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MANAGING MANAGED CARE: QUALITY IMPROVEMENT IN BEHAVIORAL HEALTH
the actual goals of treatment and the lack of consensus about what is considered successful treatment. For mental health problems, the goals of treatment differ according to the diagnosis, the severity of the illness, and past responses to treatment. Treatment generally begins with a comprehensive assessment that results in an individualized treatment plan. In many cases, full recovery from a mental health problem can be expected, with an individual returning to his or her former preillness level of functioning. Treatment also may have the goal of controlling symptoms or preventing relapses among those with recurring episodes of a disorder, such as depression. Improvements in functioning, rather than a complete return to preillness functioning, may be the goal for those with severe and chronic disorders such as schizophrenia. Improving quality of life by facilitating access to social services (e.g., through case management) may also be a goal, particularly for patients with severe debilitating and chronic mental disorders. Finally, the avoidance of violence may be a goal, such as when persons with suicidal or homicidal tendencies are restrained in a heavily supervised setting such as a hospital or locked nursing facility. Additional goals could include an improved ability to live independently in the community, or an ability to maintain employment in a supervised setting.
In the substance abuse field, a fundamental and sometimes controversial issue is whether treatment goals should be directed toward abstinence versus improvement. On the whole, alcohol treatment programs are oriented to an abstinence model rather than one of controlled drinking or improvement. Political considerations related to the management of illicit substances have played a large part in shaping treatment goals for chronic substance abusers (IOM, 1990a; Marlatt, 1983; Roizen, 1987). As a consequence of these strong ideological stances, some of the treatment interventions with proven efficacy (e.g., methadone maintenance with heroin addicts and controlled drinking strategies with carefully selected populations) are not often found in managed care treatment systems and therefore cannot be included in current managed care outcomes studies.
An additional issue affecting the definitions of outcomes for mental health and substance abuse treatment has to do with the public and policy expectations of treatment. Although some mental health and substance problems are chronic relapsing conditions like other medical problems, they also raise issues concerning individual and community responsibility that are not usually associated with other medical problems. Concerned stakeholders include individual clients, treatment programs, reimbursers, regulatory agencies or monitors, family members, agencies that have legal (the criminal justice system) or contractual relationships (employers), and the public. The goals of these groups are often conflicting, and the group whose interests are primary changes over time. These goals result in broad expectations of treatment, including reduced crime, improved health status, prevention of human immunodeficiency virus infection, reduction of unsafe sexual practices, improved employment, and improved family functioning. Reduced levels of alcohol or drug use or improved mental health symptoms are not