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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:

Stafing 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).

$46, 465 Project cost----

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 Prevention.--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 costo--

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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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 yentures 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 seryice 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

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