Multi-Method Ethnographic Assessment of Behavioral Health Reform in New Mexico

描述（由申请人提供）：2005年7月，新墨西哥州将在向低收入人群提供有管理的心理健康服务方面实施一项重大改革。17个州机构将与一个行为健康组织签订合同，监督所有公共心理健康服务的提供。这一改革的目的是减少行政成本和服务碎片化，同时改善获得与文化相关的循证精神卫生服务的机会，特别是在农村地区。然而，人们仍然担心，管理精神卫生保健项目可能会对弱势群体的获取和服务产生不利影响，并可能给农村安全网机构带来过度负担。本申请中提出的为期5年的R01研究项目将使用多方法人种学方法来检验：(1)在农村和多民族国家引入改革的过程；(2)改革在多大程度上改善了公共心理健康项目和其他安全网机构中低收入严重精神疾病（SMI）患者的护理机会和质量。这项纵向研究有三个具体目的：(1)调查在改革前、改革期间和改革后，三个农村和三个城市环境中，美国印第安人、西班牙裔和白人重度精神障碍患者的求助行为、服务获取和利用以及他们的社会支持（如家庭和亲密同伴）的变化。(2)调查改革前、改革中、改革后目标地区社会保障机构一线服务人员和工作人员工作环境、态度和行为的变化。(3)评估改革对目标地区和全州社保机构的组织和财务状况的影响。我们的多方法人种学研究策略将在两组研究中采用定性和定量方法，分别在改革实施之前和之后进行。第一组，包括行政数据库审查和民族志访谈以及对重度精神障碍患者和一线服务提供者的观察，将描述精神卫生保健利用模式和提供者行为的变化。这些研究将在三个农村县和三个比较城市县进行。第二组，包括对州政策制定者的人种学访谈和对农村和城市安全网机构临床主任的结构化调查，将确定全州范围内SMI服务提供的变化。后者在全州范围内的组成部分将有助于将社区一级的人种学数据与更广泛的系统变化联系起来。拟议的新墨西哥州改革人种学评估将提供新的实用知识，以不同利益相关者的实际经验为基础，这可能会改善国家对农村和少数SMI人口的精神卫生政策。在与新墨西哥州的合作下，我们将评估改革是否减少了就业障碍

DESCRIPTION (provided by applicant): 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.