Mental Health Services Research: Moving From Academia to the Community

We and others have noted the limitations in a large body of 20th century mental health services research. This research often focused on small, nonrepresentative, convenience samples of adults with mental illness who happened to pass through the filters that led to specialty mental health clinics at academic medical centers. This focus often seemed to disregard the larger population of older adults with mental illness in the community, including those with concomitant serious chronic health conditions. Mental health services research has now traveled beyond the limitations of a narrow focus on specialty psychiatry populations. Through this journey, researchers initially focused on primary care where most older adults receive their health care. However, researchers of mental health services also discovered a continually changing landscape of sites of healthcare for older adults. In addition to pursuing other sites of care, this research is increasingly targeting a broader range of patient with emotional and cognitive disorders and comorbid medical conditions. The articles presented in this special issue demonstrate the broad new frontiers for innovative mental health services research. In the commentary below, we highlight three important themes that run through these articles. First, to reach older adults with mental illness, providers and researchersmust go to the places where these patients are already receiving healthcare. Second, keeping pace with the new sites of care in the community requires new partnerships and new teams. Third, changes in reimbursement and definitions of value are major drivers in the change in sites of healthcare which in turn influences where mental healthcare is delivered and how its effectiveness is measured. Medicare reform and changes in Medicaid at the State level continually reshaped the landscape of sites of care. Important sites of care for the range of mental conditions that afflict older Americans now include the patient’s home, skilled nursing facilities, hospital-based long-term care, community-based longterm care, and assisted living settings among others. Notably, the content of care for any given patient within any of these sites of care may vary as greatly as content between the different sites. For example, it is possible that home-based care could include a higher intensity of skilled nursing care for any given patient than care provided to another patient residing in a skilled nursing facility. Expanding our notions of potential sites of care for mental healthcare is important because various site of care often represent different populations of both patients and providers. Differences in available resources among sites dictate which treatment approaches are both feasible and effective. Different communities and different third-party payors define and regulate these sites of care differently. Homebased care is an increasingly important site of mental healthcare for older adults, because it can overcome obstacles such as difficulty with mobility, transportation, limited space, and fear ofmedical institutions. It may also help overcome the continuing problem of the stigma of mental illness. As demonstrated in the article by Conner et al., perceptions of stigma continue to keep people from seeking care regardless of site. Aging in place often requires that increasing services be provided in the home, which is a greatly