Community Mental Health Centers and the Decreasing Use of State Mental Hospitals Charles Windle, Ph.D.* Diana Scully, M.S.W.
ABSTRACT: To test the success of the Community Mental Health Centers Program goal of reducing state hospital utilization, changes in state mental hospital resident and admission rates were calculated, using 16 states, for counties wholly within or outside of catchment areas served by operating, federally funded community mental health centers. There was no consistent relationship between the opening of centers and changes in state hospital resident rates. However, counties with centers tended to decrease more (or increase less) in state hospital admission rates than areas without centers.
In 1963 President Kennedy proposed a broad new program including community mental health centers. He said, "It will be possible within a decade or two to reduce the number of patients now under custodial care by 50% or more." Expectations of impact on state hospital admission rates were less clear, because prevention and case finding would have opposite effects. A decade has passed, and the number of state hospital resident patients has decreased 42%. This decline is consistent with the hopes for the Community Mental Health Centers Program, but it is not clear what role centers played as distinct from other factors. METHOD Each state was requested for longitudinal data, by county, on residents in and admissions to state mental hospitals. Sixteen states provided such data for at least 5 years. Counties were classified according to when (and if) they were within the catchment areas of operating, federally funded centers. For each state, state mental hospital resident and admission rates were calculated each year for counties differing by the year the center opened. The study design is what Campbell (1969) calls the nonequivalent controlgroup design in which several natural groups are compared longitudinally. The use of whole county data supplied by states avoids self-selection by centers. However, use of only areas in which entire counties are within catchment areas excludes highly urbanized areas. These results apply mainly to more rural areas.
*Dr. Windle is Program Evaluation SpecialisL National Institute of Mental Health, 5600 Fishers Lane, Rockville, Maryland 20852. Ms. Scully is in the Office of Legislative Assistance, State House, Augusta, Maine. A version of this paper was presented at the American Psychological Association Convention in Montreal, Canada, August, 1973. This study was supported in part by a contract from the National hzstitute of Mental Health (NIMH) to the junior author. The authors are indebted to state statisticians for data, and Carl Taube and Hans Schapire, NIMH, for advice. Community Mental Health Journal, Vol. 12(3), 1976
239
240
Community
Mental
Health
Journal
RESULTS
Resident Rates The procedure described above produced sets of curves. The results for the state with the largest population in counties wholly within catchment areas are s h o w n in Figure 1. There does not seem to be a striking or consistent difference between counties with or without centers, nor are fluctuations in curves clearly or consistently associated with w h e n centers opened. For another large state there are irregularities within curves, which w o u l d suggest an increase in the resident rate a couple of years after centers opened; but for other states the curves suggested the reverse. To get summary statistics we made several syntheses. The first was to count the number of states for which certain types of differences between counties with or without operating centers occurred in (a) over-all amount of change in resident rates, (b) percent change in resident rates, and (c) association between fluctuations in curves and w h e n centers opened. This summary, which weights states equally even though they differ in population, showed little difference in most comparisons for most states. Where differences did appear, they approximately balanced each other out. The second approach was to standardize the times being compared to FIGURE 1 Residents in State Mental Hospitals: Pennsylvania 350 Counties w/CMHC - ~ opening in 1968
300 Counties w/CMHC . ~ ' - ~ opening in 1970 ~ "
8"
"~'.~. "~.
250
".-._..-:....
.....
Counties w/no CMHCs "
~
~'~,~
H
..............
"
......
--. _
gr 200 ~
C
openingin 1966
~
"~'..%
"'--.~.
""i,.
",i,..
150
100 '64
I
I
I
I
I
I
I
'65
'66
'67
'68
'69
'70
'71
"When CMHCs opened
Charles Windle and Diana Scully
241
the year prior to the center's opening and 2, 3, 4, or 5 years later. Comparison statistics were based on changes during the same time periods for the counties with no operating center by 1971. The percent of states in which there was more decline in center areas than noncenter areas is shown in Table 1 for various criterion measures. There was no large preponderance of greater declines for either counties with or counties without centers. Insofar as there was any tendency, both amounts and percents of decline in resident rate appeared less often to be larger where there were centers. A third approach was to aggregate the data from all states to obtain total statistics. This, too, revealed no appreciable difference for either the aggregate rate or an average rate. Admission Rates We made similar analyses for admissions data. These were less clearcut. In the longitudinal examination of individual states most states showed no clear differences. In comparisons across the standardized times before and after centers opened, aggregate statistics showed slightly less increase in admission rates for areas with centers than for areas without, but the differences were not reliable statistically. The comparisons from groups of counties in each state with centers opening in a particular year reveal more instances for larger decreases (or smaller increases) to occur in areas with centers (Table 1). This difference is statistically significant. Thus although there seems no impact of centers on reduction in resident rates, there may be a tendency for centers to lower state hospital admission rates. Since centers have a community orientation, it is reasonable that they would have more impact on the flow of persons from the community to the hospital than on the flow of hospital patients to the community.
DISCUSSION The present study is but one part of NIMH's evaluation of the Community Mental Health Centers Program (Feldman & Windle, 1973). To be properly understood these results should be put in the context of all other evaluations. Most of the other evaluation studies found that centers were making progress in the program's various service process goals, although none of these goals has been completely achieved (Windle, Bass, & Taube, 1974). Further, the reduction of state hospital utilization is a gross program goal that needs increasing refinement as the population of state hospitals declines (Taube, 1974) and state hospital services improve (Taube, 1970). In addition, this paper has examined only a single mechanism for achieving the Community Mental Health Centers Program goals, the existence of federally funded centers. The centers program is broader than individual centers; it includes wide-spread education in new
242
Community Mental Health Journal
TABLE 1 Percent of States with Greater Decrease (or Less Increase)from I Year Before to Various Times After Centers Opened (for Areas with Centers Compared to Areas Without Centers) Two years Three years Four years Five years after c e n after cen- after cen- after centers opened ters opened ters opened ters opened Amount of decrease in resident rate
47%
44%
38%
25%
Percent of decrease in resident rate
59
44
38
31
Amount of decrease in admission rate
69
78*
69
81
Percent of decrease in admission rate
62
78*
69
94*
16
16
12-13
8
Number of States
* P
ABSTRACT: To test the success of the Community Mental Health Centers Program goal of reducing state hospital utilization, changes in state mental hospital resident and admission rates were calculated, using 16 states, for counties wholly within or outside of catchment areas served by operating, federally funded community mental health centers. There was no consistent relationship between the opening of centers and changes in state hospital resident rates. However, counties with centers tended to decrease more (or increase less) in state hospital admission rates than areas without centers.
In 1963 President Kennedy proposed a broad new program including community mental health centers. He said, "It will be possible within a decade or two to reduce the number of patients now under custodial care by 50% or more." Expectations of impact on state hospital admission rates were less clear, because prevention and case finding would have opposite effects. A decade has passed, and the number of state hospital resident patients has decreased 42%. This decline is consistent with the hopes for the Community Mental Health Centers Program, but it is not clear what role centers played as distinct from other factors. METHOD Each state was requested for longitudinal data, by county, on residents in and admissions to state mental hospitals. Sixteen states provided such data for at least 5 years. Counties were classified according to when (and if) they were within the catchment areas of operating, federally funded centers. For each state, state mental hospital resident and admission rates were calculated each year for counties differing by the year the center opened. The study design is what Campbell (1969) calls the nonequivalent controlgroup design in which several natural groups are compared longitudinally. The use of whole county data supplied by states avoids self-selection by centers. However, use of only areas in which entire counties are within catchment areas excludes highly urbanized areas. These results apply mainly to more rural areas.
*Dr. Windle is Program Evaluation SpecialisL National Institute of Mental Health, 5600 Fishers Lane, Rockville, Maryland 20852. Ms. Scully is in the Office of Legislative Assistance, State House, Augusta, Maine. A version of this paper was presented at the American Psychological Association Convention in Montreal, Canada, August, 1973. This study was supported in part by a contract from the National hzstitute of Mental Health (NIMH) to the junior author. The authors are indebted to state statisticians for data, and Carl Taube and Hans Schapire, NIMH, for advice. Community Mental Health Journal, Vol. 12(3), 1976
239
240
Community
Mental
Health
Journal
RESULTS
Resident Rates The procedure described above produced sets of curves. The results for the state with the largest population in counties wholly within catchment areas are s h o w n in Figure 1. There does not seem to be a striking or consistent difference between counties with or without centers, nor are fluctuations in curves clearly or consistently associated with w h e n centers opened. For another large state there are irregularities within curves, which w o u l d suggest an increase in the resident rate a couple of years after centers opened; but for other states the curves suggested the reverse. To get summary statistics we made several syntheses. The first was to count the number of states for which certain types of differences between counties with or without operating centers occurred in (a) over-all amount of change in resident rates, (b) percent change in resident rates, and (c) association between fluctuations in curves and w h e n centers opened. This summary, which weights states equally even though they differ in population, showed little difference in most comparisons for most states. Where differences did appear, they approximately balanced each other out. The second approach was to standardize the times being compared to FIGURE 1 Residents in State Mental Hospitals: Pennsylvania 350 Counties w/CMHC - ~ opening in 1968
300 Counties w/CMHC . ~ ' - ~ opening in 1970 ~ "
8"
"~'.~. "~.
250
".-._..-:....
.....
Counties w/no CMHCs "
~
~'~,~
H
..............
"
......
--. _
gr 200 ~
C
openingin 1966
~
"~'..%
"'--.~.
""i,.
",i,..
150
100 '64
I
I
I
I
I
I
I
'65
'66
'67
'68
'69
'70
'71
"When CMHCs opened
Charles Windle and Diana Scully
241
the year prior to the center's opening and 2, 3, 4, or 5 years later. Comparison statistics were based on changes during the same time periods for the counties with no operating center by 1971. The percent of states in which there was more decline in center areas than noncenter areas is shown in Table 1 for various criterion measures. There was no large preponderance of greater declines for either counties with or counties without centers. Insofar as there was any tendency, both amounts and percents of decline in resident rate appeared less often to be larger where there were centers. A third approach was to aggregate the data from all states to obtain total statistics. This, too, revealed no appreciable difference for either the aggregate rate or an average rate. Admission Rates We made similar analyses for admissions data. These were less clearcut. In the longitudinal examination of individual states most states showed no clear differences. In comparisons across the standardized times before and after centers opened, aggregate statistics showed slightly less increase in admission rates for areas with centers than for areas without, but the differences were not reliable statistically. The comparisons from groups of counties in each state with centers opening in a particular year reveal more instances for larger decreases (or smaller increases) to occur in areas with centers (Table 1). This difference is statistically significant. Thus although there seems no impact of centers on reduction in resident rates, there may be a tendency for centers to lower state hospital admission rates. Since centers have a community orientation, it is reasonable that they would have more impact on the flow of persons from the community to the hospital than on the flow of hospital patients to the community.
DISCUSSION The present study is but one part of NIMH's evaluation of the Community Mental Health Centers Program (Feldman & Windle, 1973). To be properly understood these results should be put in the context of all other evaluations. Most of the other evaluation studies found that centers were making progress in the program's various service process goals, although none of these goals has been completely achieved (Windle, Bass, & Taube, 1974). Further, the reduction of state hospital utilization is a gross program goal that needs increasing refinement as the population of state hospitals declines (Taube, 1974) and state hospital services improve (Taube, 1970). In addition, this paper has examined only a single mechanism for achieving the Community Mental Health Centers Program goals, the existence of federally funded centers. The centers program is broader than individual centers; it includes wide-spread education in new
242
Community Mental Health Journal
TABLE 1 Percent of States with Greater Decrease (or Less Increase)from I Year Before to Various Times After Centers Opened (for Areas with Centers Compared to Areas Without Centers) Two years Three years Four years Five years after c e n after cen- after cen- after centers opened ters opened ters opened ters opened Amount of decrease in resident rate
47%
44%
38%
25%
Percent of decrease in resident rate
59
44
38
31
Amount of decrease in admission rate
69
78*
69
81
Percent of decrease in admission rate
62
78*
69
94*
16
16
12-13
8
Number of States
* P
