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5/7/2015 12:00 AM

Referring to himself as a “medical criminal” because he was arrested numerous times as a result of manifestations of his bipolar disorder, Paton Blough took the microphone at a national launch event last week to put a human face on the problem of jail populations swelling with inmates who have a serious mental illness.

Referring to himself as a “medical criminal” because he was arrested numerous times as a result of manifestations of his bipolar disorder, Paton Blough took the microphone at a national launch event last week to put a human face on the problem of jail populations swelling with inmates who have a serious mental illness.

As one of many speakers who favor more effective crisis intervention and other strategies to avert incarceration for these individuals, Blough said of the typical jail experience of persons with mental illness, “They’re a lot more screwed up when they come out than when they go in.”

The May 5 event in Washington, D.C., was held to announce a joint initiative sponsored by the National Association of Counties (NACo), the Council of State Governments and the American Psychiatric Foundation to reduce the ranks of the more than 2 million adults with serious mental illness who are jailed in the United States each year. The Stepping Up initiative will seek to lessen the human toll on a population that, once jailed, tends to stay incarcerated longer than the general population and that runs a greater risk of being jailed again.

Among Stepping Up’s aims will be an effort to highlight effective alternatives that are already being implemented in a minority of communities, and to encourage their replication. “By creating a national conversation and offering technical assistance, we will take advantage of the moment and translate it into a movement,” Fred C. Osher, M.D., director of health systems and services policy at the Council of State Governments Justice Center, told MHW in an interview prior to the official launch announcement.

Impacts on counties

While Osher said an initiative such as this will require a number of collaborative steps because “this isn’t any one system’s problem to fix alone,” he believes it was important to involve the national organization representing county governments because “that’s the front door of the system.” Counties have a total investment of around $70 billion in local justice systems.

NACo’s incoming president, El Paso County, Colo., Commissioner Sallie Clark, says both county governments and county residents with mental illness pay a heavy price in a punishment-focused system where public safety ultimately is not being protected. “Inmates who receive federal benefits end up having to reapply for their benefits after jail,” Clark said in citing one example of a negative outcome from incarceration.

El Paso County is one of many communities around the country that have established specialty courts to seek to identify and treat offenders with mental health needs, but Clark says the program in her region is relatively small in scope.

Stepping Up will comprise two main components:

  • A call to action in which county elected officials will be asked to work with justice officials and community stakeholders toward numerous steps, including quantifying the jail population with mental illness and its recidivism risk; examining present service capacity in order to identify programs that can help individuals with mental illness and co-occurring substance use disorders; and developing a concrete plan to reduce the number of incarcerated individuals with mental illness.
  • A national summit to be held in the spring of 2016, to include the counties that have committed to the call to action. According to a summary from the initiative’s sponsors, “The summit will help counties advance their plans and measure progress, and identify a core group of counties that are poised to lead others in their regions.”

The sponsoring organizations expect that sometime after the summit next year, there may be opportunities to leverage public and private grants to offer more intensive assistance to some counties.

Osher said that some of the more widely applied strategies to combat the overrepresentation of persons with mental illness in jails include use of mobile crisis intervention teams, specialty courts and offender re-entry services.

Making strides

Blough, who is active in the National Alliance on Mental Illness and lives in Greenville, S.C., said the reasons why he had been detained by law enforcement numerous times in his lifetime had “zero to do with my character.” At the same time, he did not fault police for the experiences he endured, including once having a Taser used on him in the back of a police car. “They didn't have [Crisis Intervention Team] training,” Blough said of the police officers he encountered around a decade ago.

To demonstrate how awareness and training have improved in recent years, Blough said one of those police officers now accompanies him on speaking engagements in the community.

Others attending the launch event in Washington last week included U.S. Sen. Al Franken (D-Minn.), who discussed the progress of the bipartisan Comprehensive Justice and Mental Health Act that he co-sponsored with Sen. John Cornyn (R-Texas). The bill, which would reauthorize legislation adopted a decade ago and would extend crisis intervention training to all police officers (as well as extend support for specialty courts and corrections-based services), unanimously cleared the Senate Judiciary Committee in late April.

Franken said a major reason why the United States has 5 percent of the world population but 25 percent of the world’s prison population is “because we’ve criminalized mental illness.” He added, “We’re using our criminal justice system as a substitute for a fully functioning mental health system.”

Former U.S. Rep. Patrick Kennedy, who championed behavioral health parity legislation in Congress, emphasized county governments’ opportunity to rearrange dollars to establish new approaches to keep individuals with mental illness out of jail.

“We moved the people out of the old asylums and into the new asylums, our jails and prisons,” Kennedy said. “We arrest them for not being treated. That just doesn’t add up.”

Bottom Line

The Stepping Up initiative will seek to have a direct impact on reducing the number of individuals with mental illness who are housed in county jails, and highlighting alternative strategies that leaders say beg for replication.

3/19/2015 12:00 AM

Incomplete or missing data about the impacts of California’s decade-old Mental Health Services Act (MHSA) have offered critics of the law an opportunity to sway others by saying that the funding has been poorly targeted. This month marked the release of the first in an expected series of quantitative reports geared to fill the data vacuum and to counteract the arguments of those who doubt whether MHSA spending has significantly improved the lives of state residents with serious mental illness.

Incomplete or missing data about the impacts of California’s decade-old Mental Health Services Act (MHSA) have offered critics of the law an opportunity to sway others by saying that the funding has been poorly targeted. This month marked the release of the first in an expected series of quantitative reports geared to fill the data vacuum and to counteract the arguments of those who doubt whether MHSA spending has significantly improved the lives of state residents with serious mental illness.

This month’s review of the Proposition 63–funded initiative was released by the County Behavioral Health Directors Association of California and the Steinberg Institute for Advancing Behavioral Health Policy & Leadership, a policy group founded last year by strong mental health field supporter and former State Sen. Darrell Steinberg. The county directors group’s participation is noteworthy because the availability of county-level data on the MHSA’s effects has been inconsistent from jurisdiction to jurisdiction up to this point.

“The report reflects a shift in attitude on the part of the counties,” Rusty Selix, executive director of the California Council of Community Mental Health Agencies, told MHW. “The counties will be working together to get the information out there.”

Unveiled March 11 at a press event featuring first-person accounts from individuals helped by the MHSA’s “Whatever It Takes” intensive services approach, the report presents data showing that for the three age groups targeted in the act’s Full Service Partnership (FSP) programs, emergency services and psychiatric hospitalizations have been decreasing considerably. Homelessness and criminal justice involvement also are down in the served population, while more of these clients have been able to live independently.

The MHSA has not focused on establishing entirely new approaches to serve high-need populations such as the homeless, but rather on extending the reach of efforts that already were generating evidence of success in small pilot initiatives prior to Prop. 63.

“The real shift is this is now the main way we’re providing services,” Selix said. “It’s not just a pilot effort off to the side.”

Report findings

The voter-approved Prop. 63 created a long-term funding stream for these service expansions, in the form of a state tax on incomes above $1 million. This first report on MHSA impacts focuses largely on the populations served with the 40 percent of act dollars that are allocated for the FSP programs, or intensive services targeting high-need populations such as the homeless or those at risk of homelessness.

The report looked at the more than 35,000 Californians who served in FSP programs in fiscal year 2012. The three targeted age groups were transition-age youths in the 16-to-25 range, adults ages 26 to 59 and older adults 60 and over. The report found that when comparing client use of emergency behavioral health services one year prior to FSP enrollment to use during the first year of enrollment, such utilization decreased by an average of 79 percent. Psychiatric hospitalization rates using the same comparison dropped by an average of 42 percent (see tables).

Moreover, homelessness or use of emergency shelters decreased by an average of 47 percent, with the steepest percentage decrease in the oldest population. Arrests dropped by 82 percent, and incarcerations in county jail decreased by 27 percent, the report stated.

A cover note from the organizations that compiled the report based on county-level data states that “the evidence is clear that MHSA is reducing hospitalizations, jail time, out-of-home placement for children, and improving the lives of thousands of people.”

Turning Point Community Programs, serving half a dozen counties in the area in and around Sacramento, carries the perspective of having worked with the highest-need populations both before and after Prop. 63 was adopted. “The situation was bleak prior to passage of the act,” Turning Point CEO Al Rowlett told MHW, as programs depended on a patchwork of government funding that included sales tax and license fee revenue that was highly dependent on the overall state of the economy.

As a result, most of the service focus before the MHSA was on crisis services, with little available for prevention and early intervention initiatives, Rowlett said. With the positive impact that the MHSA has had on an underfunded system, “Our program that works with the chronically homeless has virtually doubled in size,” Turning Point Vice President of Operations John Buck told MHW.

“We are now reaching people who were unreachable prior to the MHSA, because before then we were only reaching people who would come in voluntarily,” Buck said. Now the staff resources are available to be able to engage in much more aggressive outreach, he said.

Rowlett said that one of the individuals who spoke at the event at which this month’s report was released had cycled in and out of homelessness but was able to receive permanent housing as a result of FSP services. Even when he suffered a major setback with physical illness, the support he received allowed him to remain in his housing, from which he now is able to facilitate groups for other residents.

More data to come

The newly released report also documents effects of MHSA funding for urgent-care services designed to connect individuals to support before a crisis event occurs. The report states, for example, that in Los Angeles County in fiscal year 2014, only 6 percent of individuals visiting a mental health urgent-care center subsequently visit a psychiatric emergency department in the next 30 days. Only 11 percent of these individuals are admitted to an inpatient psychiatric facility within that period.

The report’s authors state that this will be the first effort in regular reporting of outcome-based data for the MHSA. Selix added, “It’s not the end — it’s the beginning.”

On the day the report was released, The Sacramento Bee published an editorial that opened with this line that illustrates lingering skepticism about the MHSA’s impact: “More than 10 years after Californians voted for a special income tax on millionaires to pay for expanded mental health services, we still don’t know if the program is working the way its sponsors promised it would.”

The editorial added, in reaction to the new report’s data, “More extensive and independent follow-up is needed to show whether the help these people get is a short-lived salve or is turning their lives around — a crucial question.”

Bottom Line…

The first in a promised series of reports of county-level data on impacts from California’s Mental Health Services Act shows significant health and criminal justice effects from the most intensive services funded under the act.

3/12/2015 12:00 AM

Top 10 Recommendations for Significant Impact in the Mental Health and Substance Use Disorder Arena Within the Next Two Years

Submitted by the Mental Health and Substance Use Disorder Stakeholder Group

Ensure Safety Net Funding — Immediately

  • Maintain and increase funding for the Substance Abuse Prevention and Treatment Block Grant and the Community Mental Health Services Block Grant, in order to address the needs of people who remain uninsured and provide for critical health services, activities, primary substance abuse prevention and social wraparound services not covered by the Affordable Care Act (ACA). Ensure that Medicaid and commercial insurance rates for mental health/substance use disorders (MH/SUD) services, whether in federally qualified health centers (FQHCs) or free-standing specialty facilities, are at parity with other comparable medical/surgical services to support the quality that patients deserve. Increase funding for continuity of care to ensure that appropriate services are in place for patients with behavioral health conditions recently discharged from emergency departments, acute care units and inpatient psychiatric units. Patients discharged from these settings have been shown to have the highest risk of suicide of any population. Reduce Institution for Mental Disease (IMD) barriers to the use of Medicaid funds for community residential and community inpatient services, and eliminate the Medicare 190-day lifetime limit on inpatient care.

Top 10 Recommendations for Significant Impact in the Mental Health and Substance Use Disorder Arena Within the Next Two Years

Submitted by the Mental Health and Substance Use Disorder Stakeholder Group

Ensure Safety Net Funding — Immediately

  • Maintain and increase funding for the Substance Abuse Prevention and Treatment Block Grant and the Community Mental Health Services Block Grant, in order to address the needs of people who remain uninsured and provide for critical health services, activities, primary substance abuse prevention and social wraparound services not covered by the Affordable Care Act (ACA). Ensure that Medicaid and commercial insurance rates for mental health/substance use disorders (MH/SUD) services, whether in federally qualified health centers (FQHCs) or free-standing specialty facilities, are at parity with other comparable medical/surgical services to support the quality that patients deserve. Increase funding for continuity of care to ensure that appropriate services are in place for patients with behavioral health conditions recently discharged from emergency departments, acute care units and inpatient psychiatric units. Patients discharged from these settings have been shown to have the highest risk of suicide of any population. Reduce Institution for Mental Disease (IMD) barriers to the use of Medicaid funds for community residential and community inpatient services, and eliminate the Medicare 190-day lifetime limit on inpatient care.

Affordable Care Act/Parity — next 22 months

  1. The Center for Consumer Information and Insurance Oversight (CCIIO) should (1) issue guidance regarding lawful compliance with the requirements of the ACA and Mental Health Parity and Addiction Equity Act, regarding both quantitative and nonquantitative treatment limitations, including (a) issuing final parity regulations for Medicaid as quickly as possible; (b) conducting a review of all essential health benefits packages, including intermediate services (e.g., residential, intensive outpatient, partial hospitalization), medications and recovery supports; and (c) providing a mechanism for consumers and service providers around the country to report problems they experience without fear or risk of retribution; and (2) take corrective action to rectify identified problems with ACA and parity compliance and provide guidance to insurers, consumers, providers and others on compliance by (a) making available outcomes of compliance investigations — including the number of investigations opened and closed, the benefit classification(s) examined by each investigation, the subject matter(s) of each investigation and a summary analysis of the final decision rendered for each investigation — on the Department of Health and Human Services (HHS) and Department of Labor websites, with names redacted where appropriate, and (b) issuing FAQs based on reviews and compliance activities. Provide more resources to the CCIIO for these functions.
  2. Facilitate enrollment of people with untreated MH/SUD and minimize interruptions of coverage and care by (1) working with the Department of Justice (DOJ) in providing guidance to states and localities in order to facilitate enrollment and linkage to mental health, substance use disorder and physical care of everyone in the criminal justice system, including ceasing the termination of Medicaid of those who are incarcerated; (2) continuing Medicaid payments for pre-adjudicated detainees; and (3) targeting outreach to enroll and link uninsured persons to MH/SUD care by enlisting insurance navigators and peers and working with homeless service providers, recovery community organizations and mental health drop-in centers.

Care Integration/Value Purchasing/Delivery System Reform — next 22 months

  1. Provide practical models and examples of delivery system reform initiatives, including those that incorporate social wraparound services, so that state, county and city mental health and substance use disorder provider entities can undertake key steps to foster reforms that will lead to good integrated care. This can include piloting and evaluating model system reforms — including requiring public health programs overseen by HHS to provide evidence-based services, such as prescribing naloxone and treatment medications by contracting with specialty MH/SUD programs or expanding in-house staff — to identify best practices and replicable models for the rest of the health care system. Use focus groups and expert input to identify the challenges and barriers to instituting value purchasing and payment reform for MH/SUD programs (e.g., how to implement core performance measures, how to incorporate funding in case rates for preventive care to avert suicides, how to deal with payment structures that create barriers to integration of care, such as policies that prevent same-day billing for different needed health care services), and provide technical assistance to the field in resolving those problems.
  2. Facilitate operational planning and reforms so that more effective working relationships can be developed between MH/SUD providers and primary and physical health care providers, specifically FQHCs. Since these programs operate under very different federal rules, effective collaboration is frequently difficult. Specifically address the Section 223 Demonstration in these reforms.
  3. HHS has a critical window in the next two years to catalyze national implementation of first-episode psychosis programs. The National Institute of Mental Health (NIMH) has invested significant resources, and data will be published this summer on clinical trials for these programs. International and recent U.S. studies (including preliminary results from the NIMH-funded studies) indicate improved outcomes from reducing the duration of untreated psychosis and providing an evidence-based package of services. Other countries have been working on implementation, with the United Kingdom putting into effect a national strategy since 2000. We very much appreciate the work that NIMH and the Substance Abuse and Mental Health Services Administration (SAMHSA) have been doing in this area. HHS can further drive national implementation by: setting forth a national strategy, publicizing the results of the studies using the highest levels of leadership, clarifying the evidence-based practices, issuing guidance from the Centers for Medicare & Medicaid Services on how to finance these services, allowing all of the component pieces to be billed as one service under Medicaid, providing training for the workforce and technical assistance to stakeholders and states, collaborating with the Social Security Administration (SSA) on their demonstration project and encouraging private insurers to cover such services.

Opioid/Heroin Problem — next 22 months

  1. Increase funding for SAMHSA to help states, counties and localities purchase naloxone. Target funding to the substance use disorder care system (state/county/local agencies, providers, families and recovery community). Ensure that HHS divisions are coordinating on this issue and ensure agency-level coordination with the Department of Justice and Office of National Drug Control Policy. Incentivize co-prescription of naloxone with extended-release long-acting opioids by prescribers in the public health system.
  2. Maintain and increase support for treatment and prevention services addressing opioids and other drugs — including medication-assisted treatment. Provide additional funds for all effective treatments and prevention interventions. Ensure that all approved medications for treating addiction are included in all insurance and Medicaid plans, that use of medical necessity criteria and other medical management for MH/SUD is no more restrictive than for medical/surgical conditions, and that inappropriate limitations on dosage or duration and even outright exclusions of particular medications (such as recently announced by Maine) are eliminated. Incentivize all HHS-funded programs to have the capacity to prescribe medications to treat addiction. Increase funding for SAMHSA programs that target primary substance abuse prevention programs and recovery supports in order to help address access and availability, and to change community norms as they relate to opioids. This commitment should include increased support for community coalitions in order to ensure the response is localized and coordinated across a number of sectors.

Workforce — next 22 months

  1. Continue and expand Medicaid reimbursement for certified peer support specialists, including family and youth peers, addiction recovery coaches and health navigators; incentivize states to establish this access; and streamline the ability of physical health entities, including FQHCs and emergency departments, to directly bill for these services.
  2. Expand the participation of mental health and substance use trainees in the National Health Service Corps, and develop an outreach and technical assistance program to educate behavioral health organizations about how to participate in the Corps. Expand loan forgiveness, scholarship, fellowship and other workforce initiatives for MH/SUD practitioners, such as psychiatrists, psychologists, social workers, mental health nurse practitioners, marriage and family therapists, licensed counselors, certified alcohol and drug abuse counselors, addiction medicine specialists, certified prevention specialists and peer specialists, to increase the availability of licensed clinicians and improve recruitment and retention.
  3. Encourage the Health Resources and Services Administration (HRSA) and SAMHSA to take measures to promote systematic implementation of Suicide Prevention and the Clinical Workforce: Guidelines for Training, established by the Clinical Workforce Preparedness Task Force of the National Action Alliance for Suicide Prevention. (See http://actionallianceforsuicideprevention.org/sites/actionallianceforsuicideprevention.org/files/Guidelines.pdf.)

Community Culture and Strengths Initiative — Beyond the next 22 months

  • Develop a national public health campaign to assess and change community culture, demonstrate strength-based approaches to inform attitudes and perceptions commonly associated with mental health and substance use conditions, and educate the public about heroin/opioid addiction and the availability of effective mental health and substance use treatments. This national campaign will focus on core principles that promote positive coping, hope and recovery for persons living with mental health and substance use conditions.
From the Field
9/26/2013 12:00 AM
FromtheField
8/7/2013 12:00 AM
In Case
7/11/2013 12:00 AM
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    Valarie Canady
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    Valerie Canady, managing editor of Mental Health Weekly, knows the mental health field inside and out. She uncovers the essential stories and gets the scoop directly from leaders and advocates in the field.
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