Is the community mental health center a dying system for the delivery of community-based care? If so, why, and what will replace it? Have we been moving towards the development of separate primary health and mental health services at community and neighborhood levels? What are the implications of such a development? In the evolution of a rational health care delivery system, how may community health planning and mental health relate, and how does this affect public policy? These are the questions that currently face community health planners.
I would like to present a conceptual base and planning ideas for working towards a more comprehensive and relevant care-giving system for health, including mental health. The plan presented is to bring services to the neighoorhood itself, beyond the mental health center but incorporating some aspects of the MHC program; issues raised by some early experience in implementing this sort of planning are briefly presented. Finally, I would like to point out the need for increased collaboration between mental health and community health planning.
In most urban areas, people live in neighborhoods that have meaning to them in terms of family and friendship patterns, geographic boundaries, and such psychosocial issues as their own identity. The mental health field has a long history of bringing its services increasingly close to where people live and work,1 partly because it was found that geographic proximity to the care-giving facility did increase utilization. The community mental health center-idea has been based on the concept that communitybased care (with a catchment area of up to 200,000) is useful in decreasing chronicity. There has been a parallel development in primary health care;2 the Office of Economic Opportunity has pioneered in the neighborhood health center concept, which attempted to provide integrated, one-door, primary health care to low-income neighborhoods, with participation of the residents on boards and as health care workers. In each of these programs, however, there are seeds of fragmentation between health and mental health care. Even though mental health centers provide community consultation services and neighborhood health centers provide mental health services within their comprehensive program,1,3 fragmentation remains a problem.
Community mental health centers are not necessarily focused on natural population groups or on areas or neighborhoods where people live. To the poor and minority groups they frequently appear alien, distant, establishmentarian, and not relevant. This is probably less true when the mental health center is decentralized and has facilities that are part of the neighborhood psychosocial matrix, and when low-income people participate in its operation.4"6 Mental health centers that include an affiliation with general hospitals may also be more relevant to the priorities of the poor. By and large, however, the mental health centers seem to have difficulty meeting the mental health needs of the disadvantaged.
Most low-income consumers have problems in several areas of their lives. If human-service systems are relevant to these consumers' own definition of appropriate outside assistance, if they are accessible, and if they foster selfesteem, they may be utilized. Since mental health services are low priority for most lowincome persons, one would expect them to be poorly utilized. But in our experience the lowincome consumer frequently feels that health services or other neighborhood-based human services are relevant and accessible. He may enter such a neighborhood facility for assistance in health, employment, education, or legal areas. If coordination and integration of services exist at the neighborhood level, people have the opportunity to obtain more than one service or to move freely between service systems. Until recently mental health services in neighborhood health centers have been nonexistent or poorly integrated into the overall functioning of the centers,1*3 but as these services develop and become integral parts of the care-giving system, new opportunities present themselves for reaching the poor.
Certain conceptual issues are important in understanding the plan that is presented in the next section.
1. Why bring services closer to people? Our theory and experience indicate that geographic proximity is important. In addition, accessibility of services has to do with people, how they work, and the way in which the consumer sees the service and how he feels about it. For many urban dwellers, neighborhood facilities are felt to be more accessible and helpful as they are viewed as belonging to the naghborhood.1 Certain people, however, prefer to receive their care outside their own neighborhood. Frequently this has to do with issues of trust, privacy, and confidentiality, which pose dilemmas for both consumer and neighborhood resident.3
2. How can we provide as open a system as possible for mental health care and also deal with issues of relevance? This involves such issues as those raised above, especially the question of developing a care-giving system where people can enter at the most comfortable level. We need also to understand how our consumers define what is relevant to their needs and then relate our services to this definition; for example, if our consumers tell us that jobs are their highest priority, relevance demands that we build our systems of health and mental health care into job and work situations. This raises the issue of how we can move with the needs of our clients and develop our systems and practices to best fit their needs.
3. What are the gains and losses in providing integrated rather than fragmented human services? For many low-income consumers who experience difficulties in several areas, integrated services seem to make the most sense; however, we must consider the possibility that for some people at some times, more categorical services might be indicated. This raises serious conceptual and practical questions about what a particular service system, such as mental health, gains or loses in terms of its functions, practices, theories, and identity when it becomes more integrated into other service systems. As mental health has moved from state hospital and asylum practices into local communities, there has been an increase in coordination and integration with colleagues in comprehensive health and human services;7 at times this has blurred the role and function of mental health, sometimes productively and sometimes with problems.
4. How can prevention best be effected? Certainly, primary prevention in mental health must be a community activity. Since many urban communities are organized into neighborhoods as well as larger geographic groupings, this would imply the necessity of primary prevention activities at neighborhood as well as city, catchment area, or state levels.8
5. What linkages can be achieved between the complex subsystems of the overall mental health system?2 The plan described below involves the functioning of many subsystems that must be linked to each other for administrative and functional coordination. As we develop such a plan, we must keep in mind the need to think through these linkages.
A PLAN FOR MENTAL HEALTH IN A COMMUNITY OF NEIGHBORHOODS
This schema is proposed as a way of planning for an urban catchment area if we are to move beyond the mental health center to provide comprehensive mental health services. It consists of four levels of service with organization to provide for linkages that allow staff coordination and staff sharing, as well as for patient entry and preventive activities at various levels of the system.
Level 1: Primary mental health services. Primary services designed to provide direct care would be set up at the neighborhood level, operating as integral components of neighborhood health and multiservice centers.1,3,9,10 The neighborhood facility could serve 10,000 to 50,000 persons; for a population of under 10,000, the cost would be prohibitive. Consultation to schools, grass-roots agencies, and job/work programs in the neighborhood would be provided. In addition, direct clinical services would be provided both within and outside the center as part of other neighborhood 10-12 services.'""" A focus on the neighborhood operating as a complex social system and its various subsystems, such as housing projects, would allow for therapeutic and preventive interventions at neighborhood as well as individual and family levels.810 Aftercare services - including some day care programs, medication clinics, ex-patient clubs, and halfway houses - could be organized on a neighborhood basis or for more than one neighborhood, depending on population size and needs.
Mental health service costs in OEO centers are currently only 2 per cent of the total expenditure of comprehensive neighborhood health centers.13 If we decentralized mental health services to neighborhoods, certainly this percentage would increase, but these services would be less expensive in a comprehensive facility than in a solo neighborhood mental health program. Neighborhood workers, social workers, and nurse practitioners with psychiatric backup would provide the bulk of the care. While mental health services would be integrated with other services at the neighborhood level, consumers could elect to come only for mental health care, and the system could provide for the mental health staff to function semi-autonomously as well as collaboratively. Neighborhood residents and consumers would be active in the planning and would participate as board members and neighborhood workers. Level 2: Community hospital or mental health center services. Some centralized services would be maintained at a catchment-area level, for a population base of up to 200,000. These would include emergency, outpatient, shortterm hospitalization, and inpatient treatment. Consultation and education services would be provided to those agencies with responsibility throughout the catchment area rather than for just one neighborhood, such as police and welfare. Direct clinical services would also be provided, coordinated with the neighborhood consultation and education services.8·10 The central outpatient department would serve those persons who choose to come to the centralized facility rather than being seen in one of the neighborhood centers, so patients would have a choice of where to receive their primary ambulatory care.
A number of advantages accrue from centralized services that are part of a community general hospital. Links with medical, surgical, obstetric, and pediatric services are sources for early case finding and consultation. A general hospital might be utilized more readily than a mental health center by low-income persons. The system provides an opportunity to integrate general and mental health care at a second level in the community. In addition, some community hospitals will have ties to a health department that is part of the municipal or other governmental structure. The head of that department has the opportunity to work with and possibly influence other department heads whose activities are closely related to mental health and primary prevention, such as departments of housing or education. The mental health program mat works within such a structure may then have the opportunity to assist various area or city-wide agencies related to mental health.
The internal organization of such a centralized service is important, as are its links to the other levels in the system. The central service would be organized into teams or units that cut across service boundaries. Each team or unit would provide outpatient, inpatient, short-term hospitalization, emergency, child, adolescent, alcoholism, and drug-dependency services. It would be assigned to a section of the overall catchment area, subdivided along sensible population lines and consisting of one to several neighborhoods, depending on geographic and population size; a population base of 40,000 to 60,000 would be maximum. Hie team or unit would link up with the neighborhood facility, as discussed below, in order to provide comprehensive mental health service care to its subcatchment area.
The facility at level 2 would provide inpatient services only on an acute basis - i.e., a maximum hospitalization of two to four weeks. Treatment would concentrate on assisting patients to recompensate rapidly. As file teams or units would focus on a sector of the catchment area and relate closely to neighborhood center staffs, they would have an opportunity to work intensively with family members, friends, neighbors, employers, and community care givers in order to develop the supports needed to maintain mentally ill patients in the community. Such work would also entail encouraging change in family and neighborhood networks that would make possible early reintegration of the patient into the community. With such a system, many patients could be treated in the community, without prolonged hospitalization. Those who required extended care would enter level 3.
Level 3: Extended-care services. Patients requiring such care would be treated in a backup extended-care facility operating at the catchment-area level. Length of stay could be up to one year (but probably averaging three months), with the possibility of treatment by staff who have begun to work with the patient in level 1 or level 2 facilities. The level 3 facility would also have a team or unit structure, although each such unit could focus on a larger portion of the catchment area than the level 2 units, since each subcatchment area will have fewer patients at this level. It could readily and advantageously be an integral part of an extended-care general health facility. Probably 95 per cent of the level 3 inpatients could be discharged to the community within one year, with community-based follow-up. Those who required chronic care would be referred to a level 4 facility.
Level 4: Long-term care facility. Many psychiatric patients requiring long-term care can be treated in nursing homes, halfway houses, cooperative apartments, and extended day care programs or at home, but some will still require long-term inpatient psychiatric service. Such services have in the past been provided mostly by large, distant state hospitals. In the plan we have been developing, long-term psychiatric care would be provided as part of a general long-term health care system. As the numbers of such psychiatric patients would be relatively small, the facility could be a regional one serving at least two mental health catchment areas. Such a facility should be located as close as possible to population bases, with links to the community and to services in levels 1 through 3.
Linkages. These must exist within each level, between the service system and the consumers, and between levels. In level 1, for example, coordination and integration are necessary between mental health and general health and other services if mental health services are to be a functioning, integral part of neighborhood health and multiservice centers.1,9,10 Similar links are necessary at each level between mental health and general health systems. In order to ensure full community participation, consumers should be on the boards of the neighborhood centers that make up the primary mental health services. Consumer representatives of these neighborhood boards should, in turn, be on the boards of the MHCs and general hospitals that provide services at level 2.'4 And much of the operational work in this plan will have to do with developing creative linkages between facilities at each level, so that patients may enter the program at whichever level meets their needs and continuity of care is maintained and staff is shared between facilities.
Cohen15 has described a linkage system between community clinics and a central mental health facility that uses the "interface team" concept, where one member of a community clinic staff and one member of the central facility staff serve as linking agents between these facilities. We are proposing linkages that embrace all the levels of the system.
If we begin with levels 1 and 2, we find that level 2 involves a centralized service organized into teams or units, each serving a subcatchment area that includes one or more neighborhoods. One aspect of the linkage would be total staff interaction between the neighborhood facility and the central facility unit or team. These staff members become working partners, especially around patients whom they have in common and community issues that they share. Neighborhood staff would attend inpatient admission rounds on their patients, and central unit staff would attend planning conferences in the neighborhood center for their former patients. Central unit or team staff would follow patients in the primary facility, collaborate with other staff there, and consult with other neighborhood care givers when such need develops out of their direct clinical work. Neighborhood staff could continue to follow their hospitalized patients, serve as links to the family and neighborhood, and educate the staff of the central unit or team regarding people, issues, and conditions in the neighborhood from which the patient comes. As in the "interface team" model, two staff members would provide administrative linkage and tracking of patients. In the present plan, however, there is a fuller, richer interchange between central and neighborhood staffs, designed to foster their learning and growth and to enhance patient care and its continuity.
Similar links would be developed between level 1 staff, level 2 teams or units, and the units operating at levels 3 and 4.
The advantages of a program that provides mental health care within the context of neighborhood services are several:
- The neighborhood is a natural geographic division that has psychologic and social meaning to its people.
- A neighborhood center that has community participation is viewed as part of a community, owned by the residents and working for them, not as distant and alien.
- Mental health services integrated with other health services are seen as more relevant, and can be delivered by general health staff with mental health consultation and backup.
- Many low-income persons have numerous difficulties, and the neighborhood becomes a useful social unit for integrating services to ameliorate these problems.
- The neighborhood is a manageable division for workers to learn about ecologie and interpersonal forces affecting health, and thereby allows for preventive programming and development of new treatment ideas.
- A program that provides creative links between neighborhood and central facilities can maximize staff utilization and development, while permitting patient entry at whatever level meets the patient's needs.
Our attempts to implement the program outlined here in Cambridge and Somerville, Massachusetts, have shown promise and problems. The program consists, in summary, of a community mental health center that provides centralized and neighborhood-based services, with care also provided as an integral part of the Cambridge Hospital, operating as a partner of the mental health center. As we have worked with and developed the plan outlined here, it appears that neighborhood services do perform the functions outlined,12 some of the linkages are possible, and we have a useful system for reaching our low-income population. Implementation problems, however, have included staff shortages, funding problems, training deficits in mental health workers dealing with low-income and minority groups and with community care givers, and staff resistance. In addition, there are problems of priorities when one attempts to develop central and neighborhood services at the same time.
We have definitely learned from neighborhood residents, our consumers, that centralized mental health services are psychologically (if not geographically) distant, and that they will utilize neighborhood facilities. Our own work has taught us that community-based services for low-income people require close collaboration between health and mental health workers.
We conclude that the community mental health center needs new directions if it is to serve the poor. Although there is need for some centralized services, an important move is the collaboration with general health and other human services in developing comprehensive neighborhood services. We have a chance for collaboration in developing public policy in this area, creating more rational and relevant delivery systems that are comprehensive, integrate care, and save money. This move towards a neighborhood base makes sense in terms of what we know about people, but it is important to consider the kinds of public policy decisions that must be made at city, state, and national levels in order to implement it. The collaboration of workers in community health, mental health, and other human services will give us an opportunity to achieve the goals of providing meaningful services, including prevention, for low-income persons.
1 . Macht, LB. Neighborhood psychiatry. Psychiatric Annals 4: 9 (Sept., 1974). 43-58.
2. Richmond, J. Currents in American Medicine. Cambridge, Mass.. Harvard University Press. 1969.
3. Macht, LB. Mental health services in neighborhood health centers. (In preparation.)
4. Schert, D.J. The community mental health center and mental health services for the poor. In Grunebaum, B. (ed.). The Practice of Community Mental Health. Boston: Little. Brown and Co., 1970.
5. Matek, S.J. Community mental health: dilemmas and new directions - The unmanifest destiny of what we have begun. Presented at the National Conference on Social Welfare, May 17. 1971.
6. Kish, K., and Lowinger, P. Do university programs in psychiatry serve the inner city? Demographic analysis. J. Natl. Med. Assoc. 63 (1971), 276-280.
7. Macht, LB. Coordination and collaboration as community mental health functions: A contribution to theory and practice. (In preparation.)
8. Macht. L.B. Neighborhood-based mental health services: Outposts for prevention. (In preparation.)
9. Schert, D.J., and Macht, L.B. Beyond the mental health center. II: Neighborhood health services. (In preparation.)
10. Macht. LB.. and Schert, DJ. Beyond the mental health center. The neighborhood multiservice center. (In preparation.)
11. Macht, LB. Mental health programming with children of the poor. Psychiatric Opinion 8: 2 (April, 1971), 29-38.
12. Caplan. G., Macht, LB., and Wolf, A. Manual for Mental Health Professionals Participating in the Job Corps Program. Office of Economic Opportunity, 1969.
13. Sparer, G., and Johnson, G Evaluation of OEO neighborhood health centers. Am. J. Public Health 61 (1971). 931-943
14. Macht, L.B. The neighborhood base tor neighborhood-based mental health services. (In preparation.)
15. Cohen. R.E. Development of the interface team in the Harbor Area Mental Health Program. (Unpublished manuscript.)