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

描述(申请人提供)：新墨西哥州将于2005年7月在低收入人口管理精神健康服务提供方面实施重大改革。17个州的机构将与一个行为健康组织签订合同，监督所有公共精神健康服务的提供。这项改革旨在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，有管理的精神卫生保健项目可能会对弱势群体的获得和服务产生不利影响，并可能给农村安全网机构带来过重的负担。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审查：(1)在农村和多民族国家引入改革的过程，以及(2)改革在多大程度上改善了低收入严重精神病患者(SMI)在公共精神卫生计划和其他安全网机构中的护理机会和护理质量。这项纵向研究有三个具体目标：(1)考察美国印第安人、西班牙裔和白人SMI患者在改革前、改革期间和改革后的求助行为、获得和利用服务的变化以及他们的社会支持(如家庭和亲密同伴)。(2)调查改革前、改革中和改革后目标环境下一线服务提供者和安全网机构工作人员的工作环境、态度和行为的变化。(3)评估改革对目标环境和全州范围内安全网机构的组织和财务状况的影响。我们的多方法民族志研究战略将在改革实施之前和之后进行的两组研究中使用定性和定量方法。第一组包括行政数据库审查和对SMI患者和一线服务提供者的人种学访谈和观察，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的城市县进行。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的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。后一项全州范围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制度变革联系起来。拟议的新墨西哥州改革的民族志评估将提供基于不同利益相关者的实际经验的新的实用知识，这可能会改善农村和少数族裔SMI人群的国家心理健康政策。我们将与新墨西哥州合作，评估改革是否减少了 对这些服务不足的群体的关爱，以及它如何影响安全网机构提供的现有服务的生存能力。这项研究将填补在全州范围内对公共医疗保健倡议进行评估的研究空白，这些评估通常不关注患者的求助行为，以及农村、种族和少数民族面临的独特获取和利用问题。由于农村州可能会将新墨西哥州的改革作为降低行政成本和服务碎片化的模式，并增加SMI的准入，因此这项研究具有重大的全国意义。

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.