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What about the range of services provided ?

On this score, too, the program requirements were clear. Each center, they prescribed, must assure continuity of careencompassing five basic treatment services: inpatient services for those who may require short-term hospitalization; partial hospitalization-during the day or over-night; out-patient treatment for patients who might make appointments as they would routinely with their family physicians; emergency services, available around the

k; and consultation and education programs.

How have we fared ?

The center programs, I am pleased to report, are evolving as they were intended to—with a spectrum of services by mental health workers who seek to equal the range of needs brought by citizens in search of help. A number of the centers now under way sprang from agencies already providing nearly the, entire span of essential services. But the program has also given sharp rise to many new and improved services in communities across the country:

.New inpatient services will be available in 40 percent of the centers funded, and in an additional 32 percent, they will be enlarged—either through new physical facilities, increased staff, or both.

.Over half of the centers currently under way will provide partial hospitalization facilities in areas where no such capacity existed before.

.New inpatient services will be available in 40 percent of the centers funded, ters, and an additional 40 percent will improve and expand existing therapeutic approaches used on an outpatient basis—including individual and group psychotherapy, family therapy, and drug treatment.

.Half of the centers will offer new emergency services, and a third more will increase them beyond their present levels; many plan to publicize emergency facilities widely within the community in order to assure their increased use.

Forty percent of today's centers will offer new consultative services, and another 40 percent will broaden existing ones—reaching out to schools, churches, court and juvenile authorities, and welfare agencies.

The community mental health centers program was a bold confrontation of the almost universal problem of fragmentation of services—in which the interests of professional agencies reigned supreme over the needs of the patient and his family. The program placed the patient at its hub, and citizens and professionals alike responded. Already, the community mental health center has served as a model for other programs—from neighborhood centers to community delinquency programs—in which comprehensive and continuous services must replace fragmented and overlapping ones.

MEETING SPECIAL NEEDS

These data do not imply a rigid uniformity among the centers. Far from it. There is no single model, for no two American communities are alike. Each center has its individual characteristics—reflecting the needs and the resources of the area it serves. The range portrays the face of America, and the ingenuity and adaptive ability of its citizens. Some centers, for example, will reach out to crowded metropolitan areas, while others will spread their services across thinly populated mountains and plains. In Texas, Dallas will have a full span of mental health services used in the city's large general hospital. In Louisiana, in contrast, two agencies have devised a plan to serve the people of the bayou country through individual clinical units ranging over four counties; and in Kansas, two agencies have combined to provide comprehensive services to residents of a rural area spanning over 20 counties.

PATTERNS OF FINANCING

The diversity of the center programs is further reflected in funding patterns used across the country. In some States, Federal money is being matched with State money exclusively; in others with State and local money ; in still others with private funds. We are encouraging the broadest possible base for the financing of community mental health centers, and some communities have pioneered new funding programs among several counties or regions, and across State lines.

As a result of the Community Mental Health Centers Program, many States have sought to involve their communities directly in the provision of mental health services. The most common mechanism has been a State-implemented

Community Mental Health Services Act. Since the passage of the first such act in New York thirteen years ago, twenty-eight States have followed suit. These laws have provided for decentralization in the administration of community services, cost sharing by the State and localities, and the maintenance of local choice and i

initiative; State funds have typically been provided on a matching basis.

Within the last year, several States have considered and passed community mental health services legislation. Perhaps the boldest approach to date has been the recently developed act in Pennsylvania. The Pennsylvania act ensures that the localities of the Commonwealth provide a wide range of mental health services, and pledges State support of 90 percent of eligible costs.

It is a source of satisfaction for us to note that community mental health center financing efforts have often grown from the deepest roots of the communities—from the citizenry itself. The Lane County Community Menatl Health Center in Eugene, Oregon, for example, is largely the result of community sponsorship; seventeen county agencies are affiliated with the center, which will serve residents in an area reaching from the Pacific Ocean to the summit of the Cascade Mountains, as well as the 12,000 students at the University of Oregon in Eugene. In Pittsburgh, a grant from the Appalachian Regional Commission help in the realization of a center to serve an area of 160,000 residents—primarily from low-income, urban areas. At Daytona Beach, Florida, the Volusia County Mental Health Center is the result of a unique community drive to guarantee adequate mental mealth services. The local Mental Health Association initiated a campaign to raise money toward construction of the center, and the largest corporation in the country contributed the services of its public relations department to promote the drive. Civic groups and hundreds of individuals participated—physicians, bankers, lawyers, housewives; one resident contributed the income from an orange grove to the project; the clergy sponsored a Mental Health Sabbath. Most important, the total effort brought all the interests within the county together for the first time in its history.

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PART II—SELECTED EXAMPLES OF CENTERS

1. Extension of high quality care to new population groups.Temple University, Philadelphia, Pennsylvania :

Staffing grant
Fiscal year 1966:
Federal share

$420, 240 Total operating cost for 1st 12 months--

921, 240 The Temple University Community Mental Health Center is an example of how a University Department of Psychiatry can develop a Community Mental Health Center which will expand services to its surrounding population area and provide high quality care to a population that has a high incidence of social problems and socioeconomic deprivation. This facility will serve an area in Northeast Philadelphia.

This is predominantly a slum area with a high percentage of negroes (63.5% in 1960). It is also an area of social decay and multiple problems, e.g., 60 percent unemployment for youth of 15 to 21 who are not students. One-fourth of the families are at the poverty level, i.e., less than $3,000 per annum income.

The Temple University Medical Center is in the center of this area and is readily accessible to its population. It has previously offered diagnostic services to people in the area at an estimated level of 350 patients per year, but very few of these patients received subsequent interviews or treatment. Furthermore, the inpatient service was limited to private and teaching cases. Stimulated in part by the Community Mental Health Centers Program, the Psychiatry Department has just entered a new phase of rapid expansion.

A unique feature of the Temple Community Mental Health Center's program which will ultimately serve to improve the delivery of mental health services to the poor is a built-in evaluation system that is designed to provide constant feedback to the administration and assure continuity of patient care. The service program will provide the utilization data ; the evaluation unit will do the follow-up studies, and the Center will draw upon the full resources of the Medical School for survey research and sociocultural data. A variety of resources will thus be brought together into a sophisticated operations research

program that should contribute to a greater understanding of the mental health problems of the poor.

This Center has also worked out specific arrangements for members of their staff to share responsibility for the inpatient unit of the large State hospital in the area, so that the Center can assist in the aftercare of patients returning from the State hospital.

Temple University Community Mental Health Center is thus an excellent example of how the Community Mental Health Center program has encouraged the development of a project which will marshall personnel resources, research capacities, and the service capabilities of a large medical center to more effectively provide high quality mental health care to the poor.

2. Interstate cooperation.—Bristol Memorial Hospital, Bristol, Tenn. ;

Construction grant
FY 1965:
Federal share (64.5 percent)

$576, 907 Total project cost-----

888, 429 A mental health center program including essential mental health services will serve 190,000 people from two states, Virginia and Tennessee.

The development of this project necessitated a change in the state construction plans for both States and modification of the program to suit the two state catchment areas.

The applicant is the Bristol Memorial Hospital, a 215-bed voluntary nonprofit hospital located in Bristol, Tennessee. This project will serve two States and three counties, two of which are in Tennessee and one in Virginia. The participants in developing the project are this hospital and the Bristol Mental Health Clinic in Virginia.

There is a history of excellent cooperation between Tennessee and Virginia in Bristol. The state line practically divides the State Hospital property which is located in Tennessee and the clinic property, even though adjacent, will be physically located in Virginia.

3. Rural Services Coverage.—Memorial Mental Health and Mental Retardation Center, Bismarck, North Dakota :

Staffing grant
Fiscal year 1966 :
Federal grant-

$51, 249 Total operating cost for 1st 12 months.-

354, 558 Southeast Mental Health and Retardation Service Center, Fargo, North Dakota:

Staffing grant
Fiscal year 1966:
Federal grant-

$74, 745 Total operating cost 1st year.

396, 961 St. Michael's Hospital, Grand Forks, North Dakota :

Construction grant
Fiscal year 1965:

Federal share (59 percent).
Project cost

$46, 465 78, 755

Staffing grant
Fiscal year 1966:
Federal share -

$85, 936 Total operating cost for 1st 12 months.--

192, 594 Among the sparsely populated States, North Dakota is showing the way to the development of a vigorous and progressive community mental health program.

North Dakota has established three centers and two others will probably be functioning within the next year. The three established centers—at Bismarck, Fargo and Grand Forks—have received four Federal grants totaling $258,395, to date. Bismarck and Fargo have each received staffing grants while Grand Forks has received both a staffing and a construction grant. A proposed fourth center, at Minot, is expected to submit a staffing grant application in April 1967.

When all four centers are operational, three-fourths of the State's population will be within an hour's drive of a community mental health center.

Despite its rural nature (there is no city with more than 47,000 people ; 90 percent of the towns have less than 5,000 people; and the total State population is less than 700,000). North Dakota has not experienced undue difficulty to date in recruiting qualified professional personnel to staff its mental health facilities.

This is attributable in part to the unusual popular support the community mental health centers have received there. In 1965, the State passed a community mental health services act which, for the first time in North Dakota's history, permits the counties to levy taxes to establish and support mental health and retardation services. Recently, four counties approved overwhelmingly a 34-mill levy to support the Grand Forks community mental health center. A similar levy has been approved by the voters who will be served in the Minot center.

Thus, a combination of private resources, Federal aid and vigorous citizen action has enabled North Dakota to implement a successful and dynamic community mental health program.

4. Mental health services to children.-Bernalillo Community Mental Health Center, Albuquerque, New Mexico :

Construction grant Fiscal year 1965: Federal share__

$209, 852 Fiscal year 1966: Federal share (50 percent)

294, 770 Total project cost.

1,009, 244 Staffing grant Fiscal year 1966: Federal grant

$104, 115 Total operating cost for 1st 12 months..

313, 820 This center proposes to provide mental health and mental retardation services to a population of 160,000 in a designated area of Albuquerque and Bernalillo County. Plans were formulated after an intensive community survey by the Community Council and were enthusiastically supported locally.

Service area includes the widest possible range of socioeconomic characteristics, both sparsely settled rural and densely populated urban districts, and substantial numbers of Spanish-Americans, Negroes and Indians. The large proportion of young people under 19 years of age creates a special need for children and adolescent services.

Construction funds will help provide a facility which will provide full range of comprehensive services under one roof. The staffing grant will support a core staff to plan, develop and operate the first phase of the center program. For children there will be an intensive day treatment program as well as outpatient and consultation services. Specialized inpatient facilities for children (and adolescents) also will be provided. These are in addition to other services for both children and adults.

5. Specialized Services for Drug Addiction, Alcoholism and Suicide Prerention.—Meadowbrook Hospital-The Nassau County General Hospital, East Meadow, New York:

Staffing Grant
Fiscal year 1966:
Federal grant ---

$196, 525 Total operating cost for 1st 12 months --

2,030, 802 This is a private non-profit psychiatric center which is part of a general hospital serving a catchment area of 147,854 consisting primarily of a low-middle class population in a growing suburban community. It is developing a set of specialized services, based on existing facilities, in the area of drug addiction and suicide. The center will render these special services by :

1. Admitting addicts to the inpatient service. 2. Developing an intake and evaluation clinic. 3. Initiating home visits. 4. Developing a partial hospitalization program for drug addicts and alcoholics.

5. Expanding their suicide prevention service to a 24-hour a day answering service.

6. Developing an activity program utilizing voluntary county, community and state resources. The Federal assistance will be used to assist with operating costs of the entire center, but with particular emphasis on the special programs for drug addiction and suicide prevention.

6. Multiple Source Financing.-The Brookdale Hospital Center, New York City :

Construction Grant
Fiscal year 1966:
Federal share (3343%)

$1, 134, 000 Project cost--

3, 402, 400

Staffing Grant
Fiscal year 1966:
Federal grant--

$531, 641 Total operating cost for 1st 12 months.

818, 555 Support of this Community Mental Health Center was funded from several sources. The total construction cost was $3,611,674 and the Federal share was $1,134,000. The applicant supplied two-thirds of the total cost or $2,407,782, of which $1,900,000 was mortgage money and $507,782 was provided directly by the applicant.

The Federal staffing grant was $531,641. The non-Federal money was $257,619, for a total operating cost of $811,260. The non-Federal share was from the following sources : patient payments $13,660, philanthrophy $31,296, prepaid payments and insurance $50,000, NYC Community Mental Health Board (State and City) $162,663.

The Center will provide all essential services.

This project is a comprehensive community mental health center serving a population of 130,000 of middle class white population and a larger area including public housing projects in which Negroes, Puerto Ricans, and Cubans predominate.

PART III-STATISTICAL DESCRIPTION OF CENTERS FUNDED

To date we have funded 173 Centers: 100 Centers have received only a construction grant, 47 Centers have received only a staffing grant, and 26 Centers have received both a construction and a staffing grant.

The first important questions are how much these Centers cost and how they have been financed. Data are reported as "averages" if the median and the mean are esseitially identical. Where they differ, the number used is identified. The average cost of new construction funded is just over one million dollars. Of this amount, the Federal Government contributes 45 percent, the State contributes 5 percent, and local sources contribute 50 percent. Local sources of funds include mortgages, pledges, cash and bond issues. The range of cost is between $75,000 and over $2,000,000. About 20 percent of the construction grants have been given for large projects costing over $2,000,000 to build, another 20 percent cost between one and two million, and the remaining 60 percent cost less than $1,000,000.

The average Federal share of staffing grants funded is $280,000. By law during the first year this amount must be matched by an amount equal to 25 percent of the total budgeted for new professional services. Matching funds have averaged $93,000 per Center.

Data are also available on the source of operating funds for the Centers to which staffing grants have been made. Seventy-three Centers have a mean operating budget of $780,000 per Center. Of this money 45 percent is Federal in origin, 27 percent comes from the State, 10 percent is from county and local sources, 4 percent is from private philanthropy, and 14 percent is expected to come from fee payments including third party private insurance payments.

The next question of interest concerns the types of applicant institutions that applied for Centers grants. The largest group of applicants were general hospitals, either public or private non-profit. The second largest group were mental health clinics or mental health centers. Some of these applicants

1 This figure is a median. The mean is almost 10 percent because some Centers received over $1,500,000 each in State funds.

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