About 50 years ago, with the launch of the deinstitutionalization movement, advocates assumed that communities would be provided the necessary resources to support the transition of people with mental illnesses and with mental retardation into community care (Kip, 2000). However, plans for deinstitutionalization suffered from a host of problems, including a lack of community-based housing, a lack of job support, a shortage of supervision for people with mental illnesses, as well as the false belief that families and relatives would take up the burden of caring for discharged patients (Krupinski, 1995). This was compounded by the lack of clarity regarding where patients should be discharged and the lack of alternatives for patients who needed more supervision and could not be discharged to the community (Kip, 2000).
The deinstitutionalization movement, combined with this lack of community care and recent changes in Medicaid managed care, contributed to an increase in a population who has no health care or has difficulty in gaining access to existing health care services. Those who have fallen through the cracks include poor and uninsured people and people of color. African Americans seeking mental health care are specifically affected by the general lack of fiscal commitment to community-based care. They also are more likely to delay seeking mental health treatment until their problems become more severe (Neighbors, 1984). Furthermore, African Americans are less likely than white people to obtain ambulatory or inpatient mental health services (Freiman, Cunningham, & Cornelius, 1994). They are also less likely to seek health care because they are uninsured, are less likely to have a regular provider, and are more likely to believe that they are victims of discrimination
When they do seek mental health care, African Americans suffering from depression were more likely to seek informal mental health services from places such as churches (Neighbors, Musick, & Williams, 1998). In addition, African Americans in general are less likely to seek formal sources of mental health care, and studies indicate those who do seek community mental health services may not be able to obtain the type of care needed (Brown, 1984; Brown, Ahmed, Gary, & Milburn, 1995; Neighbors & Jackson, 1984).
Krupinski (1995) proposed a model of community mental health services that would provide regular psychiatric nursing supervision for people with chronic illnesses, 24-hour crisis intervention, outreach teams, and a range of rehabilitation programs, including social and living skills, budgeting, occupational training skills, workshops and recreation (Krupinski, p. 578). This column examines a service-delivery model, based on Krupinski's approach, that attempts to address the gap in the delivery of community-based mental health services to urban African Americans. This model combines a 24-hour crisis management hotline with a mobile support team and a residential care unit.
DEPICTION OF THE BCRI PROGRAM MODEL
This article focuses on Baltimore Crisis Response, Inc., (BCRI), one of the crisis interventions centers in the state of Maryland receiving community mental health funds to care for the indigent. The crisis center is located in Baltimore, a city with a population of 651,154, approximately 64 percent of whom are African American (U.S. Bureau of the Census, 2001). BCRI uses a 24-hour confidential hotline, a mobile treatment team, and a 12-bed crisis residential unit to provide mental health and psychosocial services to residents in the Baltimore metropolitan area. (See figure 1 for a summary of the service delivery model.)
Slightly more than two-thirds of the BCRI program staff are African American. The top tier of the program is represented by six clinical administrators, half of whom are African American, who are responsible for the management of this program. The second tier of the organization includes eight master's levels mental health counselors, including social workers and psychologists, a quarter of whom are African American; 10 nurses, 70 percent of whom are African American; and six physicians, half of whom are African American. …