The Federal Response: “The Government Needs to Do More”

The concern that premature hospital discharge contributed to “the revolving door phenomenon” and persistent disability among discharged patients spurred a governmental response on several fronts. The General Accounting Office (GAO) issued a report in 1977 that addressed the problem of mentally disabled persons released from institutions without adequate community-based services. In the absence of appropriate service alternatives, the report noted, patients were inappropriately placed in nursing homes, as states took advantage of federal support through Medicaid and Supplemental Security Income (SSI) to reduce the cost burden to states for care of the severely mentally ill (Comptroller General of the United States, 1977). Noting the lack of an organized system of care for the chronically mentally ill, the report specified recommendations to federal agencies to better address the needs of the mentally disabled for adequate mental health care, social services, housing, vocational training, and income support.

Later in 1977, the NIMH launched the Community Support System Program, a pilot effort to address many of the shortcomings identified in the GAO report (Turner & TenHoor, 1978). The NIMH developed contracts with the states for demonstration projects involving treatment, rehabilitation, housing, and staff training in areas such as case management and social skills training (Cutler et al., 2003). Model programs, such as the Training in Community Living Program developed by Stein and Test in Madison, Wisconsin (Stein & Test, 1980), and Fountain House in New York City (Beard, 1979), served as examples of innovative efforts to create viable community alternatives to mental hospital treatment. Community Support System funding was short-term and did not continue into the 1980s.

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