the knowledge and skill of primary care givers in diagnosing and treating mental health problems. Health centers are now encouraged to hire a mental health professional onto their staffs who can consult with and train primary health care givers to understand and manage mental health problems.

Health Maintenance Organizations (HMOs) are also a potential source of contracts for mental health services. The Genesee, New York HMO includes mental health care consultation to primary health a deliverers. This is provided for a fee by the Rochester Mental Health Center. The center also offers health and mental health education classes and birth control planning for members of the HMO.

In addition, some federal education and training funds are a d - able to incorporate courses and seminars on mental health theory and practice into the medical training of primary health care givers (National Institute of Mental Health, 1979).

funding affects priorities

I t is indisputable that the system for funding mental health ser- vice delivery affects priorities and the degree to which consultation and education and other preventive efforts can be provided. For instam, when, as in the Mental Health Study Center CMHC demonstration, a services were paid for through a budget for full-time staff, it was POSSibk

to decide to place primary emphasis on consultation and education with back-up direct services (MacLennan and others, 1970). However, if there are declining funds for staffing and reimbursements for direct service are on a fee-for-service basis, it is inevitable that primary em- phasis will be placed on treating patients even though this may be, in the long run, more expensive. Mental health agency staffs cannot afford to encourage other service care givers to manage mental health problems if there are no fees for consultation and education and if the only SOUKC

of revenue is the fee for direct treatment delivered by mental health professionals,

The Crozier-Chester Medical Center and Community Mental Health Center (Cobe, 1978), with 10 percent of its population over sixty Years of age, as part of a geriatric service grant, provides consultation and training to other care givers servicing the aged. It also provides mental health education, in regard to the mental health needs of the aged, to various support groups and to the general public. This typifies

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the trend to inclusion of indirect services in the total care package for a particular needy population. However, apart from this special grant, this center has not had much success in obtaining reimbursement for consul- tation and education. Much of the program’s efforts are expended in obtaining direct service referrals for which fees can be charged. Under the grant, the mental health consultants are paid anywhere from $1 1 for a bachelor of arts to $31 for a licensed physician for each consultation. Travel and indirect costs do not appear to be included in these figures.

The degree to which contracts with other agencies can be ob- tained depends on the resources that are available to them. In some rural areas, there are no resources. Medium-sited towns and suburban areas are often more fortunate in having funds that can be used in alternative ways. Some mental health facilities in inner cities and high poverty areas have been very successful in working with other agencies to develop special grant programs. These may be funded under Title XX of the Social Security Act, the Law Enforcement Assistance Adminis- tration, the Department of Housing and Urban Development, the La- bor Department, or Public Law 94-142, for instance. Recent trends to require the spectrum of substance abuse programs and services to pre- vent and treat family violence have created other alternative sources of funding.

In order to obtain contracts and fees, consultants must be recog- nized as expert and useful. If they are not, other organizations are neither willing to pay nor to waste the time of their staffs. Sometimes, one has to demonstrate capacity before a formal contract is arranged. In order to be paid for one’s services, someone has to have money. Unless the money comes to the facility for this purpose from government, pro- gram priorities will determine the availability of funds. An area with very few services and little money will normally not feel able to pay for consul- tation or staff development. Under Public Law 94-63, the more reim- bursement a center can obtain the more federal funds can be granted. These formulas, designed to stimulate nongovernment support, tend to favor high resource over low resource catchment areas, even though allowance may be made for poverty.

the cost of consultation

The costs of consultation or training provided other human ser- vices include not only the consultant’s time, travel, and agency support services, but also the time that the consultees give to the program. Con-

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sequently, even “free” consultation has a cost to the consultee. Mental health facilities cost-out their consultations in different ways and there is presently no uniform system. Those facilities that use a management information system which logs actual time spent by consultants and others are in the best position to cost-out their program (Mannino and Macknnan, 1978). They usually include not only the salary of the C o n -

sultant and his or her travel time but also some estimation of the cost of development and general overhead. Other facilities appear to make arbitrary charge, either a flat fee or some differential fee based on thc qualifications of consultants. For instance, one CMHC charges a blanket $150 a day; another $57 an hour; another $30 for a psychiatrist, $20 f* a psychologist, and $10 for a master of social work or master of afis psychologist.

Some mental health agencies appear to charge what the market will bear and may differentiate between contracts to government agen- cies and private industry. Private mental health consultants generay follow this system.

There is little or no attempt at cost-benefit analysis of the differ- ent strategies and approaches in the delivery of consultation, or between consultation and direct services; neither is there any consideration Of

what costs should go into such an analysis. For example, it is possible that the cost of direct treatment of emotionally troubled children and the cost of training teachers to manage such children in the classroom throu POUP consultation (including the teacher’s time) could be very simi! However, how does one assess the benefit of improved teachers’ sk which may carry over and prevent the development of problems in many other children? Some of these evaluation issues will be discussed in Chapter Eight,

summary

This chapter discussed the importance of needs assessment and the setting of priorities in the development of community mental he* consultation programs. Some needs assessment methods and examphi of priority setting were presented.

Present day opportunities and methods for funding consultation and education services include federal and state grants, fee-for-service reimbursements, contracts, accreditation of training and education, a d the development of special demonstrations. Methods for costing-out consultation were noted briefly. Consultation is never free for the con-

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sultee and, consequently, consultants must demonstrate their usefulness if they expect to be accepted and paid.

Trends in consultation today include: the integration of consulta- tion and education services into total service programs for special popu- lations such as the young, the old, or the deinstitutionalized, or in rela- tion to specific problems such as drug abuse or family violence; support from the federal government for closer integration of health and mental health services and for mental health consultation and training to pri- mary care givers; and in some states systematic funding of consultation.

A major lack is the absence of any significant effort to assess the cost-benefit and cost-effectiveness of alternative strategies for ser- vice delivery. Consequently, there is no realistic foundation for priority setting.

references

Bass, R. D. Consullation and Education Smices in Federally Funded Communit)l Men- tal Health Centers. Statistical Note No. 108. Washington, D.C.: Division of Biometry, National Institute of Mental Health, Statistical Note No, 108, Sep- tember 1974; Statistical Note No. 147, March 1978.

Bernstein, S. B., and MacLennan, B. W. “Community Psychiatry with the Com- munications Media.” American Journal Of PsychiatT, 1971, 128, 722-727.

C o b , G. M. ‘‘Program Planning Through a Goal Identification Model for a Geriatric Service in a Community Mental Health Center.” Paper presented at annual meeting of the National Council of Community Mental Health Cen- ters, Kansas City, Missouri, 1978.

Macknnan, B. W., and others. The Analysis and Evaluation of the Consultation Component in a community Mental Health Center. Lab Paper No. 36. Adelphi, Md.: Mental Health Study Center, 1970.

Mannino, F. V., and MacLennan, B. W. Monitoring and Evaluating Mental Health Consultation and Education Smi te s . Pub. No. (ADM) 77-550. Washington, D.C.: U.S. Department of Health, Education, and Welfare, 1978.

Mannino, E V., MacLennan, B. W., and Shore, M. The Practice Of Mental Health Consultation. New York: Gardner Press.

Meharry Community Mental Health Center. Goals and Objectives 1978-79. Nashville, Tenn.: Meharry University, 1978.

Naierman, N., and others. Community Mental Health Center-A Decade Later. Cambridge, Mass.: Abt Associates, 1977.

National Institute of Education. Violent SchooLr and Safe Schools: The Safe Schools Study Report to the Congress. Vd. 1. Washington, D.C.: National Institute of Education, 1978.

National Institute of Mental Health, Division of Manpower and Training. Annual Plan. Rockville, Md.: National Institute of Mental Health, 1979.

National Institute of Mental Health, Survey and Reports Branch. Data on Feder- ally Funded Community Mental Health Centers 1975-76. Rockville, Md.: National Institute of Mental Health, 1977.

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Quinn, R., and Wagner, L. M. Mental Health and Learning. Pub. No. (HSM) 72-9146. Washington, D.C.: U.S. Department of Health, Education, and Wel- fare, 1972.

Rosen, B. M. A Model for Estimating Mental Health Needs Using I970 C w Socioeconomic Data. Pub. No. (ADM) 74-63. Washington, D.C.: U.S. &pat- ment of Health, Education, and Welfare, 1977.

Taylor, E. N., and others. Procedures for Sumeying School Problems. Alexandria, Va.: Human Resources Research Organization, 1974.

Turner, J. E., and others. The Community Support Program: A Dr(tft pr+.d Rockville, Md.: National Institute of Mental Health, 1977.

Beryce u! MacLenmn is a clinical and community psychologist who has had a long-term interest in the development o f indirect services for the prevention and treatment o f mental health problem. A t present, she is assistant director o f and senior mental health adviser to the US. General Accounting Office, whme she provides technical assistance to audit divisions and consults on mental health policy. She is also k n o m as a specialist and consultant on youth employment, group psychotherapy with children and youth, and intergroup relations and the reduction of prejudice.