The Impact of Community Mental Health Centers on the Utilization of Services Haroutun M.
Babigian,
MD
. The impact of community mental health centers on the utilization of psychiatric services in Monroe County, New York, was evaluated by means of data from the Monroe County Psychiatric Case Register. The catchment areas that received centers served as their own controls. In addition, yearly utilization rates were compared for areas that obtained centers with those remaining centerless. Utilization rates increased markedly in catchment areas with centers, while the percentage of patients
at the Rochester Psychiatric Center decreased from all catchment areas. Community mental health centers increased the utilization rates of the poor, children, and young adults, while the treatment needs of patient subgroups such as alcoholics, drug addicts, and the elderly were last to be addressed. The data do not evaluate issues such as the character, quality, and effectiveness of care. (Arch Gen Psychiatry 34:385-394, 1977) seen
article is an attempt to assess the impact of mental health centers on the utilization of mental health services. Federally funded community mental health centers are required by law to provide comprehensive mental health services for the residents of a geographically defined area. Consequently, centers must provide psychiatric care not only to the educated and affluent but also to those for whom care traditionally has been minimal or nonexistent-the severely disturbed, the chronically ill, and the socioeconomically disadvantaged. Given the mandate to provide equity of service, modifica¬ tion in the utilization of mental health services ought to occur after the introduction of a community mental health
Thiscommunity
Accepted
for publication Nov 9, 1976. From the Department of Psychiatry, University of Rochester (NY) School of Medicine and Dentistry. Reprint requests to Department of Psychiatry, University of Rochester Medical Center, 300 Crittenden Blvd, Rochester, NY 14642 (Dr Babigian).
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responsible for a specific catchment area. Previous findings from studies in New Haven, Conn, have noted substantial differences between catchmented and noncatchmented areas in the delivery of psychiatric care. Catchmenting has been associated with a higher volume of care and greater accessibility,1 improved delivery of mental health care to disadvantaged groups,and more favorable clinical practices.' In spite of their apparent similarity, there is an important distinction between the New Haven studies and this one. In New Haven, the two groups being compared both had access to a community mental health center, the only difference being that one group was catchmented and the other was not. The present report focuses not so much on the impact of catchmenting on the use of mental health services as on the impact of the availability and accessibility of mental health centers themselves. This is a crucial difference for it limits the extent to which the findings from New Haven and Monroe County, New York, can be compared. As in the studies cited above, the problem of evaluation was approached quasiexperimentally. Two factors greatly facilitated this type of analysis: (1) the existence of the Monroe County Psychiatric Case Register, which provided comprehensive before-and-after data, and (2) the fact that community mental health centers were available for only two of the four catchment areas in Monroe County. This permitted the impact of community mental health centers to be demonstrated twice. In addition to the comparisons of utilization rates between catchment areas receiving centers and those remaining centerless, utilization rates from the same catchment area were also compared before and after the introduction of a community mental health center
center.
County, New York, where this evaluation project an excellent laboratory for research in of psychiatric epidemiology for several reasons.
Monroe was
the
undertaken, is area
First, its location and the attractiveness of its own mental health services ensures very little shopping for such services outside the county. Bounded by Lake Ontario to the north, Syracuse 70 miles away to the east, Buffalo 70 miles to the west, and Pittsburgh 300 miles to the south, the county is relatively isolated. Furthermore, the Buffalo and Syracuse areas do not offer psychiatric services that are unavailable locally and thus do not attract the Monroe County population. Second, the county population is quite stable. The location here of several major industries reduces the number of emigrants in search of employment elsewhere. Finally, the existence of the cumulative psychiatric case register makes it possible to compare baseline service utilization data from Jan 1, 1960, to Dec 31, 1966, during which time there were no community mental health centers, with comparable data obtained after the centers had been established. Located in the northwestern part of New York State, Monroe County is urban and has a 1970 population of approximately 712,000. Whites make up 92.1% of the population and blacks 7.3%. The majority of the black population live in the city of Rochester (population 296,000), which is located in the north central section of the county. Blacks comprise 16.8% of the city's population but only 0.6% of the county's. Rochester is surrounded by suburban areas encompassing a range of socioeconomic groups from lower middle to upper class. The county also has a significant rural community generally located at its
periphery.
The Monroe County Cumulative Psychiatric Case Register was initiated by the Department of Psychiatry of the University of Rochester School of Medicine and Dentistry on Jan 1, 1960. On that date, all patients under psychiatric care were registered. Since then, all individuals contacting public and private inpatient or outpatient psychiatric facilities have been registered regularly. The facilities reporting to the register include a university department of psychiatry with inpatient, emergency, and ambulatory services; the Rochester Psychiatric Center (formerly the Rochester State Hospital); three community mental health centers; an acute inpatient observation unit; the Veterans Administration Hospital and outpatient clinic; a children's treatment center; the Monroe County Mental Health Clinic for Sociolegal Services; and approxi¬ mately 80% of all psychiatrists in private practice. Facili¬ ties report patients cared for in their inpatient, outpatient, day treatment, and emergency services separately. Thus, an individual using different modalities of psychiatric care
within different facilities has multiple reports register, providing us with a picture of the utilization of services throughout the years. The register is described in greater detail by Gardner et al,4 Babigian,' and Liptzin and Babigian." within
one
facility
or
to the
MENTAL HEALTH SERVICES IN MONROE COUNTY
description of the mental health services in Monroe County and the nature of their responsibility for a speci¬ fied service region will now be presented. In interpreting the findings, it is essential to know whether a mental health facility has primary, sole, or no defined responsi¬ bility for serving the population of a particular catchment A
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area or
whether its services
are
available to the entire
community.
The Rochester Psychiatric Center (Formerly Rochester State Hospital).-The Rochester Psychiatric Center was preceded by the Monroe County Insane Asylum, which was established in 1864. With the creation of the New York State Department of Mental Hygiene in 1891, the state took over the operation of the asylum and converted it to a state hospital. Until the early 1900s, the hospital was physically located outside the city, away from the popu¬ lated areas. Gradually, as the community moved into the suburbs, the state hospital's location became central in the county and partially within the city's southern boundaries. The number of beds has gradually diminished from 3,000 in the 1960s to the current capacity of approximately 1,400. It has a 40-bed unit for children, a unit for adolescents, and a large unit for the treatment of alcoholics (which began in 1962 for men and in 1968 for women). Although the Rochester Psychiatric Center services six counties, over three fourths of its patient population is from Monroe County. In 1968, approximately half of the patient population was 65 years of age and older; this percentage has been decreasing gradually. The hospital
admits patients on an informal, voluntary, two-physician certification and health officer certification basis. The majority of admissions are readmissions to the hospital, transfers from acute psychiatric units, and patients referred from the psychiatric emergency service of Strong Memorial Hospital. Since 1970, the Rochester Psychiatric Center has been completely unitized. This unitization follows the catchment area delineation, with each unit serving a specific catch¬ ment area. In contrast, outpatient care is not uniformly available to all residents of Monroe County. While outpa¬ tient care for the uncovered catchment areas (C and D) is still provided by the Rochester Psychiatric Center, commu¬ nity mental health centers have gradually assumed respon¬ sibility for the outpatient care of catchment area residents discharged from the Psychiatric Center. The Monroe County Psychiatric Unit.-The Monroe County Infirmary has operated as an inpatient psychiatric service since 1906, when a special law was passed by the New York State legislature authorizing the unit to exercise involuntary detentions. This is a small unit having a capacity of 35 or 36 beds. The services provided can generally be described as emergency admission observa¬ tion and care. This unit provides services that are immedi¬ ately available to the city, county, and family courts. It has also developed, out of necessity, treatment facilities for alcoholics, drug abusers, the elderly, and those individuals who need involuntary admission. This service unit is open, to the
public
at
large.
The unit's staff was greatly strengthened when the Monroe County Board of Mental Health was founded in 1957. In 1966, the Monroe County Infirmary moved to new quarters designed so that men and women could be cared for in the same area. This combining of services enhanced the unit's effectiveness since it prevented beds specifically designated for men or women from going unused. Over the years, it has served as a triage, problem-solving, overflow catching, do-what-others-cannot-do-or-will-not-do type of
unit. On July 1, 1973, this unit was closed and converted into the inpatient unit of the Genesee Mental Health Center, serving catchment area C. The Monroe
County
Mental Health Clinic for
Sociolegal
Services.—This service was built on a one-man consultative service to the courts that emanated from the University of Rochester in the early 1930s. The clinic was formally organized in 1964 and occupies a suite of offices in the Hall of Justice in downtown Rochester. It serves multiple purposes, including the diagnostic study of accused offend¬ ers, consultative services to the courts and probation departments, education and training for probation officers, and treatment of individuals involved with viola¬ tions of the law. The clinic assists both adults and children; children are served in the Court Clinic by staff from the Rochester Child Guidance Clinic, DePaul Clinic, and Convalescent Hospital for Children. The clinic is jointly operated by the county and the University of Rochester Department of Psychiatry, and serves approximately 1,000 individuals per year from all four catchment areas of the
county. The DePaul Clinic of the Catholic Charities of the Diocese
of Rochester.—This facility was established largely through the efforts of the Monroe County Board of Mental Health in 1957. It had the specific mission of serving the parochial schools, which had not been able to use the existing child
guidance clinics. Although the DePaul Clinic is the smallest of the child guidance clinics available in Monroe County, its services are not restricted to any particular catchment area.
The Veterans Administration
Psychiatric Hospital
and
Clinic—The Veterans Administration Psychiatric Hospital is located 30 miles outside Rochester. Only Monroe County veterans admitted to this hospital are reported to the Psychiatric Case Register. In addition to the hospital, the Veterans Administration has a psychiatric clinic in down¬ town Rochester that provides ambulatory care and day treatment services. The services of this clinic have been available to the community for many years, but they have been limited by the usual eligibility requirements (mostly pertaining to service connection of the disability). Although the Veterans Administration Psychiatric Hospi¬ tal and Clinic have countywide responsibility for the psychiatric care of veterans, it is not the sole provider of such care, sharing this task with several other mental health facilities. The Alcoholism Treatment Center.-This facility, estab¬ lished in 1949, was always a small but important outpatient clinic for the treatment of alcoholics. It was absorbed into the Rochester Mental Health Center in 1967. The Rochester Child Guidance Clinic.-This clinic was founded in the mid-1930s and was supported for some time by funds from the Community Chest of Monroe County and the County of Monroe. This pattern of funding prevailed until the Board of Mental Health was founded in 1957, at which time there was a massive infusion of state aid. In 1967, the clinic was absorbed into the Rochester Mental Health Center. At this time, the clinic moved its facilities from downtown Rochester to the Rochester Mental Health Center, located in the northern section of the city.
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At the time of absorption, this clinic was the largest child guidance clinic in New York State outside of New York City. Because of the clinic's size, even after its incorpora¬
tion into the Rochester Mental Health Center, it continued assume responsibility for the care of children in three catchment areas (B, C, and D), its own and two others that were without services for children. Convalescent Hospital for Children.—This facility was established in 1958 as an inpatient psychiatric service for préadolescent children. It started with six beds, increased to 16 beds in 1960 and to 24 beds in 1962. Day treatment services for children began at the facility in 1963 and expanded progressively to a capacity of 30 children at any one time. An outpatient department for children was opened in 1953 and grew steadily until 1968 when it became a community mental health center serving the same catch¬ ment areas as the University of Rochester Mental Health Center. The Convalescent Hospital has always specialized in consultative services to community agencies, schools, settlement houses, day nurseries, and others.
to
The Department of Psychiatry, University of Rochester School of Medicine and Dentistry.—Prior to the estab¬
lishment of the Department of Psychiatry, the University Medical Center had a Division of Psychiatry under the Department of Medicine. The major interests of this division were primarily in the area of preventive mental hygiene. In 1927, the division opened a 16-bed unit for the care of mentally ill patients and began an outpatient clinic. The Department of Psychiatry was established in 1946. With the completion of its new building, wing R, in 1948, an additional inpatient floor with 35 beds was opened. In 1950, the original 16-bed floor was closed and a new 24-bed unit was opened. In 1958, another inpatient floor with 28 beds was opened in the new building, making a total of 87 beds available for psychiatric patients. In addition to these beds, 12 were provided for préadolescent children during the period between 1957 and 1963. Throughout the years, the department has operated a large outpatient department, which has carried from 1,200 to 2,000 patients at any one time. It also provides psychiatric emergency services in the general emergency department of the hospital. These services are available to the entire community. In 1968, the department developed and began operation of a community mental health center described later. The Rochester Community Mental Health Center and the University of Rochester Community Mental Health Center.— With the passage of the community mental health legisla¬ tion, planning began in 1965 to provide for the mental health needs of the county population. It was decided that four community mental health centers were required to provide total coverage of the county. The county was then divided into four catchment areas, each containing urban, suburban, and rural sections. Figure 1 presents a map of the county with the four catchment areas- , B, C, and D— and the location of the centers. Because only two of the centers were going to be immediately operational, most of the lower socioeconomic areas were included in their catchment areas (A and B).T According to the 1970 census, 56% of the level IV and 86% of the level V population were
30.0-
MONROE COUNTY, N.Y.
28.5-
27. o -
2
24.0-
Sc,
•A/
J
Fig 1.—Community mental health centers in Monroe County, New York. Catchment area A, population 180,196: A, University of Rochester Community Mental Health Center (began operation July 1, 1968); A', Convalescent Hospital for Children (began operation in 1968). Catchment area B, population 175,957: B, Rochester Mental Health Center (began operation Jan 2, 1967); catchment area C, population 146,963: C, Genesee Hospital Mental Health Center (began operation Jan 1, 1973); catchment area D, population 208,704: D, Park Ridge Hospital Community Mental Health Center (began operation In 1975). (Catchment area population figures are from 1970 census.) included in these two catchment areas. In 1967 and 1968, two community mental health centers were developed to serve approximately half the population of Monroe County, while the other half continued without the benefit of centers. The Rochester Mental Health Center, serving catchment area B, opened its doors to the public on Jan 2, 1967. Its services included an acute inpatient facility with 30 beds, a day hospital, adult ambulatory services, and walk-in services during working hours (the only preexisting service for adults absorbed into the center was the Alcoholism Clinic). In November 1969, the center began the operation of a psychiatric emergency service within the general hospital's emergency depart¬ ment during evening hours and weekends. The center's services for children and adolescents were provided by the Rochester Child Guidance Clinic. Later in 1967, a children's center, one of the two major components of the second comprehensive community mental health center, was opened at the Convalescent Hospital for Children in catch¬ ment area A. In 1968, the second component, the Univer¬ sity of Rochester Community Mental Health Center, was developed by the Department of Psychiatry of the Univer¬ sity of Rochester School of Medicine and Dentistry. Twenty-two beds were assigned to the community mental health center, and another 22 were designated as backup for its inpatient services. The new community mental health center developed its own day treatment program, ambulatory, consultation and education, and community organization services. As is evident from the above discussion, the delivery of
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1963 1964 1965 1966 1967 1968 1969 1970 1971
1972 1973
Fig 2.—Total psychiatric utilization rates for Monroe year and catchment area.
County by
mental health services to Monroe County residents was altered with the division of the county into catchment areas and the subsequent development in 1967 and 1968 of two community mental health centers. All existing psychiatric facilities were no longer available to all county residents, as had previously been the case. Instead, specific facilities were assigned the task of providing psychiatric care to specific geographic areas of the county. The Rochester Mental Health Center was given and the primary responsibility for catchment area University of Rochester Mental Health Center and the Convalescent Hospital for Children for catchment area A. It must be emphasized, however, that while these centers were primarily responsible for the mental health needs of their own catchment areas, no one was ever turned away for being a resident of another catchment area. However, patients were encouraged to utilize their own centers by all mental health services of the community. It should also be pointed out that except for the Rochester Child Guidance Clinic and the Alcoholism Clinic (which served areas B, C, and D), all remaining psychiatric facilities continued to provide services to the entire community.
appreciably
METHODS The community mental health centers being studied are (1) the Rochester Mental Health Center, serving catchment area B, which covers the northeastern segment of the county and city, and (2) the University of Rochester Community Mental Center and the Convalescent Hospital for Children, which together constitute a complete mental health center serving catchment area A. This catchment area covers the southern segment of the county and city. Catchment areas C and D in the eastern and western sections of the county are presented because they serve as natural controls since neither had an organized community mental health center. In 1973, however, a third community mental health center began operation in catchment area C. Data from Jan 1, 1960, to Dec 31, 1966, provide a baseline on the utilization of mental health care facilities in the community prior to the establishment of the first community mental health center on Jan 2, 1967. In those seven years, the only major psychiatric facility added in the community was the Monroe County Mental Health Clinic for Sociolegal Services in 1964. Although there were
47.0-
«3.039.0-
1963 196U 1965
1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973
Fig 3.—Rates for Monroe County by
new
patients entering psychiatric
care
for
year and catchment area.
1963 1964 1965 1966 1967 1968 1969 1970
1966
1967
1968 1969
1970 1971
4.—Total psychiatric utilization rates for Monroe year and socioeconomic level.
Fig
1963 1964 1965 1966 1967 1968 1969 1970 1971
1971 1972 1973
1972 1973
County by
1972 1973
65.0-
II 1963 1964
Fig
5.—Total
1965 1966 1967 1968 1969 1970 1971
psychiatric
utilization rates for Monroe
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1972 1973
County
catchment
II
1963 1964 1965 1966 1967 1968 1969 1970 1971 areas
1972 1973
A, B, C, and D by year and socioeconomic level.
8.5
__ 1963 1964 196S
1966 1967 1968 1969 1970 1971
Fig 6.—Total psychiatric utilization rates for Monroe year and age.
-L 1972 1973
County by
variations brought about within some of the facilities during seven years, in general we can assume that the availability, nature, and magnitude of services provided did not change much.
some
those
Demographic data from the Register were analyzed yearly for the years 1963 through 1973. Rates of utilization by catchment area, age, and socioeconomic level were the main variables used. Included in the calculation of utilization rate are new patients and all others who are treated in the county's mental health services in a particular calendar year. It should be emphasized that patients were counted only once in that year regardless of the number of psychiatric contacts they may have had. All graphs show catchment areas with the letters A, B, C, and D; represents the rate for the whole county. (The rates per 1,000 on the left side of each graft are not the same.) Rates are presented per 1,000 Monroe County population. Yearly population was established by linear interpolation of the 1960 and 1970 census data. RESULTS
Impact of Centers on Rates of Utilization Figure 2 presents total rates of utilization by year and catchment year. In 1963, utilization rates were lowest for The
and D and highest for A and C, the catchment areas areas richest in mental health services. In 1967, the Rochester Mental Health Center began serving catchment had the highest utilization rate area B, and by 1969 area of all four areas. The utilization rate for catchment area A, which also had a center (1968), surpassed that for area in 1972. In 1973, the rate for area A was 30.51, the highest recorded anytime since I960. Following the opening of the center in area A, the gap between utilization rates for catchment areas A and C appeared to widen, indicating more case detection and availability of services for area A. Utilization rates for catchment area D, which did not have a functioning center, lagged behind those for areas A, B, and C. Rates for new patients entering psychiatric care
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follow the same pattern as total utilization rates (Fig 3). Prior to 1967, all psychiatric facilities were concentrated in the southern part of the city and county in areas A and and D had no facilities whatsoever. The C. Areas of comparison areas and D is a crucial one since area began with a center in 1967 and area D continued as is. The operation of the center in area also affected rates in area D by increasing them since that center became the closest facility to most of area D. This indicates that location, proximity, and accessibility are crucial factors for utiliza¬ tion of services. Utilization Rates by Socioeconomic Level.—The register does not have any direct measures (such as income, occupa¬ tion, or education) of the individual's social or economic level. Instead, an indirect measure, the census tract in which an individual resides is used. Each census tract in Monroe County has been classified into one of five groups, from I (highest) to V (lowest), using a composite index combining median value of owned homes, median rental values, percentage of skilled, semiskilled, and unskilled workers, median years of education, and percentage of sound dwelling units, as determined by the 1960 census. The distribution of the 1960 Monroe County population among the five areas was as follows: area I, 12%; area II, 26%; area III, 43%; area IV, 14%; and area V, 5%. Figure 4 presents total utilizatior. rates by year and socioeconomic level for Monroe County. It is apparent that community mental health centers had a major impact on the poor population they were able to attract into service. In contrast to the siiglii increase in utilization rates for socioeconomic levels I, II, and III, rates for the two lower classes increased substantially after 1967, reaching their highest levels during the period from 1969 through 1971. Their decline in 1973 might indicate that once the initial need and emphasis on case detection is taken care of, it begins to decline. It may afeo mean that as time goes on, centers become less active and alert in case detection. Figure 5 presents total utilization rates by catchment area and socioeconomic level. As might be expected, catch¬ ment areas with community mental health centers (A and B) showed a continuous increase in rates for the two lower socioeconomic levels. This trend was most evident in catchment area A. Except for level V in area D, areas C and D continued with minimal increases. Surprisingly, socioec¬ onomic level IV in catchment area C, which had no community mental health center, showed the highest utilization rates throughout the years. Utilization Rates by Age.—Figure 6 presents total utiliza¬ tion rates by age and year for Monroe County. Of partic¬ ular note is the continuing increase since 1968 in rates for age groups 0 to 14, 15 to 24, and 25 to 34 and a continuous decline for those 65 years and over. Figure 7 presents total utilization rates for each age group by catchment area. It is obvious that utilization of services by children and young adults increased markedly, particularly for those areas with centers, and that utiliza¬ tion by the elderly decreased dramatically. The explanation for this decline, despite increases for other age groups, is that in 1968 the Department of Mental Hygiene instituted a new regulation making it more difficult for elderly individuals to be admitted to state hospitals for institu-
1963 1961 1965 1966 1967 1968 1969 1970 1971
1972 1973
1963 196k 1965 1966 1967 1968 1969 1970 1971 1972 1973
-I-1-1--k 1963 1961 1965 1966 1967 1968 1969 1970 1971 1972 1973 1963 1961 1965 1966 1967 1968 1969 1970 1971 1972 1973
1963
196U
1965 1966 1967
196B
1969 1970 1971 1972 1973 1963 196« 1965 1966 1967 1968 1969 1970 1971
1972 1973
1961 1965 1966 1967 196B 1969 1970 1971
1972 1973
Fig 7.—Total psychiatric utilization rates for each age group by catchment area and year.
1963
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2.6 9.5
2.5
2.4 -x
9.0 -
8.5
'ffl o
-
2.2 >
S
2.1 -
O
8
7.5
2.0 1.9
7.0
1.8
S 6.5
.
S
8.0
ce
1.7 6.0 1.6
1.5
-1-1-1-1-1-1-1-1-1_I 1963 1964 1965 1966 1967 1968 1969 1970 1971
8.—First lifetime year and catchment
Fig
hospitalization
rates for Monroe
1972 1973
County by
area.
5.5
4-
-I-
4-
4-
4-
1963 1964 1965 1966 1967 1968 1969 1970 1971
rates of and catchment area.
Fig 9.—Total
hospitalization
for Monroe
-L 1972 1973
County by
year
care unless they showed signs of mental illness. Community mental health centers did not pick up the lag, and elderly individuals apparently were not attracted to the centers even for diagnostic and evaluative purposes. Utilization rates for most age groups were generally
tional
lowest for area D, the catchment available psychiatric services. The
Impact of Centers
on
area
furthest away from
Hospitalization
Rates
Monroe County had quite a few inpatient facilities prior to the institution of centers—the Rochester Psychiatric Center with 2,400 beds; the University Hospital with 87 beds for the acutely ill; the Monroe County Hospital Psychiatric Unit with 35 beds for observation and detoxifi¬ cation of the acutely ill; and the Convalescent Hospital for Children with 24 beds for the long-term care of préadoles¬ cent children. In 1967, the Rochester Mental Health Center added 30 beds for acute inpatient care to the community and in 1968 the University of Rochester Community Mental Health Center added 20 beds. The Monroe County Hospital continued with 35 beds for inpatients until July 1, 1973, when it closed down. The same area was reopened as the inpatient unit of the Genesee Mental Health Center, serving catchment area C. First Lifetime Hospitalization Rates.-Figure 8 presents first lifetime hospitalization rates by catchment area. Despite the addition of 50 new beds for the acutely ill with the introduction of community mental health centers, first
admission rates dropped in Monroe County from a high of 2.48/1,000 in 1967 to a low of 1.93 in 1972, and 2.05 in 1973. In the early 1960s, catchment areas A and C had the highest rates since all the hospitals were located there. Hospitalization rates peaked in 1967 for catchment areas and C and in 1968 for area A. Since then, rates for areas A, B, and C dropped to around 2.00/1,000. In 1973, however, the rate for catchment area C increased to 2.56. These findings suggest that when new psychiatric facilities become available, there is an increase in first lifetime hospitalizations, but that once the initial demand for care
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1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 10.—Total rates of hospitalization for Monroe County by year Fig and socioeconomic level.
is met, rates decline. Catchment area D residents showed the lowest rates of hospitalization throughout, probably indicating underutilization of services. For area D resi¬ dents, the inaccessibility of community mental health centers may actually be beneficial since it reduces the likelihood of hospitalization. Total Rates of Hospitalization.-Total rates of hospitaliza¬ tion decreased for all areas after the establishment of community mental health centers (Fig 9). The highest rate for the county was 8.94/1,000 in 1967 and the lowest 7.28/ 1,000 in 1973. Areas A, B, and C, where mental health facilities were most available, showed the most precipitous decline, while that of area D was more gradual. What is most noteworthy, however, is that centers were able to increase the total utilization rates for psychiatric care in their catchment areas while keeping total rates of hospital¬ ization relatively stable. This means that the major
increase in total utilization centers
attracting
new
was
patients
brought about by the to their ambulatory
services.
Figure 10 presents total rates of hospitalization by year and socioeconomic level. Of special interest is the decline in rates for socioeconomic levels IV and V. This is probably because of the increased availability of ambulatory and other services. The
Impact of Centers
on
Catchment Areas A and
One way of assessing the impact of community mental health centers on their catchment areas is to look at the priority distribution of contacts for patients from catch¬ ment areas A and B. (Tables are available on request.) A priority contact means that if a patient is seen in any capacity at a center during the years 1963, 1966, and 1973, the patient is counted there regardless of other facilities contacted. For catchment area A, we found that in 1963 and 1966 only, 32.4% and 34.9% of patients were seen by the facilities that later became the center, while in 1973, 60.6% of patients were seen by center services. The same thing happened for area B. Between 1963 and 1973, patients treated at the Rochester Mental Health Center increased from 6.3% to 58.2%. During the same interval, patient contact with the Rochester Psychiatric Center declined by more than 20% for both catchment areas. In summary, the percentage of area A patients seen at the University of Rochester Community Mental Health Center and Convalescent Hospital for Children and the percentage of area patients seen at the Rochester Mental Center increased between 1966 and 1973. The Rochester Mental Health Center also saw an increased percentage of area C and D residents. There was no increase, however, in the percentage of area C and D residents treated at the University of Rochester Community Mental Health Center. While centers increased their own patient loads, the percentage of patients seen at the Rochester Psychiatric Center decreased not only from the catchment areas with centers but also from areas C and D, which had no
centers.
Impact of Centers on the Care of Special Groups The care of special groups such as drug addicts and alcoholics poses special problems for the health and mental health services of a community. It was hoped that with the establishment of community mental health centers, improved care could be provided to patients in these categories. The two groups will be discussed separately in this section. (Tables are available on request.) Drug Addicts (Heroin).—Prior to 1969, there were no special services provided within the mental health center facilities for the evaluation, detoxification, psychosocial, or rehabilitative care of the heroin addict. Not surprisingly, the rate of utilization was low—0.3/1,000 for the whole county. In 1969, the Rochester Mental Health Center initiated a program for the care of the addict, consisting of an ambulatory detoxification service backed by inpatient care for withdrawal, utilizing general psychiatric beds. As their program developed and became better known, the rates increased markedly as addicts went there for care. The total utilization rate in 1971 was 0.9/1,000. The experiThe
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of the Rochester Mental Health Center demonstrates that addicts seek care when it is available to them. Alcoholics.—Prior to the establishment of community mental health centers, the alcoholics of Monroe County had available to them inpatient detoxification facilities in the Monroe County Hospital. Some outpatient facilities were available, but these were limited. With the establishment of the Rochester Mental Health Center, the rate of utiliza¬ tion for catchment area alcoholics increased from 0.57/ 1,000 in 1967 to 1.56 in 1971. As alcoholism services were developed by the University of Rochester Community Mental Health Center, the utilization rate by catchment area A alcoholics served by this facility increased from 0.5/ 1,000 in 1967 to 1.65 in 1971. Both community mental health centers continued serving alcoholics in catchment areas C and D at a relatively steady rate. As the centers develop more and more programs for alcoholics, it is expected that utilization rates will continue to increase. enee
COMMENT
The impact of community mental health centers on the utilization of psychiatric services in Monroe County, New York, was evaluated with data from the Monroe County Psychiatric Case Register. The catchment areas that received centers served as their own controls. In addition, yearly utilization rates for areas that obtained centers were compared with those remaining centerless. Several conclusions can be made about the impact of these centers.
1. Even though Monroe County had a variety of psychiatric services prior to the establishment of commu¬ nity mental health centers and these services continued following the opening of these centers, it is obvious that community mental health centers are conducive to
increased utilization of mental health facilities. Centers markedly increased the rates of utilization for their catch¬ ment areas both by attracting new patients and providing continuous care to other patients. Tischler et al' have noted somewhat similar findings in their study of the impact of catchmenting in New Haven. They observed that the catchmented service provided care to a significantly greater number of people than its noncatchmented coun¬
terpart.
2. This increase in overall utilization was accompanied by a decrease in hospitalization rates. This was due in large part to increased ambulatory care, because hospitalization rates diminished despite the addition of 50 new beds for acute psychiatric care in the community. The decline in hospitalization demonstrates that in this case at least, community mental health centers have succeeded in achieving an intended objective.
3. Centers increased the percentage of their own catch¬ area patients receiving care. The Rochester Mental Health Center also saw an increased percentage of patients from the centerless catchment areas. While in¬ creasing their own patient loads, the percentage of patients seen at the Rochester Psychiatric Center decreased from all catchment areas. The importance of community mental health centers as a locale for psychiatric care is also consistent with national trends." 4. Community mental health centers were assigned the ment
responsibility for providing psychiatric
care to all catch¬ residents. This was done in order to alter the existing pattern of care whereby the affluent, the educated, and the less severely impaired received care while more disadvantaged groups remained relatively neglected. This study demonstrates that again community mental health centers were successful in meeting this objective. Centers had their greatest impact on the poor. Utilization rates for the two lower socioeconomic levels
ment
area
increased substantially. Furthermore, this was accompa¬ nied by a marked decline in hospitalization rates. For the poor, who have traditionally received more hospital care, the provision of ambulatory services marks an important modification in the psychiatric delivery system. 5. Tischler et al- also found a consistently greater repre¬ sentation of socially disadvantaged groups in the catch¬ mented service. They attributed this to the assignment of geographic responsibility that is associated with catch¬ menting. In Monroe County, the establishment of commu¬ nity mental health centers in areas with a high concentra¬ tion of the poor had a similar effect. Although psychiatric services were available to all residents of the county, utilization rates for the poor in catchment areas with centers increased appreciably compared to rates for the poor in areas remaining centerless. 6. The utilization rates for children and young adults increased at a rapid rate while those for the elderly diminished with the new regulations for state hospitals in 1968. These regulations made it much more difficult for elderly patients to be admitted to state hospitals. Centers did not pick up the slack in providing direct care, and utilization rates decreased for the age group 65 and over. 7. The experience in Monroe County also shows that the availability of general mental health services does not automatically imply that the treatment needs of categor¬ ical populations at risk, such as addicts, alcoholics, and the elderly, will also be taken care of. Indeed, the treatment needs of these three groups were last to be provided for. Similarly, Tischler et al- found that while geographic responsibility was associated with an improvement in the
delivery of psychiatric care to disadvantaged groups, it was
not associated with a more favorable allocation of mental health services to categorical populations at risk. 8. This natural experiment demonstrates the impor¬ tance of distance and availability for utilization of services. Catchment areas and D were far from all mental health services provided in the community prior to 1967 and both had low utilization rates for everything. Area developed a center in 1967 while area D remained without any center or any other major psychiatric service. With the center in area B, rates increased to the point that they matched rates for area A, the area always richest with services. Rates in catchment area D remained lowest for all variables throughout. Thus, utilization will remain low as long as mental health services are far away even though they are otherwise available. 9. Finally, while the focus of this report is on the impact of community mental health centers on the utilization of services, questions about the effectiveness of these services remain unanswered. Still to be addressed are issues about the character, effectiveness, and quality of care provided. While two assumptions of this article are that increased availability of care is better than no care and that ambulatory treatment modalities are preferable to hospitalizations and in many instances may prevent hospitalization, evidence that these assumptions are justi¬ fied is not presented. Issues about effectiveness and outcome cannot be adequately determined from the data presented here; however, the fact remains that community mental health centers substantially increased utilization of services in Monroe County, New York. This study was supported in part by contract 42-71-3 from the National Institute of Mental Health. The Monroe County Psychiatric Case Register is currently supported by the New York State Department of Mental Hygiene, the Monroe County Board of Mental Health, and the University of Rochester. From 1960 through 1969, the register was supported by grant MN-00381 from the National Institute of Mental Health. Ken Vieau provided computing assistance. Dolores Jones, MA, provided editorial suggestions on the manuscript, and Patricia Sanderl assisted in its
preparation.
References 1. Tischler GL, Henisz J, Myers JK, et al: Catchmenting and the use of mental health services. Arch Gen Psychiatry 27:389-392, 1972. 2. Tischler GL, Henisz J, Myers JK, et al: The impact of catchmenting. Admin Ment Health 1:22-29, 1972. 3. Goldblatt PB, Berberian RM, Goldberg B, et al: Catchmenting and the delivery of mental health services. Arch Gen Psychiatry 28:478-482, 1973. 4. Gardner EA, Miles HC, Iker HT, et al: A cumulative register of psychiatric services in a community. Am J Public Health 53:1269-1277, 1963. 5. Babigian HM: The role of psychiatric case registers in the longitudinal study of psychopathology, in Roff M, Robins L, Pollack M (eds): Life History
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Research in Psychopathology. Minneapolis, University of Minnesota Press, 1972, vol 2. 6. Liptzin B, Babigian HM: Ten years' experience with a cumulative psychiatric patient register. Methods Inf Med 11:238-242, 1972. 7. Babigian HM: The role of epidemiology and mental health care statistics in the planning of mental health centers, in Beigel A, Levenson AI (eds): The Community Mental Health Center. New York, Basic Books Inc, 1972. 8. Taube CA, Redick RW: Provisional Data on Patient Care Episodes in Mental Health Facilities, statistical note No. 127. Rockville, Md, National Institute of Mental Health, 1976.
Babigian,
MD
. The impact of community mental health centers on the utilization of psychiatric services in Monroe County, New York, was evaluated by means of data from the Monroe County Psychiatric Case Register. The catchment areas that received centers served as their own controls. In addition, yearly utilization rates were compared for areas that obtained centers with those remaining centerless. Utilization rates increased markedly in catchment areas with centers, while the percentage of patients
at the Rochester Psychiatric Center decreased from all catchment areas. Community mental health centers increased the utilization rates of the poor, children, and young adults, while the treatment needs of patient subgroups such as alcoholics, drug addicts, and the elderly were last to be addressed. The data do not evaluate issues such as the character, quality, and effectiveness of care. (Arch Gen Psychiatry 34:385-394, 1977) seen
article is an attempt to assess the impact of mental health centers on the utilization of mental health services. Federally funded community mental health centers are required by law to provide comprehensive mental health services for the residents of a geographically defined area. Consequently, centers must provide psychiatric care not only to the educated and affluent but also to those for whom care traditionally has been minimal or nonexistent-the severely disturbed, the chronically ill, and the socioeconomically disadvantaged. Given the mandate to provide equity of service, modifica¬ tion in the utilization of mental health services ought to occur after the introduction of a community mental health
Thiscommunity
Accepted
for publication Nov 9, 1976. From the Department of Psychiatry, University of Rochester (NY) School of Medicine and Dentistry. Reprint requests to Department of Psychiatry, University of Rochester Medical Center, 300 Crittenden Blvd, Rochester, NY 14642 (Dr Babigian).
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responsible for a specific catchment area. Previous findings from studies in New Haven, Conn, have noted substantial differences between catchmented and noncatchmented areas in the delivery of psychiatric care. Catchmenting has been associated with a higher volume of care and greater accessibility,1 improved delivery of mental health care to disadvantaged groups,and more favorable clinical practices.' In spite of their apparent similarity, there is an important distinction between the New Haven studies and this one. In New Haven, the two groups being compared both had access to a community mental health center, the only difference being that one group was catchmented and the other was not. The present report focuses not so much on the impact of catchmenting on the use of mental health services as on the impact of the availability and accessibility of mental health centers themselves. This is a crucial difference for it limits the extent to which the findings from New Haven and Monroe County, New York, can be compared. As in the studies cited above, the problem of evaluation was approached quasiexperimentally. Two factors greatly facilitated this type of analysis: (1) the existence of the Monroe County Psychiatric Case Register, which provided comprehensive before-and-after data, and (2) the fact that community mental health centers were available for only two of the four catchment areas in Monroe County. This permitted the impact of community mental health centers to be demonstrated twice. In addition to the comparisons of utilization rates between catchment areas receiving centers and those remaining centerless, utilization rates from the same catchment area were also compared before and after the introduction of a community mental health center
center.
County, New York, where this evaluation project an excellent laboratory for research in of psychiatric epidemiology for several reasons.
Monroe was
the
undertaken, is area
First, its location and the attractiveness of its own mental health services ensures very little shopping for such services outside the county. Bounded by Lake Ontario to the north, Syracuse 70 miles away to the east, Buffalo 70 miles to the west, and Pittsburgh 300 miles to the south, the county is relatively isolated. Furthermore, the Buffalo and Syracuse areas do not offer psychiatric services that are unavailable locally and thus do not attract the Monroe County population. Second, the county population is quite stable. The location here of several major industries reduces the number of emigrants in search of employment elsewhere. Finally, the existence of the cumulative psychiatric case register makes it possible to compare baseline service utilization data from Jan 1, 1960, to Dec 31, 1966, during which time there were no community mental health centers, with comparable data obtained after the centers had been established. Located in the northwestern part of New York State, Monroe County is urban and has a 1970 population of approximately 712,000. Whites make up 92.1% of the population and blacks 7.3%. The majority of the black population live in the city of Rochester (population 296,000), which is located in the north central section of the county. Blacks comprise 16.8% of the city's population but only 0.6% of the county's. Rochester is surrounded by suburban areas encompassing a range of socioeconomic groups from lower middle to upper class. The county also has a significant rural community generally located at its
periphery.
The Monroe County Cumulative Psychiatric Case Register was initiated by the Department of Psychiatry of the University of Rochester School of Medicine and Dentistry on Jan 1, 1960. On that date, all patients under psychiatric care were registered. Since then, all individuals contacting public and private inpatient or outpatient psychiatric facilities have been registered regularly. The facilities reporting to the register include a university department of psychiatry with inpatient, emergency, and ambulatory services; the Rochester Psychiatric Center (formerly the Rochester State Hospital); three community mental health centers; an acute inpatient observation unit; the Veterans Administration Hospital and outpatient clinic; a children's treatment center; the Monroe County Mental Health Clinic for Sociolegal Services; and approxi¬ mately 80% of all psychiatrists in private practice. Facili¬ ties report patients cared for in their inpatient, outpatient, day treatment, and emergency services separately. Thus, an individual using different modalities of psychiatric care
within different facilities has multiple reports register, providing us with a picture of the utilization of services throughout the years. The register is described in greater detail by Gardner et al,4 Babigian,' and Liptzin and Babigian." within
one
facility
or
to the
MENTAL HEALTH SERVICES IN MONROE COUNTY
description of the mental health services in Monroe County and the nature of their responsibility for a speci¬ fied service region will now be presented. In interpreting the findings, it is essential to know whether a mental health facility has primary, sole, or no defined responsi¬ bility for serving the population of a particular catchment A
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area or
whether its services
are
available to the entire
community.
The Rochester Psychiatric Center (Formerly Rochester State Hospital).-The Rochester Psychiatric Center was preceded by the Monroe County Insane Asylum, which was established in 1864. With the creation of the New York State Department of Mental Hygiene in 1891, the state took over the operation of the asylum and converted it to a state hospital. Until the early 1900s, the hospital was physically located outside the city, away from the popu¬ lated areas. Gradually, as the community moved into the suburbs, the state hospital's location became central in the county and partially within the city's southern boundaries. The number of beds has gradually diminished from 3,000 in the 1960s to the current capacity of approximately 1,400. It has a 40-bed unit for children, a unit for adolescents, and a large unit for the treatment of alcoholics (which began in 1962 for men and in 1968 for women). Although the Rochester Psychiatric Center services six counties, over three fourths of its patient population is from Monroe County. In 1968, approximately half of the patient population was 65 years of age and older; this percentage has been decreasing gradually. The hospital
admits patients on an informal, voluntary, two-physician certification and health officer certification basis. The majority of admissions are readmissions to the hospital, transfers from acute psychiatric units, and patients referred from the psychiatric emergency service of Strong Memorial Hospital. Since 1970, the Rochester Psychiatric Center has been completely unitized. This unitization follows the catchment area delineation, with each unit serving a specific catch¬ ment area. In contrast, outpatient care is not uniformly available to all residents of Monroe County. While outpa¬ tient care for the uncovered catchment areas (C and D) is still provided by the Rochester Psychiatric Center, commu¬ nity mental health centers have gradually assumed respon¬ sibility for the outpatient care of catchment area residents discharged from the Psychiatric Center. The Monroe County Psychiatric Unit.-The Monroe County Infirmary has operated as an inpatient psychiatric service since 1906, when a special law was passed by the New York State legislature authorizing the unit to exercise involuntary detentions. This is a small unit having a capacity of 35 or 36 beds. The services provided can generally be described as emergency admission observa¬ tion and care. This unit provides services that are immedi¬ ately available to the city, county, and family courts. It has also developed, out of necessity, treatment facilities for alcoholics, drug abusers, the elderly, and those individuals who need involuntary admission. This service unit is open, to the
public
at
large.
The unit's staff was greatly strengthened when the Monroe County Board of Mental Health was founded in 1957. In 1966, the Monroe County Infirmary moved to new quarters designed so that men and women could be cared for in the same area. This combining of services enhanced the unit's effectiveness since it prevented beds specifically designated for men or women from going unused. Over the years, it has served as a triage, problem-solving, overflow catching, do-what-others-cannot-do-or-will-not-do type of
unit. On July 1, 1973, this unit was closed and converted into the inpatient unit of the Genesee Mental Health Center, serving catchment area C. The Monroe
County
Mental Health Clinic for
Sociolegal
Services.—This service was built on a one-man consultative service to the courts that emanated from the University of Rochester in the early 1930s. The clinic was formally organized in 1964 and occupies a suite of offices in the Hall of Justice in downtown Rochester. It serves multiple purposes, including the diagnostic study of accused offend¬ ers, consultative services to the courts and probation departments, education and training for probation officers, and treatment of individuals involved with viola¬ tions of the law. The clinic assists both adults and children; children are served in the Court Clinic by staff from the Rochester Child Guidance Clinic, DePaul Clinic, and Convalescent Hospital for Children. The clinic is jointly operated by the county and the University of Rochester Department of Psychiatry, and serves approximately 1,000 individuals per year from all four catchment areas of the
county. The DePaul Clinic of the Catholic Charities of the Diocese
of Rochester.—This facility was established largely through the efforts of the Monroe County Board of Mental Health in 1957. It had the specific mission of serving the parochial schools, which had not been able to use the existing child
guidance clinics. Although the DePaul Clinic is the smallest of the child guidance clinics available in Monroe County, its services are not restricted to any particular catchment area.
The Veterans Administration
Psychiatric Hospital
and
Clinic—The Veterans Administration Psychiatric Hospital is located 30 miles outside Rochester. Only Monroe County veterans admitted to this hospital are reported to the Psychiatric Case Register. In addition to the hospital, the Veterans Administration has a psychiatric clinic in down¬ town Rochester that provides ambulatory care and day treatment services. The services of this clinic have been available to the community for many years, but they have been limited by the usual eligibility requirements (mostly pertaining to service connection of the disability). Although the Veterans Administration Psychiatric Hospi¬ tal and Clinic have countywide responsibility for the psychiatric care of veterans, it is not the sole provider of such care, sharing this task with several other mental health facilities. The Alcoholism Treatment Center.-This facility, estab¬ lished in 1949, was always a small but important outpatient clinic for the treatment of alcoholics. It was absorbed into the Rochester Mental Health Center in 1967. The Rochester Child Guidance Clinic.-This clinic was founded in the mid-1930s and was supported for some time by funds from the Community Chest of Monroe County and the County of Monroe. This pattern of funding prevailed until the Board of Mental Health was founded in 1957, at which time there was a massive infusion of state aid. In 1967, the clinic was absorbed into the Rochester Mental Health Center. At this time, the clinic moved its facilities from downtown Rochester to the Rochester Mental Health Center, located in the northern section of the city.
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At the time of absorption, this clinic was the largest child guidance clinic in New York State outside of New York City. Because of the clinic's size, even after its incorpora¬
tion into the Rochester Mental Health Center, it continued assume responsibility for the care of children in three catchment areas (B, C, and D), its own and two others that were without services for children. Convalescent Hospital for Children.—This facility was established in 1958 as an inpatient psychiatric service for préadolescent children. It started with six beds, increased to 16 beds in 1960 and to 24 beds in 1962. Day treatment services for children began at the facility in 1963 and expanded progressively to a capacity of 30 children at any one time. An outpatient department for children was opened in 1953 and grew steadily until 1968 when it became a community mental health center serving the same catch¬ ment areas as the University of Rochester Mental Health Center. The Convalescent Hospital has always specialized in consultative services to community agencies, schools, settlement houses, day nurseries, and others.
to
The Department of Psychiatry, University of Rochester School of Medicine and Dentistry.—Prior to the estab¬
lishment of the Department of Psychiatry, the University Medical Center had a Division of Psychiatry under the Department of Medicine. The major interests of this division were primarily in the area of preventive mental hygiene. In 1927, the division opened a 16-bed unit for the care of mentally ill patients and began an outpatient clinic. The Department of Psychiatry was established in 1946. With the completion of its new building, wing R, in 1948, an additional inpatient floor with 35 beds was opened. In 1950, the original 16-bed floor was closed and a new 24-bed unit was opened. In 1958, another inpatient floor with 28 beds was opened in the new building, making a total of 87 beds available for psychiatric patients. In addition to these beds, 12 were provided for préadolescent children during the period between 1957 and 1963. Throughout the years, the department has operated a large outpatient department, which has carried from 1,200 to 2,000 patients at any one time. It also provides psychiatric emergency services in the general emergency department of the hospital. These services are available to the entire community. In 1968, the department developed and began operation of a community mental health center described later. The Rochester Community Mental Health Center and the University of Rochester Community Mental Health Center.— With the passage of the community mental health legisla¬ tion, planning began in 1965 to provide for the mental health needs of the county population. It was decided that four community mental health centers were required to provide total coverage of the county. The county was then divided into four catchment areas, each containing urban, suburban, and rural sections. Figure 1 presents a map of the county with the four catchment areas- , B, C, and D— and the location of the centers. Because only two of the centers were going to be immediately operational, most of the lower socioeconomic areas were included in their catchment areas (A and B).T According to the 1970 census, 56% of the level IV and 86% of the level V population were
30.0-
MONROE COUNTY, N.Y.
28.5-
27. o -
2
24.0-
Sc,
•A/
J
Fig 1.—Community mental health centers in Monroe County, New York. Catchment area A, population 180,196: A, University of Rochester Community Mental Health Center (began operation July 1, 1968); A', Convalescent Hospital for Children (began operation in 1968). Catchment area B, population 175,957: B, Rochester Mental Health Center (began operation Jan 2, 1967); catchment area C, population 146,963: C, Genesee Hospital Mental Health Center (began operation Jan 1, 1973); catchment area D, population 208,704: D, Park Ridge Hospital Community Mental Health Center (began operation In 1975). (Catchment area population figures are from 1970 census.) included in these two catchment areas. In 1967 and 1968, two community mental health centers were developed to serve approximately half the population of Monroe County, while the other half continued without the benefit of centers. The Rochester Mental Health Center, serving catchment area B, opened its doors to the public on Jan 2, 1967. Its services included an acute inpatient facility with 30 beds, a day hospital, adult ambulatory services, and walk-in services during working hours (the only preexisting service for adults absorbed into the center was the Alcoholism Clinic). In November 1969, the center began the operation of a psychiatric emergency service within the general hospital's emergency depart¬ ment during evening hours and weekends. The center's services for children and adolescents were provided by the Rochester Child Guidance Clinic. Later in 1967, a children's center, one of the two major components of the second comprehensive community mental health center, was opened at the Convalescent Hospital for Children in catch¬ ment area A. In 1968, the second component, the Univer¬ sity of Rochester Community Mental Health Center, was developed by the Department of Psychiatry of the Univer¬ sity of Rochester School of Medicine and Dentistry. Twenty-two beds were assigned to the community mental health center, and another 22 were designated as backup for its inpatient services. The new community mental health center developed its own day treatment program, ambulatory, consultation and education, and community organization services. As is evident from the above discussion, the delivery of
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1963 1964 1965 1966 1967 1968 1969 1970 1971
1972 1973
Fig 2.—Total psychiatric utilization rates for Monroe year and catchment area.
County by
mental health services to Monroe County residents was altered with the division of the county into catchment areas and the subsequent development in 1967 and 1968 of two community mental health centers. All existing psychiatric facilities were no longer available to all county residents, as had previously been the case. Instead, specific facilities were assigned the task of providing psychiatric care to specific geographic areas of the county. The Rochester Mental Health Center was given and the primary responsibility for catchment area University of Rochester Mental Health Center and the Convalescent Hospital for Children for catchment area A. It must be emphasized, however, that while these centers were primarily responsible for the mental health needs of their own catchment areas, no one was ever turned away for being a resident of another catchment area. However, patients were encouraged to utilize their own centers by all mental health services of the community. It should also be pointed out that except for the Rochester Child Guidance Clinic and the Alcoholism Clinic (which served areas B, C, and D), all remaining psychiatric facilities continued to provide services to the entire community.
appreciably
METHODS The community mental health centers being studied are (1) the Rochester Mental Health Center, serving catchment area B, which covers the northeastern segment of the county and city, and (2) the University of Rochester Community Mental Center and the Convalescent Hospital for Children, which together constitute a complete mental health center serving catchment area A. This catchment area covers the southern segment of the county and city. Catchment areas C and D in the eastern and western sections of the county are presented because they serve as natural controls since neither had an organized community mental health center. In 1973, however, a third community mental health center began operation in catchment area C. Data from Jan 1, 1960, to Dec 31, 1966, provide a baseline on the utilization of mental health care facilities in the community prior to the establishment of the first community mental health center on Jan 2, 1967. In those seven years, the only major psychiatric facility added in the community was the Monroe County Mental Health Clinic for Sociolegal Services in 1964. Although there were
47.0-
«3.039.0-
1963 196U 1965
1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973
Fig 3.—Rates for Monroe County by
new
patients entering psychiatric
care
for
year and catchment area.
1963 1964 1965 1966 1967 1968 1969 1970
1966
1967
1968 1969
1970 1971
4.—Total psychiatric utilization rates for Monroe year and socioeconomic level.
Fig
1963 1964 1965 1966 1967 1968 1969 1970 1971
1971 1972 1973
1972 1973
County by
1972 1973
65.0-
II 1963 1964
Fig
5.—Total
1965 1966 1967 1968 1969 1970 1971
psychiatric
utilization rates for Monroe
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1972 1973
County
catchment
II
1963 1964 1965 1966 1967 1968 1969 1970 1971 areas
1972 1973
A, B, C, and D by year and socioeconomic level.
8.5
__ 1963 1964 196S
1966 1967 1968 1969 1970 1971
Fig 6.—Total psychiatric utilization rates for Monroe year and age.
-L 1972 1973
County by
variations brought about within some of the facilities during seven years, in general we can assume that the availability, nature, and magnitude of services provided did not change much.
some
those
Demographic data from the Register were analyzed yearly for the years 1963 through 1973. Rates of utilization by catchment area, age, and socioeconomic level were the main variables used. Included in the calculation of utilization rate are new patients and all others who are treated in the county's mental health services in a particular calendar year. It should be emphasized that patients were counted only once in that year regardless of the number of psychiatric contacts they may have had. All graphs show catchment areas with the letters A, B, C, and D; represents the rate for the whole county. (The rates per 1,000 on the left side of each graft are not the same.) Rates are presented per 1,000 Monroe County population. Yearly population was established by linear interpolation of the 1960 and 1970 census data. RESULTS
Impact of Centers on Rates of Utilization Figure 2 presents total rates of utilization by year and catchment year. In 1963, utilization rates were lowest for The
and D and highest for A and C, the catchment areas areas richest in mental health services. In 1967, the Rochester Mental Health Center began serving catchment had the highest utilization rate area B, and by 1969 area of all four areas. The utilization rate for catchment area A, which also had a center (1968), surpassed that for area in 1972. In 1973, the rate for area A was 30.51, the highest recorded anytime since I960. Following the opening of the center in area A, the gap between utilization rates for catchment areas A and C appeared to widen, indicating more case detection and availability of services for area A. Utilization rates for catchment area D, which did not have a functioning center, lagged behind those for areas A, B, and C. Rates for new patients entering psychiatric care
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follow the same pattern as total utilization rates (Fig 3). Prior to 1967, all psychiatric facilities were concentrated in the southern part of the city and county in areas A and and D had no facilities whatsoever. The C. Areas of comparison areas and D is a crucial one since area began with a center in 1967 and area D continued as is. The operation of the center in area also affected rates in area D by increasing them since that center became the closest facility to most of area D. This indicates that location, proximity, and accessibility are crucial factors for utiliza¬ tion of services. Utilization Rates by Socioeconomic Level.—The register does not have any direct measures (such as income, occupa¬ tion, or education) of the individual's social or economic level. Instead, an indirect measure, the census tract in which an individual resides is used. Each census tract in Monroe County has been classified into one of five groups, from I (highest) to V (lowest), using a composite index combining median value of owned homes, median rental values, percentage of skilled, semiskilled, and unskilled workers, median years of education, and percentage of sound dwelling units, as determined by the 1960 census. The distribution of the 1960 Monroe County population among the five areas was as follows: area I, 12%; area II, 26%; area III, 43%; area IV, 14%; and area V, 5%. Figure 4 presents total utilizatior. rates by year and socioeconomic level for Monroe County. It is apparent that community mental health centers had a major impact on the poor population they were able to attract into service. In contrast to the siiglii increase in utilization rates for socioeconomic levels I, II, and III, rates for the two lower classes increased substantially after 1967, reaching their highest levels during the period from 1969 through 1971. Their decline in 1973 might indicate that once the initial need and emphasis on case detection is taken care of, it begins to decline. It may afeo mean that as time goes on, centers become less active and alert in case detection. Figure 5 presents total utilization rates by catchment area and socioeconomic level. As might be expected, catch¬ ment areas with community mental health centers (A and B) showed a continuous increase in rates for the two lower socioeconomic levels. This trend was most evident in catchment area A. Except for level V in area D, areas C and D continued with minimal increases. Surprisingly, socioec¬ onomic level IV in catchment area C, which had no community mental health center, showed the highest utilization rates throughout the years. Utilization Rates by Age.—Figure 6 presents total utiliza¬ tion rates by age and year for Monroe County. Of partic¬ ular note is the continuing increase since 1968 in rates for age groups 0 to 14, 15 to 24, and 25 to 34 and a continuous decline for those 65 years and over. Figure 7 presents total utilization rates for each age group by catchment area. It is obvious that utilization of services by children and young adults increased markedly, particularly for those areas with centers, and that utiliza¬ tion by the elderly decreased dramatically. The explanation for this decline, despite increases for other age groups, is that in 1968 the Department of Mental Hygiene instituted a new regulation making it more difficult for elderly individuals to be admitted to state hospitals for institu-
1963 1961 1965 1966 1967 1968 1969 1970 1971
1972 1973
1963 196k 1965 1966 1967 1968 1969 1970 1971 1972 1973
-I-1-1--k 1963 1961 1965 1966 1967 1968 1969 1970 1971 1972 1973 1963 1961 1965 1966 1967 1968 1969 1970 1971 1972 1973
1963
196U
1965 1966 1967
196B
1969 1970 1971 1972 1973 1963 196« 1965 1966 1967 1968 1969 1970 1971
1972 1973
1961 1965 1966 1967 196B 1969 1970 1971
1972 1973
Fig 7.—Total psychiatric utilization rates for each age group by catchment area and year.
1963
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2.6 9.5
2.5
2.4 -x
9.0 -
8.5
'ffl o
-
2.2 >
S
2.1 -
O
8
7.5
2.0 1.9
7.0
1.8
S 6.5
.
S
8.0
ce
1.7 6.0 1.6
1.5
-1-1-1-1-1-1-1-1-1_I 1963 1964 1965 1966 1967 1968 1969 1970 1971
8.—First lifetime year and catchment
Fig
hospitalization
rates for Monroe
1972 1973
County by
area.
5.5
4-
-I-
4-
4-
4-
1963 1964 1965 1966 1967 1968 1969 1970 1971
rates of and catchment area.
Fig 9.—Total
hospitalization
for Monroe
-L 1972 1973
County by
year
care unless they showed signs of mental illness. Community mental health centers did not pick up the lag, and elderly individuals apparently were not attracted to the centers even for diagnostic and evaluative purposes. Utilization rates for most age groups were generally
tional
lowest for area D, the catchment available psychiatric services. The
Impact of Centers
on
area
furthest away from
Hospitalization
Rates
Monroe County had quite a few inpatient facilities prior to the institution of centers—the Rochester Psychiatric Center with 2,400 beds; the University Hospital with 87 beds for the acutely ill; the Monroe County Hospital Psychiatric Unit with 35 beds for observation and detoxifi¬ cation of the acutely ill; and the Convalescent Hospital for Children with 24 beds for the long-term care of préadoles¬ cent children. In 1967, the Rochester Mental Health Center added 30 beds for acute inpatient care to the community and in 1968 the University of Rochester Community Mental Health Center added 20 beds. The Monroe County Hospital continued with 35 beds for inpatients until July 1, 1973, when it closed down. The same area was reopened as the inpatient unit of the Genesee Mental Health Center, serving catchment area C. First Lifetime Hospitalization Rates.-Figure 8 presents first lifetime hospitalization rates by catchment area. Despite the addition of 50 new beds for the acutely ill with the introduction of community mental health centers, first
admission rates dropped in Monroe County from a high of 2.48/1,000 in 1967 to a low of 1.93 in 1972, and 2.05 in 1973. In the early 1960s, catchment areas A and C had the highest rates since all the hospitals were located there. Hospitalization rates peaked in 1967 for catchment areas and C and in 1968 for area A. Since then, rates for areas A, B, and C dropped to around 2.00/1,000. In 1973, however, the rate for catchment area C increased to 2.56. These findings suggest that when new psychiatric facilities become available, there is an increase in first lifetime hospitalizations, but that once the initial demand for care
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1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 10.—Total rates of hospitalization for Monroe County by year Fig and socioeconomic level.
is met, rates decline. Catchment area D residents showed the lowest rates of hospitalization throughout, probably indicating underutilization of services. For area D resi¬ dents, the inaccessibility of community mental health centers may actually be beneficial since it reduces the likelihood of hospitalization. Total Rates of Hospitalization.-Total rates of hospitaliza¬ tion decreased for all areas after the establishment of community mental health centers (Fig 9). The highest rate for the county was 8.94/1,000 in 1967 and the lowest 7.28/ 1,000 in 1973. Areas A, B, and C, where mental health facilities were most available, showed the most precipitous decline, while that of area D was more gradual. What is most noteworthy, however, is that centers were able to increase the total utilization rates for psychiatric care in their catchment areas while keeping total rates of hospital¬ ization relatively stable. This means that the major
increase in total utilization centers
attracting
new
was
patients
brought about by the to their ambulatory
services.
Figure 10 presents total rates of hospitalization by year and socioeconomic level. Of special interest is the decline in rates for socioeconomic levels IV and V. This is probably because of the increased availability of ambulatory and other services. The
Impact of Centers
on
Catchment Areas A and
One way of assessing the impact of community mental health centers on their catchment areas is to look at the priority distribution of contacts for patients from catch¬ ment areas A and B. (Tables are available on request.) A priority contact means that if a patient is seen in any capacity at a center during the years 1963, 1966, and 1973, the patient is counted there regardless of other facilities contacted. For catchment area A, we found that in 1963 and 1966 only, 32.4% and 34.9% of patients were seen by the facilities that later became the center, while in 1973, 60.6% of patients were seen by center services. The same thing happened for area B. Between 1963 and 1973, patients treated at the Rochester Mental Health Center increased from 6.3% to 58.2%. During the same interval, patient contact with the Rochester Psychiatric Center declined by more than 20% for both catchment areas. In summary, the percentage of area A patients seen at the University of Rochester Community Mental Health Center and Convalescent Hospital for Children and the percentage of area patients seen at the Rochester Mental Center increased between 1966 and 1973. The Rochester Mental Health Center also saw an increased percentage of area C and D residents. There was no increase, however, in the percentage of area C and D residents treated at the University of Rochester Community Mental Health Center. While centers increased their own patient loads, the percentage of patients seen at the Rochester Psychiatric Center decreased not only from the catchment areas with centers but also from areas C and D, which had no
centers.
Impact of Centers on the Care of Special Groups The care of special groups such as drug addicts and alcoholics poses special problems for the health and mental health services of a community. It was hoped that with the establishment of community mental health centers, improved care could be provided to patients in these categories. The two groups will be discussed separately in this section. (Tables are available on request.) Drug Addicts (Heroin).—Prior to 1969, there were no special services provided within the mental health center facilities for the evaluation, detoxification, psychosocial, or rehabilitative care of the heroin addict. Not surprisingly, the rate of utilization was low—0.3/1,000 for the whole county. In 1969, the Rochester Mental Health Center initiated a program for the care of the addict, consisting of an ambulatory detoxification service backed by inpatient care for withdrawal, utilizing general psychiatric beds. As their program developed and became better known, the rates increased markedly as addicts went there for care. The total utilization rate in 1971 was 0.9/1,000. The experiThe
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of the Rochester Mental Health Center demonstrates that addicts seek care when it is available to them. Alcoholics.—Prior to the establishment of community mental health centers, the alcoholics of Monroe County had available to them inpatient detoxification facilities in the Monroe County Hospital. Some outpatient facilities were available, but these were limited. With the establishment of the Rochester Mental Health Center, the rate of utiliza¬ tion for catchment area alcoholics increased from 0.57/ 1,000 in 1967 to 1.56 in 1971. As alcoholism services were developed by the University of Rochester Community Mental Health Center, the utilization rate by catchment area A alcoholics served by this facility increased from 0.5/ 1,000 in 1967 to 1.65 in 1971. Both community mental health centers continued serving alcoholics in catchment areas C and D at a relatively steady rate. As the centers develop more and more programs for alcoholics, it is expected that utilization rates will continue to increase. enee
COMMENT
The impact of community mental health centers on the utilization of psychiatric services in Monroe County, New York, was evaluated with data from the Monroe County Psychiatric Case Register. The catchment areas that received centers served as their own controls. In addition, yearly utilization rates for areas that obtained centers were compared with those remaining centerless. Several conclusions can be made about the impact of these centers.
1. Even though Monroe County had a variety of psychiatric services prior to the establishment of commu¬ nity mental health centers and these services continued following the opening of these centers, it is obvious that community mental health centers are conducive to
increased utilization of mental health facilities. Centers markedly increased the rates of utilization for their catch¬ ment areas both by attracting new patients and providing continuous care to other patients. Tischler et al' have noted somewhat similar findings in their study of the impact of catchmenting in New Haven. They observed that the catchmented service provided care to a significantly greater number of people than its noncatchmented coun¬
terpart.
2. This increase in overall utilization was accompanied by a decrease in hospitalization rates. This was due in large part to increased ambulatory care, because hospitalization rates diminished despite the addition of 50 new beds for acute psychiatric care in the community. The decline in hospitalization demonstrates that in this case at least, community mental health centers have succeeded in achieving an intended objective.
3. Centers increased the percentage of their own catch¬ area patients receiving care. The Rochester Mental Health Center also saw an increased percentage of patients from the centerless catchment areas. While in¬ creasing their own patient loads, the percentage of patients seen at the Rochester Psychiatric Center decreased from all catchment areas. The importance of community mental health centers as a locale for psychiatric care is also consistent with national trends." 4. Community mental health centers were assigned the ment
responsibility for providing psychiatric
care to all catch¬ residents. This was done in order to alter the existing pattern of care whereby the affluent, the educated, and the less severely impaired received care while more disadvantaged groups remained relatively neglected. This study demonstrates that again community mental health centers were successful in meeting this objective. Centers had their greatest impact on the poor. Utilization rates for the two lower socioeconomic levels
ment
area
increased substantially. Furthermore, this was accompa¬ nied by a marked decline in hospitalization rates. For the poor, who have traditionally received more hospital care, the provision of ambulatory services marks an important modification in the psychiatric delivery system. 5. Tischler et al- also found a consistently greater repre¬ sentation of socially disadvantaged groups in the catch¬ mented service. They attributed this to the assignment of geographic responsibility that is associated with catch¬ menting. In Monroe County, the establishment of commu¬ nity mental health centers in areas with a high concentra¬ tion of the poor had a similar effect. Although psychiatric services were available to all residents of the county, utilization rates for the poor in catchment areas with centers increased appreciably compared to rates for the poor in areas remaining centerless. 6. The utilization rates for children and young adults increased at a rapid rate while those for the elderly diminished with the new regulations for state hospitals in 1968. These regulations made it much more difficult for elderly patients to be admitted to state hospitals. Centers did not pick up the slack in providing direct care, and utilization rates decreased for the age group 65 and over. 7. The experience in Monroe County also shows that the availability of general mental health services does not automatically imply that the treatment needs of categor¬ ical populations at risk, such as addicts, alcoholics, and the elderly, will also be taken care of. Indeed, the treatment needs of these three groups were last to be provided for. Similarly, Tischler et al- found that while geographic responsibility was associated with an improvement in the
delivery of psychiatric care to disadvantaged groups, it was
not associated with a more favorable allocation of mental health services to categorical populations at risk. 8. This natural experiment demonstrates the impor¬ tance of distance and availability for utilization of services. Catchment areas and D were far from all mental health services provided in the community prior to 1967 and both had low utilization rates for everything. Area developed a center in 1967 while area D remained without any center or any other major psychiatric service. With the center in area B, rates increased to the point that they matched rates for area A, the area always richest with services. Rates in catchment area D remained lowest for all variables throughout. Thus, utilization will remain low as long as mental health services are far away even though they are otherwise available. 9. Finally, while the focus of this report is on the impact of community mental health centers on the utilization of services, questions about the effectiveness of these services remain unanswered. Still to be addressed are issues about the character, effectiveness, and quality of care provided. While two assumptions of this article are that increased availability of care is better than no care and that ambulatory treatment modalities are preferable to hospitalizations and in many instances may prevent hospitalization, evidence that these assumptions are justi¬ fied is not presented. Issues about effectiveness and outcome cannot be adequately determined from the data presented here; however, the fact remains that community mental health centers substantially increased utilization of services in Monroe County, New York. This study was supported in part by contract 42-71-3 from the National Institute of Mental Health. The Monroe County Psychiatric Case Register is currently supported by the New York State Department of Mental Hygiene, the Monroe County Board of Mental Health, and the University of Rochester. From 1960 through 1969, the register was supported by grant MN-00381 from the National Institute of Mental Health. Ken Vieau provided computing assistance. Dolores Jones, MA, provided editorial suggestions on the manuscript, and Patricia Sanderl assisted in its
preparation.
References 1. Tischler GL, Henisz J, Myers JK, et al: Catchmenting and the use of mental health services. Arch Gen Psychiatry 27:389-392, 1972. 2. Tischler GL, Henisz J, Myers JK, et al: The impact of catchmenting. Admin Ment Health 1:22-29, 1972. 3. Goldblatt PB, Berberian RM, Goldberg B, et al: Catchmenting and the delivery of mental health services. Arch Gen Psychiatry 28:478-482, 1973. 4. Gardner EA, Miles HC, Iker HT, et al: A cumulative register of psychiatric services in a community. Am J Public Health 53:1269-1277, 1963. 5. Babigian HM: The role of psychiatric case registers in the longitudinal study of psychopathology, in Roff M, Robins L, Pollack M (eds): Life History
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Research in Psychopathology. Minneapolis, University of Minnesota Press, 1972, vol 2. 6. Liptzin B, Babigian HM: Ten years' experience with a cumulative psychiatric patient register. Methods Inf Med 11:238-242, 1972. 7. Babigian HM: The role of epidemiology and mental health care statistics in the planning of mental health centers, in Beigel A, Levenson AI (eds): The Community Mental Health Center. New York, Basic Books Inc, 1972. 8. Taube CA, Redick RW: Provisional Data on Patient Care Episodes in Mental Health Facilities, statistical note No. 127. Rockville, Md, National Institute of Mental Health, 1976.
