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acute care facilities, outpatient clinics, office-based practices by individual practitioners and by groups of primary care and specialty practitioners, and nonmedical settings such as the workplace, schools and universities, and community-based settings. Thus, the continuum of care ranges from the most restrictive settings (inpatient hospitalization and residential treatment) to the least restrictive settings (community-based programs and outpatient counseling). Typically, substance abuse treatment is considered a part of mental health treatment because of the similarities in treatment and financing. In this section, the focus is on the treatment of mental health problems.

We have a pluralistic system, and we have great diversity in our service delivery system, which I think is one of its strengths.

Judith Hines

Council on Accreditation of Services for Families and Children

Public Workshop, May 17, 1996, Irvine, CA

Traditionally, states fund a large proportion of mental health treatment, dominated by inpatient hospitalization. States historically have operated with categorical budgets, with public funds earmarked for specially defined populations, such as runaways or other homeless individuals. Over the years, state mental health agencies have begun to contract with an array of practitioners, including community mental health centers and non-profit community based service agencies (Essock and Goldman, 1995). As discussed in Chapter 3, the public system delivers care for individuals who are uninsured and underinsured and serves a safety net function.

Table 4.4 and Table 4.5 display the range of mental health treatment settings, including those in both the public and private sectors.

Because community-based services play an integral part in the delivery system, the next section describes them in more detail.


In the public sector, federal and state policies have promoted the development of a coordinated continuum of care. Wraparound or “enabling ” services such as transportation to treatment, child care, employment services, legal assistance, and other services have traditionally been an integral part of publicly funded treatment systems for two primary reasons (Institute for Health Policy, 1995). First, the historical evolution of treatment systems for alcoholism and drug dependence has taken place largely outside of medical systems and medical models of care,

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