Challenges In Community Mental Health Needs Measurement

Community care can be described as the processes and tools required to enable mental health for a given population (Thornicroft, 2011).

A definition of community mental health care can be explained by having the following four elements: first, encompassing both an individual and a population-based approach to needs assessment and prevention, open access to services, and a systemized view of service offerings.

Second, it focuses on people’s strengths from a recovery perspective, and not merely from an outlook of disability.

Third, it includes the community at large and a network of resources to adequately support the population.

Fourth, it calls for evidence-based clinical practice with a scientific approach to services prioritization and intervention effectiveness (Thornicroft et al., 2016). Regardless of the definition used to describe community care, these practices share similar challenges in defining and measuring needs.

Criticism of the community care model arose in the 1980s with the closure of several mental hospitals in the UK. The National Schizophrenia Fellowship argued for adverse consequences of moving mental patients out of hospitals due to inadequate provision of aftercare, the need for stable support for families of patients, and the fact that some patients may need the lifelong care that psychiatric hospitals can provide. As an offer to debunk some of these criticisms, a book was published by the Team for the Assessment of Psychiatric Services (TAPS). The authors state there is evidence of positive effects of residential care for the mentally ill who leave the mental institutions, yet interestingly community care was not more economically resourceful than care within the hospital (Leff, 1997).

The challenges of enabling high quality community care include how we define what the needs are for a particular population, and how to best go about systematizing these assessments so they are measurable and effective in offering solutions to problems. To address this challenge, how do we measure need? A tool called the Camberwell Assessment of Need Short Appraisal Scale (CANSAS) approaches this issue by evaluating 22 areas of need and ratings that measure either no problem, an unmet need, a met need, or unknown. Some domain areas include self-care, daytime activities, psychological distress, safety to self, safety to others, and information on condition and treatment (Phelan et al., 1995).

Another approach to measuring need is the Assertive Community Treatment (ACT) service model, which highlights basic requirements for those people at risk of hospital admission, including coping skills, motivation, material resources, and an assertive support system, among others (Stein and Test, 1980). A third measurement of need is called the Manchester Short Assessment of Quality of Life (MANSA) which is a scale that measures how satisfied people are within specific areas of life, including their job, friendships, financial situation, mental health, and personal safety (Priebe et al., 1999).

CANSAS, ACT, and MANSA are comprehensive in their own right, however a question to ask is how effective are these tools in ensuring an accurate assessment of needs, which are critical for effective community care programs and policies? For example, how do we conceptually separate the concept of need from a need for a particular service? One author demonstrates an implicit and psychiatric approach to need, the main differences of which are the normalisation of basic human needs versus a biopsychosocial model that focuses on treatment and care (Holloway, 1994). Further, what processes are in place, if any, to ensure that there is a consistent framework in developing and analyzing them? The answers to these questions are elusive and arguably require an updated and universally accepted policy that can show progress that is scalable and consistently measurable.

A final thought to consider are shifts from needs-focused assessment to a primarily outcomes-focused strategy. There is a growing body of research on the subject. Recent examples include the Mental Health Network report that discusses the directions for developing an outcomes-based approach to improving mental health (Mental Health Network, 2011). In the United States, a type of model similar to outcomes-based assessment is the Collaborative Care Model (CCM), which offers a framework to provide integrated mental health care for people with mental illnesses through service in primary care settings.

The paper states that organizational and financial barriers may inhibit adoption of this policy in primary care, as a successful outcome would require complete alignment on utilization of resources and a redesign of the financial infrastructure (Goodrich et al., 2013). In summary, these alternatives to needs assessment strategy are hopeful in providing new solutions for more traditional frameworks, but they still seem far away in achieving scalable success and global impact in community mental health care.