Self-Direct Care Model Associated With Superior Client Outcomes, Lower Resource Costs

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Investigators conducted a randomized controlled trial of a mental health self-directed care program, assessing participant outcomes, service satisfaction, and cost.

A budget-neutral self-directed care model outperformed services as usual in terms of patient satisfaction and mental health outcomes, per study data published in Psychiatric Services.

Patients registered with the Texas Department of State Health Services’ Mental Health and Substance Abuse Division were randomly assigned to self-directed care (n=114) or services as usual (n=102) for 24 months. The mental health self-directed care intervention began with patients developing person-centered plans for recovery. Patients then created individual budgets, which were reviewed and approved by program management personnel. Self-directed care staff assisted patients in securing services. As a primary outcome measure, investigators captured patient-reported satisfaction with treatment. Secondary outcomes included psychosocial status, psychiatric symptom severity, and behavioral rehabilitation. Investigators performed mixed effects random-regression analyses to capture longitudinal changes in outcomes between study conditions. Differences in services costs were assessed with binomial regression models.

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Participants in both groups did not differ significantly in measured baseline characteristics (P <.05). Per administrative data, 34% of participants had a diagnosis of schizophrenia, 41% major depressive disorder, and 26% bipolar disorder. Compared with control patients, patients assigned to self-directed care improved significantly over time in Recovery Assessment Scale total scores (P =.009) and goal orientation (P =.007) and personal confidence (P =.027) subscale scores. The patients in the intervention group also improved more significantly over time in self-esteem (P =.031) and coping mastery (P =.007) scores compared with control participants. In addition, intervention participants were more likely to be employed over time (odds ratio [OR], 2.19; P =.046) and enrolled in formal education (OR, 4.14; P =.006). No significant between-group differences were observed in total per-person service costs in year 1, year 2, or both years combined. However, self-directed care participants were more likely than control participants to incur zero costs for 6 of 12 and lower costs for 4 individual services. Over 24 months of study participation, 98% of the self-directed care group purchased services and 80% made “nontraditional” purchases. Client satisfaction was significantly higher in intervention participants than controls at both 12- (P =.003) and 24-month (P <.001) follow-up.

These data suggest that self-directed care is associated with greater improvement in psychiatric symptoms and is not associated with additional costs. Additional research on a larger scale is needed to further validate self-directed care modeling.


Cook JA, Shore S, Burke-Miller JK, et al. Mental health self-directed care financing: efficacy in improving outcomes and controlling costs for adults with serious mental illness [published online January 11, 2019]. Psychiatr Serv. doi:10.1176/