California MHS Act: Impact on Practice & Organizational Culture in Public Clinics

描述(申请人提供)：这个项目将分析加州精神卫生服务法案(MHSA)带来的精神卫生保健方面的变化，重点是实现变化的机制及其对客户结果的影响。MHSA通过对个人收入超过100万美元额外征收1%的税，大大增加了对加州精神卫生保健的支持，目前每年为公共精神卫生保健创造了7亿美元的额外收入。MHSA要求各县只将MHSA资金用于基于“康复”理念的项目和干预，MHSA有可能从根本上改变加州的精神卫生保健系统。我们与洛杉矶县精神卫生局(LAC DMH)合作，建议评估MHSA对美国人口最多的县洛杉矶的服务提供和客户结果的影响。我们的首要目标是了解MHSA对客户有什么影响，以及为什么会出现观察到的影响。我们聚集了一支由精神病学家、精神卫生服务研究人员、一名经验丰富的公共精神卫生管理人员、一名历史学家、一名社会学家和一名人类学家组成的多学科团队。我们的具体目标是：1)在县一级，评估LAC DMH如何随着时间的推移制定和实施MHSA临床政策；2)在临床层面，评估诊所如何实施LAC DMH对MHSA的解释，以及这种实施如何改变临床文化、结构以及提供者对疾病和治疗的理解；以及3)在客户层面，评估当地临床转型对客户的客观结果和主观治疗体验的影响。我们采用纵向设计来评估两个接受MHSA资助的诊所和两个没有接受资助的诊所在MHSA实施的头三年中的变化。方法包括客户(n=480-640)和提供者(n=377)自我管理调查；对LAC DMH管理人(n=28)、提供者(n=50)和客户(n=50)的定性访谈；临床互动录音(n=20对)；人种学观察；文件分析；以及对LAC DMH数据库的分析。内容提要：《加州精神卫生服务法案》(MHSA)将“康复”的概念置于严重精神病患者(SMI)治疗的前沿，从而从根本上改变了公共精神卫生保健系统。本项目的目的是研究MHSA在三年期间对SMI客户的影响和他们的治疗。通过研究MHSA，我们希望提供一个全面和有启发性的例子，说明当一项可能影响数千名患者的新政策被强加给公共精神卫生保健系统时会发生什么，目的是改善护理。

DESCRIPTION (provided by applicant): This project will analyze the changes in mental health care brought about by the California Mental Health Services Act (MHSA), focusing on the mechanisms by which change is achieved and the impact on client outcomes. The MHSA significantly increases support for mental health care in California via an additional 1% tax on personal income above $1 million, currently generating $700 million in additional yearly revenue for public mental health care. Mandating that counties use MHSA funds only for programs and interventions based on a philosophy of "recovery," the MHSA has the potential to radically transform the mental health care system in California. In collaboration with Los Angeles County Department of Mental Health (LAC DMH), we propose to assess the impact of MHSA on service provision and client outcomes in Los Angeles, the country's most populous county. Our overarching goal is to understand both what effects the MHSA has on clients and why the observed effects occurred. We have gathered a multidisciplinary team of psychiatrists, mental health services researchers, an experienced public mental health administrator, an historian, a sociologist, and an anthropologist. Our specific aims are: 1) at the county level, to assess how LAC DMH develops and implements MHSA clinical policy over time; 2) at the clinic level, to assess how clinics implement LAC DMH's interpretation of the MHSA, and how this implementation transforms clinical culture, structure, and providers' understandings of illness and treatment; and 3) at the client level, to assess the impact of local clinical transformations on clients' objective outcomes and subjective treatment experiences. We employ a longitudinal design to assess change in the first three years of MHSA implementation in two clinics receiving MHSA funding and two not receiving funding. Methods include client (n=480-640) and provider (n=377) self-administered surveys; qualitative interviews of LAC DMH administrators (n=28), providers (n=50), and clients (n=50); audio-taped clinical interactions (n=20 dyads); ethnographic observation; document analysis; and analysis of the LAC DMH database. LAY SUMMARY: The California Mental Health Services Act (MHSA) represents an effort to radically transform the public mental health care system by putting the concept of "recovery" at the forefront of treatment for the severely mentally ill (SMI). The purpose of this project is to study the impact of the MHSA on SMI clients and their treatment over the course of three years. By studying the MHSA, we hope to provide a comprehensive and instructive example of what happens when a new policy, potentially affecting thousands of patients, is imposed upon a public mental healthcare system with the goal of improved care.