Competing Priorities: Assessment and Engagement in Community Mental Health Practice Under Fiscal Austerity and New Public Management
Community mental health practice research has long emphasized the mutual importance of clinical assessment and therapeutic engagement for enhancing access to services, especially for hard to reach populations. Assessment techniques enable practitioners to acquire background information, identify strengths, and tailor the treatment plan to the needs and objectives of consumers. Engagement strategies emphasize the value of a trusting therapeutic relationship, continuity of care, a low entry threshold, and stigma reduction. Recent national policy trends have identified assessment and engagement as collaborative goals of a recovery-oriented, consumer-driven community mental health system. At the same time, federal and state policies have introduced austerity measures and new public management strategies in order to reduce costs, increase efficiency, and improve accountability through performance measurement. This study analyzes the response of one street-level community mental health organization to emerging fiscal and administrative reforms, looking specifically at how these reforms have re-shaped practices of assessment and engagement.
Methods:
This study uses the ethnographic methods of participant observation, interviewing, and archival research to examine the interface of policy and practice. Over a twelve-month period, the researcher spent 1100 hours observing the day-to-day routines of street-level workers in a community mental health organization, using field notes to track emerging patterns of practice. 28 structured interviews were conducted with frontline workers, team leaders, and program administrators. 73 informal interviews were conducted with line workers and administrators as questions emerged about day-to-day practices. Archival documents such as agency reports, instruction manuals, and disciplinary actions were reviewed for themes relating to assessment and engagement. These multiple data sources allowed the researcher to test emerging hypotheses in an ongoing and iterative fashion.
Results:
This study finds that under the current pressures of fiscal downsizing through “Medicaid maximization,” assessment and engagement strategies compete on the front lines of service delivery for increasingly scarce organizational resources. Medical necessity requirements place administrative burdens on providers to routinize the assessment process in order to meet stringent and time-sensitive billing requirements. Street-level workers respond to fiscal and managerial reform by adopting strategies that de-personalize individual treatment plan development. Administrative requirements also compete with traditional strategies of engagement. This is especially true for clients who are the hardest to reach, who because of homelessness, cognitive disorganization, and/or emotional instability struggle to navigate the Medicaid fee-for-service system. The new wave of fiscal and managerial reform not only imposes barriers to entry, but necessitates potentially stigmatizing processes and mitigates against the formation of trusting therapeutic relationships.
Implications:
The implications of this study for social work research and practice are significant. Findings suggest that, under the conditions of fiscal austerity and managerial reform, administrative requirements both routinize assessment practices and place them in competition with engagement strategies, compromising the mission of community mental health to provide individually tailored treatment and to lower the threshold of entry for those who are hardest to reach.