The International Journal of Psychosocial Rehabilitation

An Impact Evaluation Model and Quality Improvement Mechanism for Mental Health Programs in Developing Countries

Arthur J. Anderson, Ph.D.
Consulting Clinical Psychologist - Honduras


Citation
Anderson, A. J. (1999). An Impact Evaluation Model and Quality Improvement Mechanism for Mental
Health Programs in Developing Countries. International Journal of Psychosocial Rehabilitation. 4, 55-64



Abstract: Discusses the rationale for using responsive evaluation in mental health and substance abuse programs. Demonstrates the need to include both standard and local indicators in evaluation studies and how this can be used by all the stakeholders of a program to continue the quality improvement initiatives of any mental health program in a way that incorporates all levels of data and opinions. Presents and actual evaluation proposal and instruments in both Spanish and English.


An Impact Evaluation Model and Quality Improvement Mechanism for Mental Health Programs in Developing Countries

In both mental health and substance abuse treatment, it may be that there are no resistant patients; only resistant programs and clinicians, who are reluctant to change their mode of service delivery to meet their patient's needs. To determine the extent to which programs and service models meet the needs of patients, program evaluations must be performed to assess the impact of the entire program and therapeutic environment (Anderson, 1997). Only then can rates of efficacy and effectiveness be objectively determined and improvements panned, initiated and reviewed to continue the improvement of services over time. Thus, program evaluation and continuous quality improvement can be incorporated into a comprehensive quality of care mechanism to more closely match services with the changing needs of patients, families, funding sources and all other stakeholders over time (Guba and Lincoln, 1981, 1989).

This brief article details a strategy of program evaluation and quality improvement that has been successfully used in programs located in the United States and in Honduras (Anderson, 1997a). Written as a program research proposal, the following outline proposals and associated instruments serve as tools that can be applied to almost any mental health or substance abuse program setting.

This evaluation strategy consists of two groups of indicators; standard and local indicators. Standard indicators, listed below, were developed in such a way as to be applicable to all mental health programs. Generally, these indicators are analyzed by a skilled evaluator who can statistically manipulated the large volume of program, demographic and clinical data. However, for the purposes of determining treatment benefits on a programmatic level, simple descriptive statistics can be used on these indicators to demonstrate levels of programmatic efficacy. Local indicators are patient, infrastructure, process or other program characteristics that are mutually agreed upon for study by all the stakeholders of a program. These stakeholders include clinicians, administrators, funding sources, families and of course patient representatives.

The local indicators allow all the stakeholders of the program to determine what additional indicators are needed to demonstrate their program's effectiveness. As the data from both sets of indicators is accumulated monthly or quarterly, trends develop which require actions from some or all of the stakeholders to improve that area of the program. Once problems have been resolved, new indicators can be developed to continue the positive change process. Over time, this process serves to continually improve patient services and match treatment to the needs of the patient, instead of matching the patient to the needs of the program.

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Collaboration ------>measure------>Data Reporting & Action ------->measure----->Data Rept. & Action----->

The following evaluation proposal and tools serve only as a model. Please feel free to use all or part of it and the associated instruments for any evaluation project you wish to undertake. I have provided the proposal in both English and Spanish for your convenience. Though originally written for programs that treat mentally ill chemical abusers in Honduras, it and the model can be applied to almost any mental health program setting.
 
 

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Project Impact Research Proposal Summary

An Evaluation of Integrated and Disease Specific Programs for
Mentally Ill Chemical Abusers

 
 









Objectives:

1. To identify the most effective mental health and substance treatment strategies in Honduras that may be generalizable to developed nations and other developing countries.

2.. To introduce a 'state of the art' impact evaluation model in a developing Latin American country. This should not only provide health and mental health program data, but provide a comprehensive strategy for sustained program/project evaluation and a mechanism for continuous quality improvement within individual health programs in Honduras.

3. To provide the ministry of health with a strategy to monitor treatment efficacy across health and mental health sectors and sub-sectors.

Introduction: Patients diagnosed with severe mental illness who also suffer from other psychiatric and medical disorders present a variety of individual, social, fiscal and political challenges not only for program funding, but planning and implementing effective rehabilitative treatment programs as well. This is especially true in Honduras and Central America where programs operate at minimal funding levels. Severe mental illness coupled with severe personality, behavioral, addictive, cognitive or physical disease, stretches the ability of community based treatment programs to effectively treat these patients. This has led to the development of a wide variety of treatment models designed to serve the multiple needs of these patients (Bachrach, 1984; Drake, 1989, 1991; Minkoff 1987). An evaluation of the clinical effectiveness of these models would not only lead to more cost effective use of limited treatment resources, but more importantly, improve clinical treatment options for the dually diagnosed throughout Central America.

Focusing a program model evaluation on current treatment programs for the most commonly reported dually diagnosed population, mentally ill chemical abusers (MICA), would demonstrate the differential rates for effectiveness for the most commonly used program models. These results would be invaluable to Honduran and international policy planners, administrators, legislators and program developers who must design and implement the most effective treatment programs possible with limited resources.

Treatment programs for the dually diagnosed primarily fall into two main categories: disease specific and integrated program models (Minkoff,1991). Disease specific program models tend to focus treatment on what they consider to be the primary area of distress and minimize the importance or urgency of other areas of dysfunction. Many substance abuse treatment programs and traditional hospital based mental health programs typically model their treatment programs in this manner. Integrated program models, found in both hospital and community based settings, are designed to provide individualized treatment planning and services which focus attention on all areas of patient dysfunction are designed to aggressively treat all patient symptoms and associated problems within a single program.

The development of these models has not been based so much on the clinical efficacy, but more on availability of funding and political interest in treating specific patient populations (Humphreys & Rappaport, 1993). This fragmentation of program models has been perpetuated through the development of artificial and arbitrary administrative divisions at the federal, state and local levels without regard to clinical measures of success for the various program models. This is not only the case in industrialized countries but in developing nations as well. Consequently, it is possible that many public sector and grant funded programs continue to be financed through a variety of funding streams with little or no demonstrable clinical success. This siphons critical funds from those programs that use more clinically viable models.

An evaluation of relative treatment outcomes for these two main program models would demonstrate the effectiveness of each model to treat chemical abusers. These results would also enable program planners to create or modify existing programs to more effectively treat their target dual diagnosis populations. Using responsive evaluation methodologies, in which specific clinical program indicators are studied along with indicators chosen by the program's clinical team, the programs under investigation in this pilot study will not only derive efficacy data but have a clear mechanism to continuously improve the quality of care far into the future. Thus, not only will there be data as to program model's effectiveness, but a quality improvement mechanism to improve health and mental health care into the future.

A large proportion of chemical abusers (50-70%) also suffer from concomitant psychological disturbances. In this respect they can be considered dually diagnosed. Dually diagnosed patients in general and specifically MICA patients have complex treatment needs and interactive symptomatology that requires a more integrated approach than is generally employed (Breakey, 1987). It therefore seems likely and is hypothesized that integrated treatment models would be clinically more effective in treating the dually diagnosed MICA patient than population specific models. Evaluating the positive treatment outcomes produced by each program model, treating a similar patient population, should demonstrate the relative clinical effectiveness and cost effective utility of each program model to treat the dually diagnosed. In addition, the use of the local participants (or stakeholders) in the study to first assist in the design of the local indicators, then participate in the measurement of all the indicators, and finally meet periodically to derive action plans that address programmatic deficits will continue quality improvement of both programs under investigation and serve as models of quality improvement to other, similar programs in Honduras.

Methodology:

This investigation will evaluate patient outcomes for two treatment programs at in Honduras that treat mentally ill chemical abusers. The purpose of this is to determine the relative value of each program to treat MICA patients. Clinical outcomes in a traditional drug and alcohol treatment program, a disease specific substance abuse treatment program, will be compared with outcome data from a more comprehensive, community based rehabilitation program that uses an integrated program model. Since both programs have goals of rehabilitating MICA patients over a six month period and promoting long term, drug free community tenure, have similar staffing patterns and are located in the same geographic area, a comparison of program outcomes, based on standard indicators, can be performed to determine the relative value of integrated and disease specific treatment models to treat these patients.

All mentally ill chemical abusing patients who enter the programs during the 6 month period of the study will be included in the investigation. Thus, the investigator(s) must be on site to rate patients during the six month period of the data collection, and remain available for an additional three months to analyze data and continue to refine the data set on the local indicators. For this proposed investigation, the treatment program admission criteria of a major Axis I diagnosis in addition to substance abuse will be the same for both programs. Thus, the patient 'pool' for these two programs are assumed to be identical for the purposes of this study (See Subject Selection). This, however, will be confirmed through the analysis of variance between the groups on the dimensions of age, diagnosis, GAF level at the onset of treatment, and duration and type of substance abuse.

Indicator Selection: In addition to using a set of standard indicators that can be applied to almost any health care program, both programs will also be asked to determine three to five local indicators of successful treatment that are particular to their programs. This information will be of greatest value to the quality improvement component of this study. As information becomes available on both sets of indicators (standard and local) the major stakeholders of each program can agree on the remedial actions necessary to improve the quality of care and improve future performance. If this process continues beyond the six month scope of this pilot study, the net result will be a trend toward improving care on a local programmatic level. Such quality improvement mechanisms are currently not in use in programs that serve the street people and poor of Honduras.

Subject Selection: The patients for both programs under study will be selected on the basis of their meeting the diagnostic admission criteria for the programs. Patients who are ambulatory and not in need of acute care, who are diagnosed with a major Axis I disorder and/or an Axis II diagnosis, and have additional substance abuse diagnosis are admitted to both programs directly from street and other referral sources and will be included in the study upon admission to the programs.

Patient Characteristics: Programs goals of patient rehabilitation and functional community assimilation of mentally ill chemical abusers within a six month time frame are generally the same for each program model. In addition, both program models require patients to meet the target diagnostic and functional criteria for treatment in the programs and from the programs' point of view are expected to functionally improve to the point of community readiness. Since this study compares patient outcomes against the program goals, we can consider the patient populations identical only in this respect. Both groups are comprised of male and female MICA patients with similar backgrounds from the same geographic location.

Standard Indicators and Data Analysis

The two programs will be evaluated by the following standard criteria:

Indicator 1: Successful Treatment Outcomes This will be determined by results of the Level of Functional Assessment scale (Modified)(LOFA); a 53 item scale that quantifies functioning across independent areas of social, cognitive and physical skills (Uehara, Smulker & Newman, 1994. Within two weeks of admission, each patient will be rated on the LOFA . Level and type of addiction will be noted along with other diagnostic and demographic data on the Patient Information Sheet. Patients will be rated again at three months and again at their six month point in the program to note changes in their functional level due to their treatment. All data will be recorded on the Patient Information Summary Sheet.. Patients who reach a GAF level of at least 70, as determined by their LOFA equivalent score, will be counted as meeting their program's objectives for successful treatment outcomes.

Indicator 2: AMA Discharge Within the context of this evaluation, the percentage of patients who do not complete treatment and who leave the programs against medical advise will be compared across programs as a measure of the treatment program's inability to meet the needs of the target population. Since both program models have clinical failures of this type, the percentage of patients who leave each program against medical advise or for cause will be included as AMA Discharge measures of negative clinical outcomes..

Indicator 3: Correlation of Service Hours delivered. A correlation between actual number of service hours delivered and the percentage of successful treatment outcomes per program will be performed to evaluate whether variable amounts of treatment affect overall program outcomes and success. This will demonstrate any relationship between amount of services delivered and successful treatment outcomes.

Indicator 4: Subpopulation Outcomes Differential success rates between diagnostic subpopulations (i.e. schizophrenic, substance abusers versus mood disordered, substance abusers), will also compared to determine whether the models are best suited to one sub-population or another. This measure will be applied to the criteria indicators listed above.

Indicator 5: Relative Rates of Recidivism Percentage rates of patient recidivism for program graduates will also be determined as a measure of the program's relative inability to effectively rehabilitate their target MICA population. Recidivism within the context of this study is defined as any patient who returns to the streets or resumes substance abuse activities.

Indicator 6 - Patient Satisfaction Patients in both groups will complete a Spanish version of the NYSOMH standard patient satisfaction survey at the six month point in their program or upon successful completion and discharge from the program. This will provide a measure of the patients' qualitative level of satisfaction within each program model.

Indicator 7: Cost Efficiency Rate Relative cost per service unit will be determined for patients who successfully meet the goals of the program (See Indicator 1). This measure is included to illustrate differential program costs for those patients who met program goals and is considered a gross measure of program efficiency within the context of this study.

Local Indicators: The two programs will also be asked to form a committee which includes all the stakeholders that may have interest in each program. This may include the governmental monitoring agencies, funding sources, program directors, clinical staff and administrators. The stakeholder committee will be asked to select at least three outcome indicators that reflect effectiveness of treatment. Once determined, these indicators will be monitored, measured for six months, analyzed by the committees and reported in addition to the standard indicators. Once reported on, these two committees will develop action plans to address deficit areas determined in either the standard or local indicators for their particular programs. These committees will meet after the next interval (three months) and develop action plans to either address problematic areas determined through local indicator data measures and/or develop new action plans for the next three month interval.

Expected Results, Potential Benefits and Reporting Findings:

1. Based on similar studies of this kind (Anderson, 1996), we can expect to see higher levels of clinical efficacy in the integrated program design than in the disease specific program model. This should not only be reflected in the cost efficiency results but in the clinical indicators as well.

2. Deficit program areas should emerge that are specific to these particular programs. Such statistics and qualitative data will point the way toward improving the quality of future quality of care in the respective program models.

3. Since the results of this investigation will be shared with the respective programs, the program models can be modified to increase positive clinical and fiscal gains in each program.

4. Study results will not only be made available to the grant funding sponsors, but will also be reported to the ministry of health to assist in their future mental health planning efforts. The responsive evaluation methodology research model, used in this investigation, will be outlined in detail and reported to the ministry for use in follow-up impact investigations. This will ensure sustainability of the impact evaluation effort and mechanism for continuous quality of care improvements in both health and mental health sectors.

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INSTRUMENTS (English & Spanish)
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(SPANISH VERSION)

Propuesta de Investigación sobre impacto de programas

Evaluación comparativa de modelos de atención integrales y de tratamiento específico para farmacodependientes con problemas mentales

Objetivos:

1. Identificar los tratamientos más efectivos para alcohólicos y farmacodependientes con problemas mentales que puedan ser replicados en otros paises, tanto en desarrollo como industrializados.

2. Introducir un modelo de evaluación de impacto que permita no solamente obtener datos sobre salud y salud mental, pero también definir una estrategia para la evaluación contínua de programas y proyectos y que ofrezca un mecanismo para el mejoramiento contínuo de la calidad de estos programas y proyectos.

3. Ofrecer al Ministerio de Salud estrategias para monitorear la eficacia de los modelos de tratamiento ofrecidos en salud y salud mental.

Introducción :Pacientes que han sido diagnosticados con enfermedades mentales serias, quienes también sufren de otros problemas médicos presentan retos individuales, sociales, económicos y políticos no solamente para el financiamiento de programas dirigidos a ellos, pero para la implementación de programas efectivos de rehabilitación. Esto es particularmente cierto en Honduras y otros países Centroamericanos donde estos programas operan con un mínimo de financiamiento.

Enfermedades mentales serias acompañadas de problemas de personalidad, comportamiento, adicción y problemas físicos, sobrepasan la capacidad de atención de programas que funcionan a nivel comunitario. Para resolver esta problemática se han desarrollado varios tipos de programas diseñados para dar respuesta a las necesidades múltiples de estos pacientes. La evaluación de la efectividad de los diferentes tipos de programas resultará en una mejor utilización de los limitados recursos disponibles, y lo que es más importante, mejorará el tratamiento para pacientes diagnosticados con enfermedades mentales y farmacodependencia y-o alcoholismo.

Programas de tratamiento para pacientes con enfermedades mentales y farmacodependencia y/o alcoholismo tienen dos modalidades principales: las que tratan problemas específicos y las que ofrecen tratamiento integral (Minkoff, 1991). Los programas que ofrecen tratamiento específico tienden a enfocar el tratamiento al área de mayor disfuncionalidad y a minimizar la importancia o urgencia de tratar los síntomas considerados secundarios. Muchos programas de tratamiento para alcohólicos y farmacodependientes, así como programas dentro de los hospitales ofrecen esta modalidad de tratamiento. Los programas de tratamiento integral que se encuentran en algunos hospitales y clínicas comunitarias han sido diseñados para ofrecer planes de tratamiento individualizados y servicios de atención que tratan todos los síntomas del paciente agresivamente dentro del mismo programa.

Una evaluación de los resultados de estas dos modalidades diferentes de tratamiento demostrará la efectivdad de cada modelo para pacientes con problemas de farmacodependencia y/o alcoholismo. Los resultados de la evaluación permitira a los planificadores de programas que modifiquen programas existentes o que creen nuevos programas para tomar en cuenta los resultados de la evaluación del tratamiento de este tipo de pacientes. Los programas objeto de esta investigación utilizarán metodologías modernas de evaluación mediante las cuales se estudiaran indicadores de éxito del programa, así como indicadores de eficacia seleccionados por el personal profesional del programa. Esto permitirá obtener datos sobre efectividad del programa y también mecanismos para mejorar continuamente la calidad de atención de los programas.

Metodología:

Esta investigación evaluará los resultados del tratamiento recibido por los pacientes en dos programas que dan atención a personas con problemas mentales y problemas de farmacodependencia y/o alcoholismo. El objetivo es determinar la efectividad relativa de cada programa para ofrecer tratamiento a este tipo de paciente. Los resultados clínicos de un programa tradicional que ofrece servicios de atención a farmacodependientes y/o alcohólicos con problemas mentales serán comparados con los resultados de un programa que ofrece atención integral al mismo tipo de paciente. Dado que ambos programas tienen el objetivo de rehabilitar a los pacientes en un período de seis meses y ofrecer servicios que promuevan la conducta prosocial en los pacientes, que ambos programas tienen personal similar y están ubicados en la misma área geográfica, se puede realizar una comparación de los resultados del programa, basada en indicadores estándar para determinar la efectividad relativa de los diferentes modelos para tratar este tipo de pacientes.

Todos los pacientes que ingresen al programa durante un período de tres meses, con problemas de farmacodependencia y/o alcoholismo serán incluidos en la investigación. Para esta investigación los criterios de admisión con una diagnosis de Axis I, además de farmacodependencia y/o alcoholismo deben ser los mismos. Por lo tanto, el grupo de pacientes de estos dos programas será considerado idéntico para propósitos de este estudio (ver el párrafo sobre selección de pacientes). De cualquier manera, esto será confirmado mediante un análisis estadístico.

Selección de indicadores: Además de utilizar un grupo de indicadores estándar que pueden ser utilizados en cualquier tipo de programa de atención médica, ambos programas deberán seleccionar entre tres a cinco indicadores particulares a cada programa que permitan determinar el éxito del tratamiento. Esta información será de mucha utilidad para el componente de mejoramiento de la calidad del tratamiento de estos programas. A medida que se obtenga información sobre todos os indicadores (estándar y particulares), los interesados de cada programa pueden ponerse de acuerdo en acciones necesarias para mejorar la calidad del tratamiento y mejorar la operación futura del programa. Si este proceso continúa después de los tres meses del estudio piloto, el resultado será una mejora a nivel de programación local. Al presente, estos mecanismos de mejoramiento de la calidad del tratamiento no son frecuentemente utilizados en programas que ofrecen servicios a personas con problemas de farmacodependencia y/o alcoholismo.

Selección de pacientes: Los pacientes para ambos programas incluidos en este estudio serán seleccionados con base en los criterios de admisión a los programas. Estos serán solamente pacientes que son AMBULATORY y han sido diagnosticados con problemas de Axis I o Axis II y adicionalmente tienen problemas de farmacodependencia y/o alcoholismo.

Características de los pacientes: Los objetivos de ambos programas incluyen la rehabilitación y la promoción de conducta prosocial en los pacientes en un período de tres meses. Además, ambos programas requieren que los pacientes cumplan con los criterios de admisión para tratamiento dentro de los programas y desde el punto de vista de los programas se espera que éstos mejoren al punto de estar listos para su reinserción en la comunidad. Dado que este estudio compara los resultados relacionados a la mejora de los pacientes con los objetivos del programa, los grupos de pacientes se considerarán idénticos únicamente en este aspecto. Ambos grupos estarán compuestos por hombres y mujeres de BACKGROUND similar y de ubicación geográfica similar.

Indicadores estándar y análisis de datos:

Los dos programas serán evaluados mediante los siguientes criterios:

Indicador 1: Tratamiento exitoso. Este será determinado a través de los resultados de la escala de nivel de conducta funcional (LOFA). Esta es una escala de 53 itemes que cuantifica la conducta funcional en diferentes áreas, tales como el abilidades sociales, cognitivas y físicas. Dentro de las primeras dos semanas de ser aceptado en el programa, a cada paciente se le administrará la prueba LOFA. Se anotará el nivel y tipo de adicción junto con otra información relacionada al diagnóstico y datos demográficos en el formulario de Información sobre el paciente. A los pacientes, se les administrará nuevamente la prueba el dia en que son dados de alta del programa.

Indicador 2: Dada de alta. En el contexto de esta evaluación, el porcentaje de pacientes que no completen el tratamiento y que dejen el programa en contra de la recomendación médica, serán comparados en los dos programas mostrando la inabilidad de los dos programas de dar respuesta a las necesidades de la población meta. Dado que los programas sufren de fracasos de este tipo, el porcentaje de pacientes que deja el programa sin aprobación médica o por alguna otra cause será incluido como un indicador de resultados negativos.

Indicador 3: Correlación de horas de atención. Se hará un análisis de corelación entre el número actual de horas de atención ofrecidas y el porcentaje de tratamientos exitosos por programa para evaluar si la variación en horas de atención afecta el resultado y éxito del tratamiento ofrecido por cada programa. Este análisis mostrará la relación entre horas de atención y éxito del tratamiento.

Indicador 4: Resultados por grupo de pacientes. Tasas de éxito entre grupos de pacientes (por ejemplo, esquizofrénicos con problemas de farmacodependencia y/o alcoholismo comparados con pacientes con desorden de conducta a nivel del afecto y con problemas de farmacodependencia y/o alcoholismo) también serán comparadas para determinar si los tratamientos son más exitosos en un grupo de pacientes que en otro. Estas medidas se aplicarán a los indicadores 1 a 3. 4

Indicador 5: Tasas relativas de recaída. Los porcentajes de pacientes que completan el tratamiento y recaen serán utilizados como una medida de la efectividad del programa en la rehabilitación de la población meta. En el contexto de este estudio, se define la recaída como una reversión a la conducta aberrante que conlleva el uso y abuso de fármacos, alcohol y drogas, después de un período de abstinencia y ajuste social satisfactorio.

Indicador 6: Satisfacción del paciente. Los pacientes en ambos programas completarán un cuestionario estándar para dar su opinión sobre el programa y el tratamiento recibido a los tres meses de haber iniciado el programa o al ser dados de alta. Esto aportará información cualitativa sobre la satisfacción del paciente con el programa y tratamiento.

Indicador 7: Costo eficiencia. El costo relativo por unidad de atención será determinado para pacientes que cumplen con los objetivos del programa (ver indicador 1). Se incluye esta medida para mostrar la diferencia en costos unitarios para pacientes que cumplieron con los objetivos del programa y es considerada una medida bruta de la eficiencia del programa en el contexto de este estudio.

Indicadores locales. Se espera que cada programa conforme un comité que incluya a todos los interesados en el programa. Este comité puede incluir instituciones de gobierno, donantes, directores del programa, personal médico y administradores. El comité deberá seleccionar por lo menos tres indicadores de resultados que reflejen la efectividad del tratamiento. Una vez que estos indicadores han sido definidos, se les dará seguimiento mensualmente . Los resultados serán analizados por los miembros del comité quienes serán responsables de elaborar un plan de acción para resolver áreas problemáticas en el siguiente mes.

Resultados esperados, posibles beneficios y resultados del estudio

1. Con base en estudios similares (Anderson, 1996) se espera obtener mejores índices de eficacia del programa que ofrece servicios de atención integral a los pacientes comparado con el programa que ofrece tratamiento a enfermedades específicas. Esto se debería ver reflejado no solamente en los indicadores de costo eficiencia del programa, sino también en los indicadores clínicos.

2. Se espera identificar áreas problemáticas en los programas. Los datos estadísticos así como la información cualitativa recopilada permitirá mejorar cualitativamente la atención y tratamiento ofrecidos a los pacientes.

3. Dado que los resultados de este estudio serán puestos a disposición del programa respectivo, estos podrán hacer modificaciones en su funcionamiento para mejorar los aspectos clínicos y financieros.

4. Los resultados del estudio serán puestos a disposición del Ministerio de Salud para su utilización en el proceso de planificación y definición de estrategias de atención a la salud mental. La metodología de evaluación participativa utilizada en el estudio será descrita en detalle y entregada al Ministerio de Salud para que la institución la utilice en futuras evaluaciones de impacto de programas bajo su responsabilidad. Esto puede asegurar la sostenibilidad de este esfuerzo de evaluación de impacto y también puede servir como un mecanismo para el mejoramiento de la calidad de los servicios de atención de salud y salud mental.

INSTRUMENTS (English & Spanish)

References

Anderson, A. J. (1997). Methodological Approaches in Mental Health Services Research and Program Evaluation. International Journal of Psychosocial Rehabilitation. 1(1), 3-20.

Anderson, A. J. (1997a) A Comparative Impact Evaluation of Two Therapeutic Programs for Mentally Ill Chemical Abusers. International Journal of Psychosocial Rehabilitation. 1(1), 34-46.

Bachrach, L.L. (1984). The homeless mentally ill and mental health services: An analytical review of the literature. In H.R. Lamb. (Eds.) The homeless mentally ill (pp. 11 33). Washington DC: American Psychiatric Press.

Breakey, W.R. (1987). Treating the homeless. Alcohol and Research World, 11, 42 47.

Drake, R.E., Antosca, L., Noordsy, D.L., Bartles, S.J., Osher, F.C. (1991). Specialized services for the dually diagnosed. In K. Minkoff and R.E. Drake (Eds.), Dual diagnosis of major mental illness and substance disorder (New directions in Mental Health (pp. 67 67). San Francisco: Josse Bass.

Drake, R.E., Osher F.C., Wallach, M. (1989). Alcohol use and abuse in schizophrenia a prospective community study. Journal of Nervous and Mental Disease, 177, 408 414.

Drake, R., Osher, F., Wallach M. (1991) Homelessness and dual diagnosis. American Psychologist, 46(11), 1149 1158.

Guba, E.G. & Lincoln, Y. (1981) Effective Evaluation. San Francisco: Josey Bass.

Guba, E.G. & Lincoln, Y. (1989) Forth Generation Evaluation. Newbury Park, CA: Sage Publications.

Humphreys, K., & Rappaport, J. (1993). From the community mental health movement to the war on drugs. American Psychologist, 48(8), 892 901.

Minkoff, K. (1987). Beyond deinstitutionalization: A new ideology for the postinstitutional era. Hospital and Community Psychiatry, 38, 945 950.

Uehara, E.S., Smukler, M., & Newman, F.L. (1994). Linking resourse use to consumer level of need: Field test of the level of need care assessment (LONCA) method. Journal of Consulting and Clinical Psychology, 62, 695 709.




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