Indiana Consortium For Mental Health
Services Research
Indiana University, Bloomington, Indiana

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Abstract

Reprint # 6: BRINGING THE "COMMUNITY" INTO UTILIZATION MODELS  

A perennial problem that has vexed models of health care utilization targets how "social structure," particularly the opportunities and limits set by the lay community and the formal health delivery system, can be conceptualized, measured, and brought directly into the study of individuals' health and illness behavior. The advent of health care reform and advances in treatments designed for implementation outside hospital walls require, more than ever before, an understanding of the link between micro-processes of help seeking at the individual level and macro-structures of community and organizations at the system level. Specifically, these changing conditions shape new roles for providers and consumers, bringing to the fore issues of how these two larger contexts influence how individuals use care, whether they decide to remain in care, whether they follow medical advice, and what kinds of outcomes they experience. In this paper, I argue that three distinct systems-the nature of the social support system, the structure of specific treatment facilities, and the organization of the larger health care delivery system-form the key "communities" affecting the fate of ill individuals. Social networks, in their availability, strength and content, offer a real way to tap into each of these communities over the course of an "episode" of help seeking or throughout an individual's "illness career." In short, a network approach has wide applicability across types of illness particularly when long­term chronic problems are at issue. I sketch out a multi-level model of utilization and hypothesize how social network ties within and across these three levels influence illness behavior and outcomes. Because predictions under the model must be adapted to the particulars of the type of illness and the organizational capacity to respond, I use the case of mental illness and one health system context as a specific illustration. A broader discussion of different types of chronic illness (particularly HIV, AIDS, and Alzheimer's disease), different health care markets, the role of personal vs. organizational ties in delivery systems, and the nature of protocol challenges follows. Finally, focusing on the experiences in the Robert Wood Johnson Foundation's Program on Chronic Mental Illness, I discuss the advantages and limitations of both current and proposed conceptualizations and protocol in addressing how system changes shape individual use and outcome.