The County Department, along with all other public mental health departments throughout the State of California, is several years into the process of becoming a capitated managed care plan, responsible for ensuring mental health services to low-income individuals with specified diagnoses and medical necessity. The major steps of this process are seen in Figure 1.
Figure 1
One can see county departments becoming increasingly involved with private, Fee-For-Service providers such as Psychiatrists and Psychologists. Prior to Phase I, county departments received payment from the State Department of Mental Health (DMH) for providing services to Medi-Cal clients. Meanwhile, private or Fee-For-Service providers were paid through the State Department of Health Services (DHS). During consolidation DHS assumes less and less responsibility for mental health services. When consolidation is finished, all Medi-Cal money for mental health providers will be distributed by DMH via capitated contracts or block grants to each county department.
In Phase I, departments were mandated to contract with all private hospitals within their county that had historically seen Medi-Cal clients. Figure 2 shows the hospitals within the county which provided mental health inpatient services to Medi-Cal patients during any portion of 1995 or 1996. Not shown are hospitals outside of the county which provided inpatient services to San Bernardino County Medi-Cal beneficiaries.
Figure 2 
During the planning of Phase II, maps have become useful as planning tools. As departments implement Phase II and move into Phase III, it is possible for maps and a Geographic Information System to become even more important as planning tools and perhaps even as a critical business tool.
Although there can be overlap among these categories, especially since each of these three items could be shown as themes on the same map, there are also different uses for each of these categories.
Figure 3 
Figure 4 
As can be seen, the Department currently has contract providers in outlying desert and mountain communities. Looking at the detail map in figure 4, one can see that most cities in the urbanized southwest corner already have at least one Departmental provider.
County departments have received data files from the State DHS paid claims database to aid in the planning process. Although I have analyzed the files using such relational databases as, R:BASE by Microrim (Bellevue,Washington) and Microsoft Access (Redmond, Washington), it is not possible to reliably map FFS service sites or client information using that data.
In addition to showing the location of clinics for internal use or for such documents as annual reports, maps may also be used for site selection. A simple example is Figure 5, which shows existing clinics and a recently proposed new clinic site.
Figure 5 
Figure 6 
Gaining a better understanding of clients, particularly the more than 10,000 San Bernardino County Medi-Cal clients served by nearly 700 FFS mental health providers in Fiscal Year 1995-96, is important to making sure the most appropriate services are delivered. For example, if a large number of clients living in the same community were found to be using excessive inpatient services, the Department may provide clients in that area with more case management and outpatient services.
ArcView's immediate usefulness is its ability to help departments respond to State managed care mandates revolving around needs assessment and cultural competency. This includes comparing ethnicity and age of clients with both total county population and the Medi-Cal population. One example of this is Figure 7, which shades census tracts based on the number of individuals identified as "Black" reported in the 1990 census data files. Printed over the demographic data are the geocoded addresses for clients seen in Fiscal Year 1994-95 which were identified as "Black" in the Department's centralized data system. It appears at first glance that clients identified as "Black" in parts of the desert may not be served by the Department in proportion to the number of identified in the 1990 Census as "Black".
Figure 7 
This is a good example of the dangers of uncritically accepting maps at face value.
There are at least a couple reasons to be skeptical of this map. For example, although "Black" individuals make up 8% of the county's population, they accounted for nearly 17% of the Department's admissions during Fiscal Year 1995-96. Also, nearly 3,000 clients were not able to be geocoded. It is known that clients in the desert and mountain areas were less likely to be geocoded successfully than clients having a street address within the major cities. When these two factors are considered, one can see that further analysis is needed to prove the "obvious" fact that individuals living in parts of the desert areas of San Bernardino County who are identified as "Black" are less likely to receive mental health services. If this were indeed found to be true, it would obviously be of concern to the Department.
Although these types of maps are fairly easy to create, it is critical that readers understand the data limitations before reaching a final conclusion. This is especially true in the health and social services communities which are undergoing many changes.
California Department of Mental Health, "The Spring 97 Medi-Cal Consolidation Phase II Workshop, Southern Region," April 10, 1997
California Medi-Cal Specialty Mental Health Consolidation Part II Program Subcommittee, "Proposed Quality Management Standards," 3/12/97 draft
Center for Mental Health Services. Mental Health, United States, 1996. Manderscheid, R.W., and Sonnenschein, M.A., eds. DHHS Pub. No. (SMA)96-3098. Washington D.C.: Supt. Of Docs., U.S. Govt. Print. Off., 1996.