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

描述（由申请人提供）：新墨西哥州将于2005年7月在为低收入人群提供有管理的精神卫生服务方面实施一项重大改革。17个州机构将与一个单一的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。这一改革旨在减少行政费用和服务分散，同时改善获得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，令人担忧的是，有管理的精神卫生保健计划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检查：（1）在农村和多民族国家引入改革的过程和（2）改革在多大程度上改善了公共精神卫生计划和其他安全网机构中低收入严重精神病（SMI）患者的护理机会和质量。 这项纵向研究有三个具体目标：（1）检查美国印第安人，西班牙裔和白色SMI患者寻求帮助行为，获得和利用服务的变化及其社会支持（例如，在改革之前、期间和之后，在三个农村和三个城市的环境中，(2)调查在改革之前、期间和之后，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策略将在两组研究中采用定性和定量方法，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人种学访谈和观察与SMI患者和一线服务提供者，将描述精神卫生保健利用和提供者的行为模式的变化。这些研究将在三个农村县和三个比较城市县进行。第二组，包括与国家政策制定者的民族志访谈和农村和城市安全网机构的临床主任的结构化调查，将确定在全州范围内为SMI提供服务的变化。后一个全州范围的组成部分将促进社区一级人种学数据与更广泛的系统变革的联系。 拟议的对新墨西哥州改革的民族志评估将提供新的实用知识，这些知识以不同利益相关者的实际经验为基础，可能会改善该州针对农村和少数族裔重度精神障碍人群的心理健康政策。我们将与新墨西哥州合作，评估改革是否减少了 这些服务不足的群体得到的照顾，以及它如何影响安全网机构提供的现有服务的可行性。 这项研究将填补全州公共卫生保健举措评估研究的空白，这些举措通常不关注患者寻求帮助的行为以及农村，种族和少数民族所面临的独特访问和利用问题。由于农村各州可能会转向新墨西哥州改革作为一种模式，以减少行政成本和服务碎片化，并增加获得SMI，这项研究是非常重要的国家相关性。

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.