were entirely new organizations, others were cooperating groups of already existing facilities which incorporated to become Centers. Other types of applicants included mental hospitals and university teaching hospitals. Considering the applicants from another vantage point, approximately 40 percent were public facilities or agencies, and 60 percent were private nonprofit groups of one type or another. More than 70 percent of the Centers funded are planned as cooperative ventures involving two or more agencies, each of which contributes space and personnel for elements of the Center program. Examples of such cooperating agencies are: a non-profit general hospital providing inpatient service and a county health department providing outpatient service; or a private mental hospital providing inpatient and partial hospitalization service, while a child guidance clinic provides consultative and outpatient services. There are even some Centers which have as many as 5 cooperating agencies. Each Center has associated with it a defined population group-a catchment area. The Center has the responsibility to provide all mental health services to the residents of the catchment area. The average number of people in Centers catchment areas is 165,000. We find that 30 percent of funded Centers are in cities of 500,000 people or more, 35 percent are in cities of 50,000 to 500,000, and 35 percent are in cities or towns of 50,000 people or fewer. Thirty-five percent of Centers serve a rural county. These figures serve to demonstrate that the Federal program has been able to assist in the development of Centers in communities of all kinds. There are applicants from depressed areas and from wealthy areas; from oneindustry towns, and from cities with a broadly diversified industrial bases. There are applications from some of the strongest medical centers in the country, and from some of the areas which historically have had the most difficulty in attracting and holding professional personnel. The most important features of the Mental Health Center program are the services which will be provided and the people who will provide them. New inpatient services will be provided in 40 percent of Centers funded. Such new services will offer milieu therapy and group individual therapy as well as the somatic therapies. In another 32 percent the applicant already provided some inpatient service but planned to upgrade and expand this service either by providing new physical facilities or by providing new and increased staff. Among the applicants for construction funds, many had no inpatient beds available to them at all, a number had over 50, and the remainder were distributed evenly between five or less and 40 or more. The number of beds proposed in the new construction ranged from zero in a few rural centers which planned to hospitalize patients on medical wards to over 100 in a few of the larger centers. The average number of planned beds was 24 to serve an average of 165,000 people. Thus the average proposed bed: population ratio is 14.5 beds: 100,000 people. New outpatient services will be offered by 45 percent of applicants, and an additional 40 percent of the applicants will upgrade and expand existing services. Fifty-five percent of the applicants will provide new partial hospitalization services, and an additional 15 percent of applicants will increase the size and scope of their partial hospitalization efforts. Partial hospitalization represents a relatively new service even for those applicants who already have some service in operation. The development of this service represents one of the substantial contributions of the Community Mental Health Center program. Consultative assistance by NIMH central and regional office personnel has proved to be of value to applicants in helping them develop plans for this service. Plans for partial hospitalization include services which will care for all patients including the very ill. Such services will provide back-up for inpatient services to deal with the occasional patient who needs 24-hour care for a few days at some point in his course of treatment. Other partial hospitalization programs will tie in more closely with inpatient services, and patients will very often be treated first as inpatients, then as day or night patients as they travel the road to recovery and return to the community. New emergency services will be provided by 50% of applicants, and 30 percent of applicants will increase their emergency services beyond what is already available. In a few rural centers the emergency service will consist of a general hospital emergency room with a nurse on duty and a physician on call. In a larger town there may be an intern on duty and a psychiatrist on call. In an urban center a psychiatric resident will be available 24 hours a day. New personnel will be hired and further training will be provided to personnel already available. Additionally, many centers plan to publicize their emergency services more heavily within the community so that better use can be made of them. Forty percent of applicants will offer new consultative services, and another 40 percent will upgrade and increase existing consultative services. Existing services are for the most part informal and do not account for a large proportion of professional time or budget. The centers are planning to develop formal consultative relationships with other community agencies. Most frequently consultative relationships are with schools, churches (clergymen's groups), court and juvenile authorities, welfare agencies, and Alcoholics Anonymous and other groups concerned primarily with alcoholics. The emphasis on consultation in the Centers represents one of the important innovations of the Community Mental Health Center program. This emphasis grows out of the broader NIMH philosophy regarding provision of services. We encourage existing service resources to deal with human problems wherever possible, rather than referring people for treatment to a mental health professional. We are committed to a public health model of provision of services. In mental health such a model implies that treatment by professionals should be a last resort, to be sought only when indigenous efforts at managing a human problem fail. To that end we encourage the use of mental health professionals, not only as direct treatment agents, but as consultants to those who are directly concerned with human problems. The development of the five named essential services takes priority over the development of other services in the Community Mental Health Center program. For this reason many centers have concentrated their immediate efforts on developing these services, while planning to provide at a later time the five additional services characteristic of a comprehensive center. These five additional services are diagnosis, precare and aftercare, rehabilitation, training, and research and education. Separate diagnostic services are planned in those centers which are sufficiently well staffed to justify a separate service. In smaller centers diagnosis is currently carried out by staff members as part of their initial evaluation of patients within the framework of existing services. Precare and aftercare services are also carried out within the framework of existing outpatient and inpatient services. In large, well-staffed centers, precare and aftercare have been developed as separate services, as a result of efforts to establish channels for early case referral and efforts to assure that the patient discharged from inpatient status can maintain his optimal level of functioning in the community. Rehabilitative services are being developed to meet the specific needs of center patients for occupational retraining. Many centers have established liaison with State Vocational Rehabilitation Services, and rehabilitation counselors are available for consultation to centers on a part-time basis. Again, the larger more comprehensive centers are staffing their own full-time rehabilitative services. Almost all the centers recognize that the center is a training resource as well as a service resource. Several States have explicitly considered this in developing their plans and have attempted to place centers close to sources of potential trainees. Plans for training in all mental health disciplines are being developed. These include psychiatric residency and community psychiatry training programs, psychology internship programs, social worker placement programs, psychiatric nurses' training, and training for occupational therapists, activity therapists, and various aides and other subprofessionals. Research and evaluation services are seen by all centers as desirable. The staffing patterns for the centers give a further perspective on the magnitude of the proposed effort. We report the data as full-time equivalents (FTE's), rather than as numbers of personnel, since many centers make extensive use of part-time professional staff. The average center uses between five and six psychiatrists. The range is from one to 32. The average center uses between four and five FTE psychologists. The range is from one to 29. The average number of social workers planned for is between 11 and 13, and the range is from one to 62. For registered nurses the projected average is 77-607-67-3 between 14 and 16, and the range is from one to 80. These data serve to illustrate the great range of efforts. The smaller rural centers have a staffing pattern of two or three professionals, and the larger metropolitan centers plan have well over 150 professionals. The professionals are of course supported by non-professionals in all cases. Our data on non-professionals are less exact, but we estimate that each professional is supported by approximately two non-professional workers. PART IV-GOALS AND PROSPECTS The outlook, then, is a positive and promising one-reflecting substantial progress in the Community Mental Health Center program itself, and in the allied programs of the NIMH converging on that effort. This statement would be incomplete, however, without an acknowledgment of the problems we must yet face. We must continue our efforts to fill the enormous reservoir of manpower demanded by the Community Mental Health Center program, without which our highest purposes will be frustrated. Through careful research, we must continue to pursue the kinds of creative approaches to the treatment of the mentally ill that alone can give true meaning to the establishment of comprehensive services. We must encourage close collaboration among the many professional disciplines working in the interests of the Nation's health, molding them into the kinds of compassionate staff that best serve the patient's interests. We must assure that existing patterns in the financing of mental health services are maintained and strengthened in the States and communities across the Nation. Despite our progress, we must be constantly aware that the Nation's need is still great-that nearly half a million Americans continue to reside in mental hospitals, and that a third of our citizens are significantly impaired at some time in their lives by symptoms of mental illness. We have made only a modest start in meeting the mental health needs of the American people; the great bulk of our population remains to be served through the 2,000 centers planned by 1980. Difficult tasks and obstacles are still clearly before us, yet I have every reason to believe that we will succeed. This conviction arises out of the confidence and strength we feel as partners with communities throughout the Nation. Ours is a cooperative venture embracing various segments of society. Across the country we have stimulated a wave of rising hopes. We shall continue in our efforts to satisfy those hopes-and thereby advance the well-being and productivity of our people. APPENDIX Centers funded by State and locality as of Mar. 1, 1967 |