Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
RESPONSE TO THE CRISIS Opening Doors to Recovery Summit Report and Directives For Southeast Georgia SEPTEMBER 2009 TABLE OF CONTENTS PAGE ACKNOWLEDGEMENTS i PREAMBLE iv EXECUTIVE SUMMARY v INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . PURPOSE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Complexity and Limitations of Mental Health Planning . . . . . . . . . . . . . . . . . . . . . . . . The NAMI Approach in Region 5 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . NEED . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Description of the Service Area . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Prevalence of Serious Mental Illness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Prevalence of Substance Abuse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Georgia Regional Hospital-Savannah 30-day Readmissions . . . . . . . . . . . . . . . . . . . . . Additional Indicators . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Priority Counties at Risk . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . RESOURCES AVAILABILITY AND ACCESSIBILITY. . . . . . . . . . . . . . . . . . . . . . . Defining the Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Staff Recruitment, Retention and Training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Other Undervalued Public Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . TRANSFORMING MENTAL HEALTH SERVICES . . . . . . . . . . . . . . . . . . . . . . . . . . Re-defining Care from Symptom-Blame to Recovery, Wellness and Empowerment . . Access to the Mental Health System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Management Information Infrastructure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Gaps and Barriers to Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . DIRECTIVES FOR CHANGE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Geographic Parameters and Directives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Management Information Systems and Infrastructure Directives. . . . . . . . . . . . . . . . . . Structural Characteristics of the Southeast GA System of Care . . . . . . . . . . . . . . . . . . . Specific Operational Directives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . FINANCING STRUCTURE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Current and Proposed Expenditures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Cost by Program by Service Area. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Appendices 1 2 2 3 5 5 7 7 8 8 14 15 15 18 18 20 20 20 21 21 26 26 27 28 33 36 36 36 Acknowledgment List NAMI Georgia (National Alliance on Mental Illness) acknowledges and thanks the following people for their contributions and dedication to our efforts. Executive Branch Governor Sonny Perdue, State of Georgia Mary Eleanor Wickersham, Office of the Governor Georgia Dr. Frank E. Shelp, Commissioner DBHDD Georgia BJ Walker, Commissioner of Georgia DHS Jason Bearden, OPB Gwen Skinner, Georgia MHDDAD, Georgia DHR Audrey Sumner, Director Adult Mental Health, DBHDD Charles Ringling, Region 5 Coordinator, DBHDD Lorr Elias, Region 5, DBHDD Dr. Charles Li, Georgia Regional Hospital-Savannah Dr. Jim Degroot, Georgia Department of Corrections Semona Holmes, Georgia DHS Bobby Pack, Department of Labor Patricia Merritt, Department of Juvenile Justice Legislators/Elected Officials Representative Buddy Carter, Savannah Representative Burke Day, Savannah Commissioner Jeff Felser, Chatham County Representative Pat Gardner Senator Johnny Grant, Baldwin County Senator Lester Jackson, Savannah Senator Eric Johnson, Savannah Honorable Otis Johnson, Mayor, City of Savannah Representative Ron Stephens, Savannah Commissioner Pete Liakakis, Chatham County Region 5 Summit Committee Chairs Dr. Frank A. Bonati, Gateway Behavioral Health Services – Data Collection – Battle #1 Stanley Williams, Gateway Behavioral Health Services – Community Services – Battle #2 Mark Baggett, Savannah Homeless Authority – Housing – Battle #3 Julie Spores, Georgia Consumer Network – Recovery Support Specialists – Battle #4 Stakeholders & Participants Leslie Backus, Recovery Place of Savannah Frank Barker, Recovery Place of Savannah i Cassandra Barnwell, MH Director, Chatham County Detention Center Suzanne Baroody Michael Berkow, Chief of Police, Savannah Leslie Bietberg, Pinewoods Retreat Savannah Capt. Larry Branson, Savannah Chatham Metropolitan Police, CIT Coordinator for Law Enforcement Robert Brown, Chief Deputy, Effingham Sheriff’s Dept. Leola Bunkley, President of NAMI of Brantley County Karey Burgsteiner-Lee, Community Services, Memorial Behavioral Health Center Lou Caputo, Family Connections Terry Cassidy, Union Mission Michael Chappel, Statesboro Police Department Arlise Clark-Milton, Clinical Director, Memorial Behavioral Health Center Dr. Shawna Clifton, Savannah Counseling Services, Inc. Chris Colson, Georgia Legal Services Arnie Correa, Georgia Regional Hospital-Savannah Steve Derr, SCCPSS June DiPolito, CEO, Pinelands CSB C. Dowse, People PC organization Richard Edwards, United Way of the Coastal Empire Abdul El-Amin, Mobile Crisis & ACT team, GA Regional Hospital-Savannah Dr. William Ellien, Behavioral Health Medicine Center, Memorial Hospital Lei Ellingson, Carter Center Hillary Faulk, Pinewoods Retreat Savannah Judge Gregg Fowler, Chatham County Penny Freesemann, Judge, Superior Court/Mental Health Court, Chatham County Mikki Garcia, Chatham County School System Richard Garrison, Franklin Covey Organization Cordele Golden, American Work, Inc., Savannah Gregg Graham, Georgia Crisis & Access Line Dr. Rick Gray, Memorial Hospital Behavioral Health Center Mark Hamil, Glynn County School System Brenda Harrell, Behavioral Health Services of South Georgia Nora Haynes, NAMI Georgia Dr. T. Hickey, Memorial Behavioral Health Center Paul Hinchey, CEO, St Joseph’s/Candler Hospital Bill Hubbard, Savannah Chamber of Commerce Oliver Hunter, Georgia Sheriff’s Association Hunter Hurst, St Joseph’s/Candler Hospital Polly Johansen, NAMI Savannah Roz Johnson, Behavioral Health Services of South Georgia Stan Jones, Mental Health America Angela Kimball, NAMI National Greg Kirk, LPCA Bill Kissel, NAPHCare Tom Kurtz, Georgia Regional Hospital-Savannah ii Rick Lally, American Work, Inc., Savannah Jane Martin, OAC Dr. Katherine Martin, Medical College of Georgia Bill Massee, Sheriff, Baldwin County Capt. Claire McCluskey, Savannah Chatham Metropolitan Police Department Dr. Cathy McCrae, Professor of Social Work and Private Practice Bill McDonald, Emory Jimmy McDuffie, Sheriff Effingham County Dr. Carl McKinnie, Social worker (retired) Ruby Moore, GAO Jane Nangle, Pinewoods Retreat Josh Norris, GAO Terry Norris, Georgia Sheriff’s Association Vivian Ortiz, Memorial Hospital Nick Pecone, Goodwill of the Coastal Empire Ronald Pounds, Department of Community Affairs Dr. John Prather, Savannah Counseling Services, Inc. John Quesenberry, Georgia DHS Diane Reeder, NAMI Savannah Jacquie Reynolds, SABHC Kris Rice, Coastal Children’s Advocacy Center Savannah John Richards, NAMI Savannah Eric Spencer, NAMI Georgia Sheriff Al St. Lawrence, Chatham County Dr. Glyn Thomas, CEO, Satilla CSB Carolyn Tinkham, NAMI of Golden Isles Dr. Karl Ullrich, CIT Instructor Erica Usher, Chatham County Mental Health Court Dr. Bryan Warren, NAMI of Coastal Georgia CJ Washington, Pinewoods Retreat, Savannah Klay Weaver, Gateway CSB Jane R. Weilnman, DOC Mark Welsh, Chief of Police Elberton Ken Whiddon, American Work, Inc. Dr. James Williams, Savannah State University Steven Williams, First Presbyterian Church Jerry Wilson, NAMI Savannah Jennifer Wright, Memorial Hospital Stan York, Statesboro Police Department iii PREAMBLE NAMI Georgia (National Alliance on Mental Illness) is pleased to present this ‘Opening Doors to Recovery’ Summit Report and Directives for Southeast Georgia on behalf of all our loved ones and family members who have died and suffer daily from the outrage and oppression of an under funded, fragmented mental health care system. As an advocacy organization, NAMI believes that awareness of the problems of mental illness and education on best practice solutions are the pathways from the Darkside. To this end, NAMI Georgia has produced this first in a series of reports on the status of mental health care in the State of Georgia and is a Call to Action to Georgia’s Community Leaders in this time of crisis. For about a year NAMI Georgia and NAMI Savannah along with numerous Region 5 stakeholders have been working on a transformation plan for the mental health system in that Region. During that time a Mental Health Blueprint plan was developed by DHR and the closing of GA Regional Hospital-Savannah looked imminent. A letter (Appendices) was written to Governor Sonny Perdue asking for the Summit participants to be given more time to work on this plan. Director Gwen Skinner then responded (Appendices) pledging that the Department would work closely with the Region 5 Summit Battle Groups. This Summit Report is not meant to be a decisive document as to which agency is to provide what service for whom and for how much money. Rather, it is a statement of a prevailing belief that the structure and delivery of mental health services in southeast GA needs to be aggressively pursued by decision makers in a logical way based on the best information available at this time. It is said that tall buildings need strong foundations. This Summit Report is a conceptual foundation for high-reaching action yet to come. It is not, in and of itself, a blueprint to be followed without exception. State, regional and local political, religious, business and community service entities must all have their voices heard and considered. Over 340,000 adults in Georgia—and tens of thousands of our children and youth—live with serious mental illnesses. Mental illness is common and highly treatable, yet too few in Georgia receive the care they need to experience recovery. The consequences touch every aspect of our communities from our homes and businesses to our schools, our streets, every State agency in Georgia—from our court system, corrections, and our local jails to education. The crisis in our State hospital system reveals what we have known all along—we need a transformed mental health system that can provide the right care at the right time to promote recovery in the community. And we need your help. To transform care in Georgia will take more than funding and State agencies, it will take the efforts of business and community leaders working together to reduce stigma and become part of the solution. Today, we call on you to join us in “Opening Doors to Recovery.” Dan Hagaman, President NAMI Georgia iv EXECUTIVE SUMMARY Years of underfunding and neglect have resulted in a network of services that has become increasingly cumbersome to manage and increasingly unresponsive to consumer demands. Region 5 exhibits many of the problems found throughout Georgia: staffing shortages, inaccessible services, and inefficiencies in the delivery of care. This report is a “Response to The Crisis” in behavioral health that is being experienced by thousands of Georgia’s most vulnerable citizens every day. The “war” that was declared in Region 5 was to reduce the recidivism of those with serious mental illness who are in jail, prison, State hospital or homeless. Four “Battle Groups” were formed to: 1) Address problems surrounding Management Information Systems; 2) Study Best Practice Services; 3) Increase the capacity of housing for the seriously mentally ill; and 4) Develop a family/peer/self-case management or case coordination tool. Each Battle Group described the current extent of their respective issue in Region 5, identified gaps or barriers in services as a result of the problem and recommended potential interventions for corrective actions to be taken. This National Alliance on Mental Illness (NAMI) report is limited to examining issues related to the provision of behavioral health care to adults, who are at or below 200% of the Federal Poverty Level (FPL) and living in the 44 counties of Southeastern Georgia that constitute the GA Department of Behavioral Health and Developmental Disabilities’ (DBHDD) Region 5. There is an overwhelming number (47,063) of Seriously Mentally Ill (SMI) persons in Region 5 who are not being treated. And, only 7,033 adults below 200% FPL, with a diagnosable addictive disease are being served. A “snapshot” was taken of available resources within Region 5 to meet this pent-up need. Current DBHDD funded providers (public non profit, private non profit and for profit) were identified. Undervalued or underutilized community safety net assets were also defined. GA Regional Hospital-Savannah is the only State facility in Region 5 for inpatient care. Their 30-day readmission rate was studied, along with other relevant factors e.g. mentally ill inmates in State prisons and county jails, overcrowded hospital Emergency Rooms, suicide rates, and available housing for persons with SMI. The Battle Groups then identified 13 “Gaps or Barriers to Care.” In response to these problems, 22 “Directives for Change” are specified. Three Directives call for changes in the geographic boundaries of the Region, so that a true system of care with closer linkages between the hospital and community based providers are established. Two Directives address the problems related to systems’ infrastructure and the need for more efficiency in management information systems and electronic health records. A major transformative process is described in a new “HUB and Spoke” Southeastern GA System of Care. This System of Care concentrates the expensive specialty services in counties of highest need, while allowing every citizen in the service area an opportunity to access a fundamental level of care. The final 17 Directives address problems related to co-morbidity, housing, staffing, quality of care, criminal justice, hospitals and case coordination. v The participants of the Region 5 Adult Mental Health Summit identified 13 Gaps which keep doors to Recovery closed: 1. Mental Health Professional Shortage 2. Underutilized Provider Resources 3. Limited Master’s Licensed Clinician Parity 4. No Case Coordination 5. Minimal Supported Employment/Vocational Educational Services 6. Role Confusion and Lack of Coordination Between Georgia Regional Hospital-Savannah and Community Based Providers 7. No Specialized In-Home Support 8. Lack of Funding Incentives for Best Practices 9. Managed Care Organizations Burden 10. Inadequate Housing 11. Minimal Judicial and Law Enforcement Linkages with Community-Based Providers 12. Lack of Systemic Benchmarks for Quality Improvement 13. Overcrowded Community Hospital Emergency Rooms The Directives suggested to Open Doors to Recovery for those with Mental Illness: 1. A New Service Paradigm for Region 5 (Southeast GA System of Care) 2. Georgia Regional Hospital-Savannah for In-Patient Care only 3. Georgia Regional Hospital-Savannah and Community Providers should track recidivists 4. DBHDD should launch Electronic Health Records 5. All DBHDD core service providers should be required to participate in the Southeast GA System of Care Health Information Exchange 6. Federally Qualified Health Centers and Community Service Boards should be Formally recognized by the GA Department of Community Health and the GA Department of Behavioral Health and Developmental Disabilities as Georgia’s two “safety net programs” for somatic and psychiatric illnesses 7. DBHDD should adopt a new attitude towards community based providers 8. Fund a “Housing Specialist” at each CSB within the Southeast GA System of Care 9. Coordination with GA Department of Corrections on a program for released inmates with a mental illness 10. Jails and Prison should use common assessments for mental illness and formal linkages with community based providers 11. More Mental Health and Drug Courts 12. Reimbursement incentives for Evidence Based Practice care 13. Implement Telepsychiatry 14. Fund Case Coordinators and Recovery Specialists 15. Fair market Medicaid reimbursement rates 16. Fund Supported Employment 17. Develop Outcome, Performance, Benchmarks work group 18. Uniform Drug Formularies among all State funded providers 19. University Linkages and incentives to increase work force 20. Fund Mental Health at the National average 21. Convene a Blue Ribbon Taskforce to set System of Care priorities and corresponding budget implications before the 2010 Legislative Session vi “But who will do this?” asked Ahab. The prophet replied, “This is what the Lord says: ‘The young officers of the provincial commanders will do it.’ “And who will start the battle?” he asked. The prophet answered, “You will.” 1 Kings 20:14 The tree the tempest with a crash of wood Throws down in front of us is not to bar Our passage to our journey’s end for good, But just to ask us who we think we are Insisting always on our own way so. She likes to halt us in our runner tracks, And make us get down in a foot of snow Debating what to do without an ax. Robert Frost On a Tree Fallen Across the Road INTRODUCTION The current public system of behavioral health care in Region 5 is inadequate to meet the needs of its citizens. Some of the factors that limit the ability of the system to deliver the needed level of service to the most seriously ill adult consumers are: lack of funding to hire the number of staff needed to meet the demands of the increasing number of individuals in need of services; the vast and diverse geographic nature of Region 5; and inefficiencies in the current delivery of care among different providers in the Region, e.g. there is no universal assessment process, no consumer health information exchange, no common formulary for the use of psychotropics, and continual change in the payment and eligibility process for services rendered. Adults with Serious Mental Illness (SMI)1 require intensive services to help keep them stable in the community, manage their symptoms and medications, and avoid needless hospitalization, incarceration, homelessness or death. Underfunding of programs limits providers in their ability to have sufficient resources to deliver all but the minimum core services to clients. NAMI recognizes this Crisis as being Georgia’s time and opportunity to create a vision and system for consumer driven mental health recovery. We have forged a coalition of consumers, families, providers and agencies affected by a system in crisis. We have now shaped and created a clearer direction that moves this Region forward by creating an effective and efficient recovery-based service system. 1 PURPOSE A. Complexity and Limitations of Mental Health Planning Recently, a series of studies on the need for adequate mental health services in GA have been published: The Forensic Taskforce of the NAMI Board of Directors (September 2008); Adults with Serious Mental Illness (SMI) Comparison of Estimated Need (Prevalence) to Consumers Served, FY2008 (August 2008); Adults with Substance Abuse Comparison of Need to Consumers Served, FY2008 (August 2008); Georgia’s Mental Health Gap Analysis: Building an Action Agenda, Eleventh Annual Rosalynn Carter Georgia Mental Health Forum, (May 19, 2006)2; Georgia Association Chiefs of Police, Mental Health and Law Enforcement Encounters: A Review of Current Problem and Recommendations (nd) 3; Chief Justice-Led Task Force to Promote Criminal Justice/Mental Health Collaboration—A Call To Action: Final Report and Recommendations. Presented to Chief Justice Leah Ward Sears, (November. 7, 2008)4; Governor Sonny Perdue's Mental Health Service Delivery Commission: Final Report, (December 4, 2008)5. ‘Opening Doors to Recovery’ Summit Report and Directives for Southeast Georgia does not duplicate any of the aforementioned efforts; but it does examine specific issues that are unique to the needs of Region 5 and develops a plan that is transformative in improving the delivery of services and care for the Region. This Report is intended to assist in the identification, development and adoption of specific treatment services and approaches that are most responsive to the Regional needs. The ‘Opening Doors to Recovery’ Summit Report makes directives that are intended to improve efficiencies and practices for the purpose of transforming the existing public mental health system of care so as to enable adults with serious mental illnesses to engage in a recovery-based model that will assist them to live, work, learn, and participate fully in their communities. The Region 5 NAMI Georgia Summit participants ascribed to a vision that was based upon a commitment to increase quality care to use evidence-based services, to emphasize providing services in the most integrated, community-based settings possible, and to foster community integration for consumers in housing, employment, social, and recreational activities in their own communities. They established that the services must be rendered in a fashion that promotes recovery and an acceptance that consumers can play a vital part in the direction of their own care within the framework of a recovery model. However, throughout the Summit literature review and data gathering process, we discovered problematic issues in identifying 2 the existing system of care due to limitations in regional and state wide information gathering systems across agencies and disciplines, the absence of specific information on funding allocations for community infrastructure, as well as deficiencies in the number of trained licensed professionals delivering care. When NAMI convened this group of professionals and lay mental health advocates in the early summer of 2009, a decision was made by them to design a Model System of Care for the 44 counties in Region 5 that would reduce recidivism for adults with Serious Mental Illnesses. Four Battle Groups were organized to study issues related to Information Systems, Services Delivery, Housing Group and Case Coordination. B. The NAMI Approach in Region 5 WAR: Reduce recidivism of those with serious mental illness who are in jail, prison, State hospital or homeless. BATTLE 1: Problems surrounding Management Information Systems The Information Systems Workgroup methodology was to identify the prevalence6 of mental illness and addiction in Region 5, make reasonable estimations of the level of unmet need, and identify principal data systems available to provide information on services that most significantly affect the rates of recidivism for low income adults with Serious Mental Illness (SMI).7 Starting with the results of a recent DHR funded “Mental Health Gap Analysis”8 by APS, the Management Information Systems Battle Group was able to examine each of the 44 counties in the Region and determine the estimated number of persons in need of treatment for either SMI or addiction. Knowing the number of persons in need of State supported care, it was then necessary to determine what data would give us the best baseline against which to measure the success of subsequent interventions to be proposed in the Model System of Care. BATTLE 2: Study Best Practice Services The goal of this Battle Group was to explore current evidenced based practices and processes that would reduce recidivism, maximize services, and identify gaps in service delivery. Because of the limitations in funding, prevalence of SMI, population density factors and the large geographic area that needs treatment services, the Battle Group decided that there are identified areas in the region at greater risk than are other geographic areas. Accordingly, based upon existing patterns of service delivery, this Battle Group identified those priority counties needing essential levels of care and based upon that framework proffered the framework for a Model Recovery System of Care. The concept of system of care within a recovery model was cited by Kaplan (2008)9, through his work with Substance Abuse and Mental 3 Health Services Administration (SAMHSA), as a promising practice that supported a person-centered approach which was strength-based and empowering to the consumer while assisting communities to become accountable for the health and wellness of their citizen-consumer. Building upon Kaplan (2008) and SAMHSA’s framework, the Services Delivery Battle Group examined strategies and approaches to strengthen both the consumer in their home and in their community with care that was more geographically accessible to the consumer. BATTLE 3: Increase the capacity of housing for the seriously mentally ill The Housing Battle Group was to explore the shortage of affordable housing available to the SMI population. Those with chronic mental health issues have had historical challenges with sustaining employment, connecting with public services, and being consistent with their mental health treatment. In Region 5, all mental health providers reported an overwhelming need for watchful oversight, transitional housing and supportive housing. Funding streams were determined to be almost nonexistent. Currently, most providers do not have formal relationships with the Department of Community Affairs or the Interagency Council on Homelessness. BATTLE 4: Develop a family/peer/self-case management or case coordination tool This Battle Group established the premise that adults with SMI cannot access case management, which is key to recovery. Case Coordinators (Recovery Specialists) provide an array of services to help individuals and families cope with complicated situations in the most effective way possible, thereby achieving a better quality of life. They help people to identify their goals, needs and resources. The Case Coordinator and the client (individual or a family) together formulate a plan to meet those goals. The Case Coordinator helps clients to find resources and facilitates connection with services. Sometimes, she/he advocates on behalf of a client to obtain needed services. The Case Coordinator also maintains communication with the client to evaluate whether the plan is effective in meeting client’s goals. Any efficient and cost-effective Model Recovery System of Care that would facilitate the promising practices aspects cited by Kaplan (2008) and SAMHSA would include Case Coordination in its service mix. 4 NEED A. Description of the Service Area Region 5 encompasses 44 counties of southeastern GA and has a population of 1,180,795. With a land mass of over 20,156 square miles, it covers 34.1% of the State and is larger than nine states in the country. The geographic area is bound by Route 75 to the West, Route 16 and the South Carolina State Line to the North, the Atlantic Ocean to the East and the Florida State Line to the South. A number of large military bases are located in the Region including Kings Bay Submarine Base (home of the Trident Nuclear Submarine), Moody Air Force Base, Hunter Army Air Field and Fort Stewart. Colleges and Universities are found in nine of the Region’s counties: Abraham Baldwin Agricultural College, Armstrong Atlantic State University, College of Coastal Georgia, East Georgia College, Georgia Southern University, Middle Georgia College, Savannah State University, Skidaway Institute of Oceanography, South Georgia College, Valdosta State University and Waycross College. Agriculture and recreation are major forces in the economy of Region 5. Melons, peanuts, cotton, broilers and timber are top products. The Oconee River, Ocmulgee River, St. Marys River, Suwannee River, Canoochee River, and the Alapha, Ohoopee, Willacooche and Satilla rivers and the Okefenokee Swamp provide for recreation and tourism. Principal cities in Region 5 with populations over 11,000 are Brunswick, Douglas, Dublin, Hinesville, Pooler, St. Marys, Savannah, Statesboro, Valdosta and Waycross. Fig. 1. GA Department of Behavioral Health and Developmental Disabilities, Region 5, Southeast GA 5 Table 1. Region 5 counties by population and percent10. County Population Percent Appling Atkinson Bacon Ben Hill Berrien Bleckley Brantley Brooks Bryan Bulloch Camden Candler Charlton Chatham Clinch Coffee Cook Dodge Echols Effingham Emanuel Evans Glynn Irwin Jeff Davis Johnson Lanier Laurens Liberty Long Lowndes McIntosh Montgomery Pierce Tattnall Telfair Tift Toombs Treutlen Turner Ware Wayne Wheeler Wilcox 17,419 7,609 10,103 17,484 16,235 11,666 14,629 16,450 23,417 55,983 43,664 9,577 10,282 232,048 6,878 37,413 15,771 19,171 3,754 37,535 21,837 10,495 67,568 9,931 12,684 8,560 7,241 44,874 61,610 10,304 92,115 10,847 8,270 15,636 22,305 11,794 38,407 26,067 6,854 9,504 35,483 26,565 6,179 8,577 1,180,795 1.5% 0.6% 0.9% 1.5% 1.4% 1.0% 1.2% 1.4% 2.0% 4.7% 3.7% 0.8% 0.9% 19.7% 0.6% 3.2% 1.3% 1.6% 0.3% 3.2% 1.8% 0.9% 5.7% 0.8% 1.1% 0.7% 0.6% 3.8% 5.2% 0.9% 7.8% 0.9% 0.7% 1.3% 1.9% 1.0% 3.3% 2.2% 0.6% 0.8% 3.0% 2.2% 0.5% 0.7% 100.0% 6 B. Prevalence of Serious Mental Illness (SMI) The presence of a Serious Mental Illness means that a person has such severe and persistent mental illness that they are limited in their daily functioning. Only 27% of the SMI are being cared for in Region 5. Over 80% of the SMI in Bacon, Bryan, Camden, Echols, Effingham, Liberty, Long, Tattnall, and Wheeler are going without care. Only 6% of adults in need of treatment for addiction are receiving services. Fig. 2 Prevalence of Serious Mental Illness (SMI) C. Prevalence of Substance Abuse In Atkinson, Bleckley, Brooks, Bryan, Camden, Charlton, Coffee, Echols, Effingham, Irwin, Johnson, Lanier, Liberty, Long, Montgomery, Telfair, Turner, and Wilcox counties, over 95% of adults with a diagnosable addictive disease are not being served. Fig. 3 Prevalence of Substance Abuse 7 D. Georgia Regional Hospital 30-Day Readmissions As a whole, the 30-day readmit percent to Georgia Regional Hospital in Savannah in FY08 at 13.6% was about the same as that of the State at 14.2%.11 Individual Region 5 counties ranged from 0 to 31.3% in FY08. Counties with 30-Day readmits of 20% or over included Brooks, Dodge, Lanier, Montgomery, Wheeler and Wilcox. The set goal for the State of Georgia is for there to be less than a 10% 30-day readmission rate to GA Regional Hospitals. Fig. 4 Georgia Regional Hospital 30-Day Readmissions Counties with 30-Day Readmission Rate of 20% or greater 14.2% 13.6% E. Additional Indicators 1. Homelessness On any given night, over 20,000 persons in GA are homeless12. In Region 5, Chatham, Bulloch, Treutlen, Laurens, Coffee and Lowndes each has between 100 and 500 homeless persons. The California Psychiatric Association estimates that 20 to 40% of all homeless persons suffer from SMI.13 40% 60% Fig. 5 8 2. Hospital Emergency Rooms According to the GA Department of Human Resources, Division of Public Health, Office of Health Information and Policy (OASIS database), three percent of all ER visits are for mental and behavioral disorders. The GA Hospital Association (GHA) lists psychosis as the number four most frequent diagnosis of patients in emergency rooms (GHA Today Aug/Sept 2008). They also report that due to overcrowding of State psychiatric hospitals, ERs often have to hold patients up to 90 hours before they are transferred. Fig. 6 3. Prisons and Jails The State prisons and County jails have become the new de facto public psychiatric hospitals. Lamb and Weinberger (1998)14 reported that clinical studies indicated that 6 to 15% of persons in city and county jails and 10 to 15% of persons in state prisons have severe mental illness. Chronic offenders with mental illness problems typically have chronic mental illness and poor social skills which impact recidivism and an inability to obtain stable employment (Ibid., 1998). 9 The GA Department of Corrections inmate count (which includes all of the GA State Prisons, private Prisons, Transitional Centers, Boot Camps and Probation Detention Centers) has increased by 30% from 40,797 inmates during 1999 to over 53,000 in May 2009. 15 The number of prison inmates with a serious mental illness doubled from 4,500 to 9,200 during that same period; representing 16% of the general prison population. (“The Future of MH in Georgia” by James F. Degroot, PhD. Unpublished paper. 25 June 2009.) Most inmates admitted to GA prisons in FY 2009, reported a substance abuse problem (60%) and 22% reported that they were receiving some type of mental health care at the time of their arrest.16 Approximately, 70% of the mental health caseload inmates receive psychotropic medications. (Op. Cit., JL Metzner, 2009). Nationally, 92% of all inmates with SMI were non-compliant with their medications at the time of their arrest.17 Fig. 7 The number of suicides per 100,000 inmates averages 14.7; which is 56% higher than the State suicide rate. One-third of the Department of Behavioral Health and Developmental Disabilities consumer population being served is forensic. Dr. James F. Degroot at the GA Department of Corrections has reported that Mental Health prison population in GA has doubled over the last 10 years (from 4,500 in 1999 to 9,200 in 2009). In 2008, 466 prison inmates with a mental health diagnosis were released in Region 5 (J.F. Degroot, 2009). Last year, 39 seriously mentally ill persons per month were released to live in Region 5. Region 5 accounts for 16% of all prison inmates in GA. Chatham is the home county for 28% of all prison inmates in the Region; Laurens for 4%; Lowndes 7%;Tift 4%; and Ware 4%. It is estimated that 10 to 20% of prisoners are SMI. 18 State Board of Pardons and Paroles reported that in calendar year 2008, 299 persons with SMI were paroled in Region 5. 10 Fig. 8 There are State Prisons in Bullock, Charlton, Chatham, coffee, Dodge, Effingham, Emmanuel, Johnson, Lowndes, Montgomery, Tattnal1 (4), Telfair (2), Ware, Wheeler and Wilcox counties. The Department of Corrections also has two Pre-release Centers in Appling and Turner counties and Transitional Centers in Chatham, Lowndes and Tattnall counties. From January 1998 to January 2009, the GA county jail population rose from 25,000 to 39,91919. There are 38 county jails in Region 5. Six counties (Charlton, Echols, Lanier, Long, Montgomery and Treutlen) do not have a county jail. As of January 2009, there were 7,041 inmates in jail; 4,527 of them in jail awaiting trial, 627 serving County sentence, 846 inmates sentenced to State and 1,041 in another inmate category. 11 Table 2: County Jail Report January 200920 County Total Number of Inmates in Jail Number of Inmates Sentenced to State Number of Inmates Awaiting Trial in Jail Number of Inmates Serving County Sentence Appling 70 19 33 4 Atkinson 33 6 21 0 2 Bacon 43 2 35 Ben Hill 107 13 90 0 Berrien 86 0 0 58 Bleckley 26 7 14 4 Brantley 0 0 0 0 Brooks 60 4 38 10 Bryan 57 6 51 0 Bulloch 341 29 180 74 Camden 173 9 140 0 Candler 50 8 37 5 Charlton (No Jail) 0 0 0 0 1,820 177 1,581 46 Clinch 24 12 5 0 Coffee 274 31 238 5 Cook 131 39 47 4 Dodge 67 16 44 6 Echols (No Jail) 0 0 0 0 Effingham 111 30 68 8 Emanuel 91 4 51 4 Evans 12 3 0 9 Glynn 499 62 323 13 Irwin 402 6 20 0 Jeff Davis 36 8 27 0 Johnson 37 8 3 1 Lanier (No Jail) 0 0 0 0 Laurens 236 7 201 18 Liberty 258 42 175 12 0 0 0 0 Lowndes 718 69 488 101 McIntosh 82 1 28 0 Chatham Long (No Jail) Montgomery (No Jail) 0 0 0 0 Pierce 67 39 12 15 Tattnall 54 14 32 7 Telfair 30 4 26 0 Tift 229 41 37 138 Toombs 5 130 42 76 Treutlen (No Jail) 0 0 0 0 Turner 45 0 0 38 Ware 421 19 269 39 Wayne 178 51 116 0 Wheeler 16 5 8 0 Wilcox 27 13 13 1 7,041 846 4,527 627 12 Fig. 9 JAIL POPULATION – ANNUAL TREND JANUARY 2000 – JANUARY 2009 50,000 47,500 45,000 42,500 40,000 37,500 35,000 32,500 30,000 27,500 25,000 22,500 20,000 2000 2002 2004 2006 2008 2010 4. Suicides About 16% of all suicides in GA were in Region 5 in 2006.21 Camden (7), Chatham (29), Glynn (13), Liberty (8) Lowndes (12), and Wayne (8) accounted for 55% of all suicides in Region 5 in 2006. The Region has a higher rate of suicide than the State as a whole (Georgia has the 12th lowest U.S. state suicide rate).22 Fig. 10 13 F. Priority Counties at Risk There was a consensus among the Work Groups that there needed to be a more rational distribution of services in Region 5. Furthermore, it was determined that every resident of the Region must have access to a basic, essential level of care and that expensive “deep end” programs must be centralized but accessible. Fig. 11 Priority Counties At Risk High - Chatham Moderate to High - Bulloch - Lowndes - Glynn Moderate - Liberty - Effingham - Camden Low to Moderate - Laurens - Tift - Coffee - Ware - Bryan Low - All Others 14 RESOURCE AVAILABILITY AND ACCESSIBILITY A. Defining the Services In Region 5, there are 11 agency providers and one public hospital (GA Regional Hospital-Savannah). 1. Community Service Boards Of the $29,845,287 allocated by the DBHDD to providers in the Region, $23,852,678, or 80%, is contracted out to the Community Service Boards (CSBs). They are: Gateway Behavioral Health Services, CSB of Middle GA, Ogeechee BHS, Pineland CSB, Satilla CSB and Behavioral Health Services of South Georgia. Although CSB programs may vary somewhat from agency to agency, their services typically include medications, medication management, crisis services, peer support, supportive employment, residential day services, and outpatient counseling. In the Official Code of Georgia Annotated 37-2-6, et sequentes, the CSBs are defined as “an instrumentality of the State of GA.” Since their inception, they have served as the mental health safety net for the State of Georgia and together serve over 23,000 consumers annually. Other Region 5, DBHDD funded agency providers (profit and nonprofit) are American Work, G&B Works, Georgia Therapy Associates, Glynn County Drug Court (Resiliency Institute), Recovery Place, and Volunteers of America. Table 3. Region 5 Agencies by Type of Corporation & Amount of State Funding FY2010 PROVIDER American Work CSB of Middle GA G&B Works Gateway Behavioral Health Services Georgia Therapy Associates Resiliency Institute (Glynn County Drug Court) Ogeechee CSB Pineland CSB Recovery Place Satilla CSB Volunteers of America AMOUNT OF STATE FUNDING $698,160 4,410,273 140,472 7,234,829 TYPE OF CORPORATION 201,132 310,138 For Profit For Profit 493,340 4,703,688 1,424,560 7,010,548 3,218,147 Public Non Profit Public Non Profit Private Non Profit Public Non Profit Private Non Profit For Profit Public Non Profit For Profit Public Non Profit 15 2. GA Regional Hospital-Savannah The annual budget for GA Regional Hospital-Savannah (GRH) is approximately $23 million. The hospital campus covers over 25 acres with 16 structures valued at $7 million. GRH serves over 2,000 persons (adults at the hospital plus children at a Crisis Stabilization Program in nearby Bloomingdale) annually. For adults with a primary diagnosis of mental illness, GRH operates three units: a secure forensic unit (34 beds), a recovery care unit (34 beds) and an acute care unit (33 beds). In addition, GRH operates a 32 bed Crisis Stabilization Program on the hospital grounds. A Mobile Crisis and an ACT Team for Chatham and adjacent counties are also operated by the hospital. GRH serves 24 of Region 5’s 44 counties. The southwest corner (Valdosta area) of Region 5 relates to Southwestern State Hospital in Thomasville (Thomas County) for services. Region 5 counties to northeast (Middle GA and Dublin area) tend to use Central State Hospital in Milledgeville (Baldwin County) for services. Counties served by GRH-Savannah are: Appling, Atkinson, Bacon, Bulloch, Brantley, Bryan, Camden, Candler, Charlton, Chatham, Clinch, Coffee, Effingham, Evans, Glynn, Jeff Davis, Liberty, Long, McIntosh, Pierce, Tattnall, Toombs, Ware, and Wayne. (See Fig. 12) 16 Fig. 12 Georgia Department of Behavioral Health and Developmental Disabilities Overlayed with Hospital Catchment Areas (borders) 17 B. Staff Recruitment, Retention and Training The ability of the mental health system to successfully deliver services to the most seriously mentally ill, achieve positive outcomes, and transform the system depends on a competent, trained, and experienced work force. Appropriate staffing closes service gaps, helps consumers move towards recovery and autonomy by utilizing best practices to reduce symptoms, and manages resources in a cost-effective manner. The Region 5 System of Care must be able to hire licensed and credentialed staff that are skilled and understand the mental health service delivery system and best practices. At the present time, nearly all mental health providers in Region 5 have licensed staff vacancies. This creates two problems: insufficient staff to meet consumer demand; and current staff are asked to perform multi-tasks that are not related to direct patient care. This requires fewer staff to manage bigger caseloads of clients, while also performing additional hours of on-call, after hours, and crisis services. This additional burden creates stress, burnout, and leads to higher-than-average staff turnover, as individuals leave local community mental health providers for private sector positions and programs with adequate work forces and higher pay. There are several strategies for meeting the current mental health services staffing shortage. C. Other Undervalued Public Resources According to the Bazelon Center for Mental Health Law, 20% of adults discharged from psychiatric hospitals suffered from chronic/serious physical illnesses such as HIV infection, brain trauma, cerebral palsy and heart disease…as many as 75% of those with schizophrenia have diabetes, respiratory, heart and/or bowel problems and high blood pressure. Half of the counties in Region 5 are served by a Federally Qualified Community Health Center (FQHC). These FQHCs serve as a primary medical care safety net for the underinsured and uninsured. They are well positioned to screen for SMI and addiction among their patients, treat routine behavioral health problems and develop integrated services with community based mental health providers. This is perhaps one of the greatest undervalued assets in treating mental illness in Region 5. Barsky and Borus (Somatization and Medicalization in the Era of Managed Care, JAMA 1995) report that 60% of persons with common psychiatric disorders seek help from their Primary Care physicians. In Region 5, the FQHCs serve over 53,000 per year who are mostly uninsured or underinsured. There are eight separate non-profit community-based corporations operating 22 separate primary care sites in the Region. 18 Fig. 13 FQHC Footprint in Region 5 Community Health Care Systems, Inc. - Johnson - Laurens Curtis V. Cooper Primary Health Care, Inc. - Chatham Diversity Health Center, Inc. - Liberty - Long East Georgia Healthcare Center, Inc. - Candler - Emanuel - Montgomery - Tattnall - Toombs - Treutlen McKinney Community Health Center, Inc. - Bacon - Brantley - Charlton - Pierce - Ware South Central Primary Care Center, Inc. - Atkinson - Coffee - Irwin Southwest Georgia Health Care, Inc. - Dodge - Wilcox Union Mission, Inc. - Chatham 19 TRANSFORMING MENTAL HEALTH SERVICES A. Re-defining Care from Symptom-Blame to Recovery, Wellness and Empowerment Jennifer Pyke23 aptly described recovery from a combined viewpoint of Deegan (1988)24 and Anthony (1993)25 when she stated “There is no single agreed upon definition of recovery. However, the main message is that hope and restoration of a meaningful life are possible, despite serious mental illness.” How we engage consumers in Region 5 is critical to maintenance of their self-respect, autonomy, and positive motivation in care. Anthony (2004)26 in a report to the U.S. Department of Health and Human Services, expressed concern that in transforming traditional mental health from outcomes that have inherently low-expectations and no input or vision from consumers - to a system that is empowering to consumers would require major changes in how we view treatment and the consumer. Therefore, in order to shift to a recovery system of care, Region 5 would need to re-think policies and mission to incorporate language that is consistent with a recovery model. Anthony (2004) reported that mission statements for services from all levels of leadership must shift their understanding of treatment to infuse language, values and beliefs that the consumers can recover and have a stake in being successful. The Region 5 transformative processes would involve ensuring services are delivered close to the consumer’s home which will facilitate advocacy and intervention from natural supports such as churches and local community groups. Region 5 must utilize language, beliefs, and values that recognize that although consumers may not exhibit full control of their symptoms and behaviors, through a recovery process they can achieve stability and regain control over their lives toward a trajectory of wellness and an improved quality of life. This vision is in line with the Georgia Mental Health Service Delivery Commission 2008 Final Report in which they also recommended that services should be within the framework of recovery-focus within both community-based and hospital-based services while utilizing best and evidence-based practices. B. Access to the Mental Health System Within Region 5, there are barriers that prevent consumers from accessing care. They include: the stigma attached to defining consumers as chronically sick versus recognition that they can recover, poor public transportation and providers having insufficient resources to engage overwhelming numbers in need. A 2009 National Council of Community Behavioral Health report to SAMHSA27, concerning advancing health through system reform, stated that improper funding was problematic and impacted consumer access to coordinated and integrated care. When a mental health core provider must deliver services to an unlimited number of individuals (anyone who enters services) without proper reimbursement for the extra intensive 20 interventions, then the amount of resources available to each person receiving care diminishes, as the number of persons receiving intensive intervention services increases. C. Management Information System Infrastructure There are three principal data information systems of relevance to the provision of care in Region 5: the Multipurpose Information Consumer Profile, the State Hospital Utilization Review and the Monthly Income and Expense Report. 1. Data on all DBHDD funded programs are uniformly collected through the Multipurpose Information Consumer Profile (MICP). The MICP collects the following data from the following instruments: Registration Information (33 data elements), Assessment Information on Adults (45 data elements), Assessment Information on Child & Adolescent (40 data elements), and Community Data on Discharge Information (16 data elements). 2. The State Hospital Utilization Review accounts for: State Hospital Inpatient Acute Care Admission Information (24 data elements), State Hospital Inpatient Acute Care Continuing Stay Information (18 data elements), State Hospital Inpatient Acute Care Review Information (15 data elements) and State Hospital Inpatient Acute Care Discharge Review Information (13 data elements). 3. The Monthly Income and Expense Reports (MIERS) consists of information sent into the State from service providers that contains a list of consumers served and number of units of mental health and addictive disease provided; a list of consumers served in residential programs; list of persons receiving rent subsidies who are in personal care homes; and information on the number of women served under the Temporary Assistance to Needy Families program. D. Gaps and Barriers to Care In order to recover from a serious mental illness and make a meaningful contribution to their community, one must have appropriate, comprehensive health care, a safe place to sleep and a meaningful day. Gap 1: Mental Health Professional Shortage Area and Health Manpower Shortage Area According to Kaiser State Health Facts, as of September 2008, 29% of Georgia’s underserved population was living in a Mental Health Professional Shortage Area (MHPSA). More specifically, the US Dept of Health and Human Services Health Resources and Services Administration (HRSA), currently identifies 33 of the Region’s 44 counties as designated mental health professional shortage areas. Access to behavioral health services will continue to be severely hampered without sufficient numbers of mental health professionals or alternative means to provide services. 21 Gap 2: An Underutilized Provider Resource As was previously stated, Georgia’s FQHCs can provide mental health services as part of their provision of primary health care services. At many sites, these FQHCs have received federal and state funding to do so. And yet, according to 2006 data (Bureau of Primary Health Care, Section 330 Grantees Uniform Data System, Georgia) only 527 individuals, out of the 248,205 served State wide, received mental health services through an FQHC. Gap 3: Limited Master’s Licensed Clinician Parity and Staff Recruitment At the present time, only a Licensed Board Certified Psychiatrist, Licensed Psychologist or Licensed Clinical Social Worker (LCSW) can independently sign off on an involuntary commitment order (1013 and/or 2013) and perform many reimbursable clinical services. In some parts of the Region, particularly rural counties, recruiting for these professionals can be a problem. In particular, community services providers report extreme difficulty in recruiting and employing LCSWs, Board Certified Psychiatrists, and other licensed professionals. Gap 4: No Case Coordination Although case coordination is the key component in ensuring continuity of care, developing care plans, connecting consumers between levels of care and among agencies, and providing critical skills development for consumers, Georgia does not reimburse for case coordination or case management services. Most persons with severe mental illness are involved with a myriad of medical and support service providers and agencies. Lack of reimbursement for case coordination has resulted in patients literally and figuratively being lost in the various systems of care; resulting in increased utilization of high end intensive services, lack of linkage to needed supports, and overall diminished treatment plan recovery and compliance. Gap 5: Minimal Supported Employment/Vocational Educational Services Supported Employment and Vocational Educational services are important services which assist clients in getting and keeping a job. Only a few community providers are successfully working with the GA Department of Labor, Division of Vocational Rehabilitation (DVR) to deliver these services to persons with SMI. However, in most locations, DVR does not have adequate staff to serve mental health clients and are not connected with community providers. One of the core outcomes for mental health services is to help clients become employed, whenever feasible. Developing these services, tailored to meet the needs of mental health clients, is critical for helping clients live independently. Currently, access and resources committed to employment support services for SMI clients are not adequate. Gap 6: Role Confusion and Lack of Coordination Between GRH-Savannah and Community Based Providers There are many challenges within the existing system that involve the hospital and community providers. Although there is some level of dialogue and communication between hospital and community providers, the inability to have a coordinated seamless care system creates problems for consumers and providers. 22 The lack of common drug formularies and medical history data exchange between the two entities creates both confusion and duplication of work, when consumers reenter their communities for community based services. Case coordination is limited to hospital discharge actions instead of pre-hospital admission. The roles and the missions of hospitals and community providers are out of sync related to current recovery models with GRH-Savannah providing what are traditionally community level programs, such as Crisis Stabilization and Mobile Crisis Programs. Gap 7: No Specialized In-Home Support There are some types of interventions and approaches that are not necessarily facilitated by a licensed therapist but are critical in the movement towards recovery and wellness. Specialized services are designed to develop skills to help a client learn to live independently (e.g., budgeting, shopping, getting along with neighbors/roommates, and other activities of daily living); to obtain a job (e.g., timeliness, hygiene, getting along with co-workers); attend school (e.g., attend class, complete assignments on time); and develop a social support network (e.g. recreation and socialization). These services are recovery life skills, which are critical in meeting the needs of persons with a serious mental illness. Gap 8: Lack of Funding Incentives for Best Practices Reimbursement is based upon a type of service, such as group or individual. However, financial incentives are not provided for the provider who offers Evidenced-Based Practices (EBPs) or promising practices. The Substance Abuse and Mental Health Services Administration (SAMHSA) is the leader in identifying best practice services and treatment approaches. EBPs are interventions for which there is consistent, scientific evidence showing that they improve consumer outcomes. National studies have shown that a majority of individuals diagnosed with a severe mental illness do not have access to these EBPs. While the adoption of such evidenced-based practices can result in increased treatment success, the costs to implement such practices (e.g. staff training, creation and adoption of new protocols) are not reimbursable in Georgia. Gap 9: Managed Care Organizations Burden on Providers While the overall merit and benefit of managed care in Georgia is still in question, the negative impact to service providers continues to increase. In Region 5, three Medicaid managed care organizations oversee, authorize, and pay for the provision of behavioral health services: Amerigroup, Centene, and Magellan. GA Department of Behavioral Health and Developmental Disabilities (DBHDD) contracts with APS Healthcare to provide oversight and authorize the provision of services. All four organizations have different processes (computerized or paper) for service authorization, billing, and oversight, which increases the administrative and IT burden of clinicians, clerks and other support staff. All four managed care organizations have different service staffing requirements (licensed, unlicensed, bachelor, masters, credentialed, etc.) and have diminished reimbursement for more effective means of treatment; namely group training and counseling. 23 An additional barrier is the Medicaid reimbursement rate for behavioral health services set by the State. Unlike other medical reimbursement rates for hospitals and other private medical providers, which are regularly adjusted based on Medicaid cost data, the State has kept rates for behavioral health services based on year 1999 data. With the failure of the State to undertake cost studies and by keeping reimbursement rates artificially low; providers are increasingly faced with critical financial losses, reduction in the provision of services by providers and more behavioral health providers dropping out of the Medicaid program. Gap 10: Inadequate Housing Within Region 5, the shortage of affordable housing and limited resources prevents individuals with severe mental illness from achieving recovery and improving their quality of life. Those with chronic mental illness have historical challenges with sustaining stable employment, connecting with public services, and being consistent with their mental health treatment. The 2003 President Bush New Freedom Commission on Mental Health observed that the lack of housing and supports “causes people with serious mental illnesses to cycle among jails, institutions, shelters, and substandard housing” as part of their normative functioning. (President Bush 2003 New Freedom Commission on Mental Health website: http://www.mentalhealthcomission.gov/). In Region 5, all mental health providers reported an overwhelming need for “watchful oversight”, transitional housing and supportive housing. Funding streams through the DBHDD are either non-existent or extremely circumscribed. And, given the correlation between SMI and the criminal justice system, the housing situation is made even worse since persons with criminal records cannot live in HUD funded housing. Currently, core service providers do not have any formal relationships with the Department of Community Affairs, the Corporation for Supportive Housing, or the Interagency Council on Homelessness. Gap 11: Minimal Judicial and Law Enforcement Linkages with CommunityBased Providers Georgia Supreme Court reported in their Mental Health America Fall 2007 Newsletter28 that mental illness had a profound affect on the administration of their judicial system. They explained in the report that there was a vicious and costly cycle of individuals with mental illness being arrested, prosecuted, incarcerated, released and re-arrested as a result of gaps in services, lack of proper community reentry programs and coordination of care. The Georgia Association Chiefs of Police Mental Health and Law Enforcement Encounters Report (nd)29 expressed similar concerns regarding an insufficient amount of core services throughout Region 5 and lack of coordinated care that resulted in individuals with mental health needs funneling back into the criminal justice system. 24 Finally, among the jails in Region 5, there is no standardized assessment methodology to diagnose who is mentally ill; nor are there any standards with regard to treatment, practices and protocols. Jails usually do not have any formal relationship with the local community mental health center provider and often contract with independent private providers for inmate treatment and medications. Upon discharge from jail, this absence of a formal relationship with no coordination of care and treatment, coupled with no common drug formulary causes mental health patients to yoyo back and forth from community to jail. Gap 12: Lack of Systemic Benchmarks for Quality Improvement The Region, as well as the State, lacks the ability to gather meaningful data that would be used in identifying systemic problems, planning solutions and tracking changes. There is lacking a core set of client outcomes and system-level performance measures to demonstrate the effectiveness and efficiency of services. Gap 13: Overcrowded Community Hospital Emergency Rooms (ERs) State psychiatric hospital bed reductions and decreases in community mental health funding have resulted in increasing numbers of uninsured and underinsured mentally ill patients coming to ERs for services. GHA reports indicate that 39% of psychotic patients are self-pay with hospitals having to pick up the cost. Delays in State bed availability result in patients waiting up to 20 hours before being transferred; compromising ER staffing resources and space availability for other medical emergencies. 25 DIRECTIVES FOR CHANGE A. Geographic Parameters and Directives It is not possible to design a single system of care given the historical patient flow patterns in the area. Figure 10 on page 13, clearly shows how Region 5 counties actually relate to four different hospital systems: GRH-Savannah, Southwestern State Hospital in Thomasville, Central State Hospital in Milledgeville and East Central Regional Hospital in Augusta. In a System of Care paradigm that focuses upon reduced recidivism rates for the SMI, it is imperative that community based mental health care services relate to a hospital for specialized in-patient care. There are already long established patterns of referral and treatment in which 20 of the counties in Region 5 utilize hospital care in neighboring Regions. Each State hospital needs to have a formal structure in place that creates a partnership with a comprehensive safety net provider in its catchment area (D. Gay, 2009)30. This will allow DBHDD the ability to better track hospital discharges and readmits, do more inclusive discharge planning and maintain continuity of care within a defined System. In some cases, the local core providers of mental health services are not involved in the involuntary commitment process and are not notified in real time if a consumer from their service area is admitted to GA Regional Hospital. The current system emphasizes inpatient services for the most acute consumers and limits services for those consumers with short-term needs who are at risk of decompensation and eventual inpatient care. The most costly services, such as Inpatient Hospitalizations, prisons and State Hospital services, are primarily funded by the State. Overrun jails, homeless shelters, and community hospital emergency rooms become a burden on to the local taxpayer. Directive 1: A new service paradigm (Southeast GA System of Care) should be formed that is geographically compatible with the GRH-Savannah catchment area encompassing 24 counties: Appling, Atkinson, Bacon, Bulloch, Brantley, Bryan, Camden, Candler, Charlton, Chatham, Clinch, Coffee, Effingham, Evans, Glynn, Jeff Davis, Liberty, Long, McIntosh, Pierce, Tattnall, Toombs, Ware and Wayne. (Response to All Gaps & Barriers) Directive 2: GRH-Savannah should provide in-patient care for people with criminal justice histories, forensic patient, dangerous persons, and extremely difficult to discharge patients. Community based services such as Crisis Stabilization Programs, Intensive Treatment Residential Programs, ACT and Mobile Crisis Programs should be operated by community based safety net provider(s). (Response to Gap 6) 26 Directive 3: A formal relationship should be established between the GRHSavannah and safety net providers to track hospital discharges, to provide continuity in discharge planning/community integration and follow-up on patients with a special risk for hospital readmission. (Response to Gaps 4 & 6) B. Management Information Systems and Infrastructure Directives Profit margins on services being provided are virtually non-existent. Thus, the opportunity for most providers to invest in an Electronic Health Record system simply does not exist. This dearth of EHR systems is an opportunity for providers in the Region to seek commonality and share costs. A common EHR would also facilitate participation in the exchange of management and certain consumer driven information. Timely access to information is a key component of providing high quality care in the Region. In order to better use and access the many different data elements, a Regional Health Information Exchange (HIE) or repository should be created. The Regional HIE would allow all partnering care providers to share data pertinent to providing patient care. It would also allow data to be updated to reflect the most current status or condition as consumers/patients present to the many different providers. A side benefit of the regional HIE would be a potential cost savings for providers as, in many cases, they could verify existing shared information instead of collecting and entering this data again. Benefits for providers: Provides more timely access to data Reduces costs related to data collection Provides data that allows trending Provides a more comprehensive care background on patients Benefits for consumers: Speeds up the admission/readmission process Aids to provide a more consistent level of care due to better information Benefits for the system: More current data collected by partnering providers More comprehensive data collection for review, trending or analysis Directive 4: The Department of Behavioral Health and Developmental Disabilities (DBHDD) should decide on a common data platform to be used in the establishment of Electronic Health Records for the state hospital and all core service providers in the proposed Southeast GA System of Care and provide financial incentives for their participation.(Response to Gaps 4, 6, 9 & 12) 27 Directive 5: All DBHDD core service providers should be required to participate in the Southeast GA System of Care Health Information Exchange. (Response to Gaps 4, 6, 9 & 12) C. Structural Characteristics of the Southeast GA System of Care The delivery of mental health services requires a delicate balance of delivering the right amount of service at the right time. Intensive and costly services, such as those offered at GRH-Savannah, should be reserved only for those consumers who are the most acute and unable to get care within their own community. The public mental health services system provides a safety net protection for people who are poor, uninsured, or for those whose private insurance benefits run out during their illness. The State funded public mental system is meant to ensure that mental health treatment is available for those who are most in need of mental health care. However, jails and prisons currently serve as the final “safety net.” Although, the State funds both private and public entities to form a care delivery system, there is a vital need to maintain a public safety net provider(s) in order to ensure that a minimal level of core services remain for Georgia’s citizens. The National Council for Community Behavioral Health Care testimony to the Federal Appropriations for Substance Abuse and Mental Health Services Administration regarding the FY2010 budget bolstered the need for States to have safety net providers loyal to the interest of the State and its citizens due to recent economic times creating budget shortfalls leading to the closing of mental health programs. The “Georgia’s Mental Health Gap Analysis: Building an Action Agenda,” Eleventh Annual Rosalynn Carter Georgia Mental Health Forum indicated in their findings that when building a system of care of private and public providers, a distinct difference between a public and private provider is that the public facilities can not refuse consumers entering care while private providers could decline acceptance of a consumer. Within our current delivery of care configuration in Region 5, we have an opportunity to build upon an existing fragmented system of public safety net providers, private providers of care, and other agencies that provide some level of care to the mentally ill (e.g. the criminal justice system) to form a more seamless system of care. The National Governor’s Association Center for Best Practices 2001 Report from their Health Policy Studies Division entitled, “Strengthening the Mental Health Safety Net: Issues and Innovations” recognized the importance of State funded public mental health safety net providers whereas they could be the foundation for States to coordinate other levels of specialty care provided by other providers who have access to other funding streams for care such as state, county, city, foundation funded mental health care. The proposed System of Care that follows orchestrates the delivery of various community-based services designed to help consumers live independently in safe, stable environments; manage symptoms; obtain and keep employment; and develop a community-based social network. When consumers have timely access to this 28 supportive network of services, his or her need for inpatient care will be minimized or even eliminated. Fig. 14. Southeast GA System of Care The proposed Southeast GA System of Care is a type of HUB and SPOKE paradigm that encourages a full continuum of outpatient services, with an emphasis on offering services as close as feasible to the client’s home within a regional configuration that promotes optimal outcomes. Services rendered in the community create the least disruption in the client’s life and provide the optimal situation by allowing them to remain close to family, work, and friends. The Southeast GA System of Care Model is a template for creating greater regionalization of services, which will provide the opportunity to offer services that can be delivered cost-effectively to as many of Region 5 citizens as possible. The service delivery system extends into both rural and urban areas, while having specialized supports for the higher population centers. Given the presence of GA Regional Hospital and a population of 232,048 with corresponding gaps in services, Chatham County 29 should clearly be designated the HUB SITE for mental health services in Region 5. As such, the HUB will have a concentration of the more expensive, “deep end” services necessary to anchor care in the System. The HUB will include the following services: Hospital and Criminal Justice GA Regional Hospital – (Savannah GRH) GRH will focus on those special SMI populations with no ability to be served in a community setting i.e. forensics and persons who are hard-to-discharge due to the severity of complex, co-morbid psychiatric and medical conditions, who are constant risk of harm to themselves or others. Mental Health Court Drug Court Law Enforcement Crisis Intervention Team APIC Program Community Based Care Crisis Stabilization Program for Adults Mobile Crisis Services Social Detox Program Women’s Residential Program Case Coordination Mental Health Core Services Clubhouse Behavioral Aides Intensive Treatment Residential Housing Supportive Housing Bulloch, Glynn and Liberty counties have a second level of priority for sophisticated services that will meet the identified needs in their respective county and serve as a CLUSTER SITE for the surrounding counties. CLUSTER SITES will include the following services: Criminal Justice Mental Health Court Drug Court Law Enforcement Crisis Intervention Team 30 Community Based Care Crisis Stabilization Program for Adults Mobile Crisis Services Social Detox Program Case Coordination Mental Health Core Services Clubhouse Intensive Treatment Residential Housing Supportive Housing Finally, SATELLITES will be located in Camden, Coffee and Ware counties. These SATELLITES will include the following services: Criminal Justice Mental Health Court Law Enforcement Crisis Intervention Team Community Based Care Case Coordination Mental Health Core Services Consumer-Run-Drop-In Center Housing Supportive Housing All other 17 counties in Southeast GA System of Care will have access to the following community based care: Case Coordination Mental Health Core Services 31 SOUTHEAST GA SYSTEM OF CARE Fig. 15 HUB CLUSTER SATELLITE All Others Chatham County (pop. 232,048) Bulloch County (pop. 55,983) Glynn County (pop. 67,568) Liberty County (pop. 61,610) Camden County (pop. 43,664) Coffee County (pop. 37,413) Ware County (pop. 35,483) 17 Counties (pop. 272,352) Hospital and Criminal Justice Mental Health Court Drug Court Law Enforcement Crisis Criminal Justice Mental Health Court Drug Court Law Enforcement Crisis Intervention Team APIC Program GRH-Savannah Community Based Care Crisis Stabilization Program for Adults Mobile Crisis Services Social Detox Program Women’s Residential Program Case Coordination Mental Health Core Services Clubhouse Behavioral Aides Intensive Treatment Residential Housing Supportive Housing Criminal Justice Mental Health Court Law Enforcement Crisis Intervention Team Intervention Team Community Based Care Crisis Stabilization Program for Adults Mobile Crisis Services Social Detox Program Case Coordination Mental Health Core Services Clubhouse Intensive Treatment Residential Housing Supportive Housing Community Based Care Case Coordination Mental Health Core Services Consumer-Run-Drop-In Center31 Community Based Care Case Coordination Mental Health Core Services Housing Supportive Housing 32 D. Specific Operational Directives Directive 6: Given their focus upon serving persons below 200% of the Federal Poverty Level, their status as not-for-profit organizations and their historic partnership with State government, Federally Qualified Health Centers and Community Service Boards should be formally recognized by the GA Department of Community Health and the GA Department of Behavioral Health and Developmental Disabilities as Georgia’s two “safety net programs” for somatic and psychiatric illnesses respectively. (Response to all Gaps & Barriers) Directive 7: DBHDD should adopt a new attitude towards community based providers. For the past 10 years, funding for community mental health services has been declining while billing and service authorization procedures have been increasing exponentially. Morale is at a very destructive low point among providers. DBHDD has an opportunity to serve as a service advocate, research, and technical resource for positive change, rather than as a “regulatory policeman” and disinterested funding source. (Response to all Gaps & Barriers) Directive 8: The DBHDD should fund a “Housing Specialist” at each CSB within the Southeast GA System of Care to develop local housing alternatives for the SMI within the priority counties. The Housing Specialist should serve as a liaison with the GA Department of Community Affairs to pursue the establishment of “watchful oversight”, transitional and supportive housing and linking consumers to those residences. (Response to Gap 10) Directive 9: The SAMHSA best practice approach of APIC (Access, Plan Identify & Coordinate) improves coordination among the GA Department of Corrections, prisons, jails and community mental health services should be piloted in HUB of Chatham County and replicated, if successful, in other priority counties. (Response to Gaps 8 & 11) Directive 10: Jails within the Southeast GA System of Care should have a common assessment tool and best practice treatment programs with formal linkages to their local community mental health center. (Response to Gaps 8 & 11) Directive 11: Mental Health Courts need to be established in Bulloch, Camden, Coffee, Glynn, Liberty and Ware Counties. Drug Courts need to be established in Bulloch and Liberty Counties. Formal linkages need to be established between the Courts and the local community mental health center provider especially to case coordinate co-morbid consumers. (Response to Gap 11) 33 Directive 12: DBHDD needs to adequately compensate trained therapists in Enhanced Best Practice (EBP) services by providing higher reimbursement for EBP care. Additionally, regional planning and training should occur through partnerships with local colleges for certificate programs in EBP. (Response to Gap 8) Directive 13: Telepsychiatry allows for licensed mental health professionals to provide services in underserved and professional shortage areas through live video communications. Increase the provision and utilization of telepsychiatric services including: a. Authorize the provision of Medicaid and State reimbursable telepsychiatric. services to include those provided by licensed mental health professionals (assessment, individual, and group) b. Insure both ends of service (consumer and provider side) receive reimbursement. Consumer side needs reimbursement for equipment usage, staff and administrative costs. (Response to Gap 1) Directive 14: DBHDD should fund Case Coordination a. Add case management as Medicaid and State contracted reimbursed services for community mental health and FQHC providers. b. Fund Case Coordinator positions for those persons with SMI who are high utilizers of intensive costly services. c. Develop certification and training program for Recovery Specialists to do case coordination. (Response to Gaps 1, 2 & 4) Directive 15: The present funding systems does not establish reimbursement rates based upon cost reports, increases in cost of living or inflation. Request DCH, DBHDD conduct a cost analysis for the purposes of adjusting the Medicaid reimbursement rates to reflect 2009 expenses for community behavioral health providers. (Response to Gap 9) Directive 16: Supported employment funding needs to be restored and formal linkages need to be made with GA Department of Labor, Division of Vocational Rehabilitation (DVR) and local community behavioral health providers. (Response to Gap 5) Directive 17: DBHDD should coordinate the development of a regional and Statewide work group to formulate consumer outcome, system-level performance measures and benchmarks based upon National measures. (Response to Gap 12) Directive 18: The issues of common formularies have been a historical gap in ensuring continuity of care among multiple providers of mental health services (e.g. 34 prisons, jails, hospital, community mental health providers). We concur with the Georgia Mental Health Service Delivery Commission 2008 Final Report which supports establishment of electronic medication exchange that would include a common, preferred medication list. The DBHDD should take the leadership to coordinate policy with other State agencies and local government, e.g jails to identify best practices in treatment and psychotropic medication formularies. a. DBHDD should also explore opportunities for group purchasing of medication to lower medication costs to providers. b. DBHDD needs to coordinative with other State Departments and jail associations to develop processes for rapid re-enrollment of eligible consumers into Medicaid after they have been released from State institutions. (Response to Gap 11) Directive 19: According to the State of Georgia, Board of Professional Counselors, Social Workers and Marriage and Family Therapists, as of 05/26/2009 there are 3,807 LPCs, 629 LMFTs, and 2,606 LCSWs actively working in Georgia. a. DBHDD should take the lead by developing Statewide linkages with community colleges and universities to facilitate increased mental health professional staff development and paid internships in community mental health programs. b. Conduct yearly mental health staff comparative salary surveys to insure competitive recruitment. c. Request the State Board review and compare authorized services and duties provided among master’s level licensed clinicians and insure consistent privileges commensurate with education and training. (Response to Gap 3) Directive 20: Georgia should license those community hospitals wanting to serve as emergency receiving facilities and allow them to be reimbursed for “23 hour holds” on psychiatric patients in their Emergency Room, until further care can be arranged by the local mental health core service provider. (Response to Gap 13) Directive 21: Georgia should spend at least what the average per capita expenditure is among all the states for mental health services. GA spends $60.92 per person and the national average is $103.53. (Response to all Gaps and Barriers) Directive 22: DBHDD should convene a Blue Ribbon Taskforce of key stakeholders to establish priorities among the aforementioned System of Care Directives and their corresponding budget implications prior to the 2010 Legislative Session. (Response to all Gaps and Barriers) 35 FINANCING STRUCTURE A. Current and Proposed Expenditures The National Association of State Mental Health Program Directors Research Institute, Inc. has reported that in FY06, Georgia spent $565 Million on mental health services; $60.92 per capita. The average national per capita expenditure was $103.53. (http:www.nri-inc.org/projects/Profiles/Prior_RE.cfm#2006) The 24 counties in the proposed Southeast GA System of Care account for 10% of the population in GA, or 806,121 people. If GA were to allocate funding at the national average of $103.53, it would mean $83,457,707 for the Southeast GA System of Care. Since GRH-Savannah is a specialty service for the whole System, its annual budget of $23 million would leave $60,457,707 to be allocated (based upon population) to community based services as follows: HUB (Chatham County) CLUSTER (Bulloch, Glynn and Liberty Counties) SATELLITE (Camden, Coffee and Ware Counties) $17,532,735 $13,905,272 $ 8,464,079 All Other Counties TOTAL for community based services $20,555,620 $60,457,706 Thus, NAMI is proposing a 24 county model Southeast GA System of Care, including hospital and community based care, for a TOTAL COST of $83,457,706. B. Costs by Program by Service Area Georgia Mental Health Service Delivery Commission 2008 Final Report supported a movement toward appropriate deinstitutionalization and community reintegration of consumers in order that the cost savings from deinstitutionalization would stretch State funding and ensure that all citizens had access to treatment services. 36 Table 4. HUB Programs by Cost HUB CATEGORY ANNUAL BUDGET HOSPITAL & CRIMINAL JUSTICE Mental Health Court Drug Court CIT APIC (3 staff) GRH-Savannah COMMUNITY-BASED CARE CSP Mobile Crisis Response Teams (3) Social Detox Women’s Intensive Residential Case Coordination (6) staff Behavioral Aides (6 staff/3 teams) Mental Health Core Services* Clubhouse ITR (three 4-bedroom homes) HOUSING Supportive Housing Specialist (2) TOTAL COSTS $ PROJECTED ANNUAL CAPACITY 180,000 180,000 20,000 180,000 23,000,000 200 200 350 400 1,900,000 364,285 2,640,000 1,000,000 360,000 200,000 9,292,450 36,000 1,100,000 750 900 16 18 600 150 6,398 600 144 80,000 200 $40,532,735 Table 5. CLUSTER Programs by Cost CLUSTER CATEGORY CRIMINAL JUSTICE Mental Health Court Drug Court CIT COMMUNITY-BASED CARE CSP Mobile Crisis Response Teams (3) Social Detox Women’s Intensive Residential Case Coordination (3) staff Mental Health Core Services* Clubhouse ITR (three 4-bedroom homes) HOUSING Supportive Housing Specialist (2) ANNUAL BUDGET $ 180,000 180,000 15,000 1,900,000 364,285 1,700,000 1,000,000 180,000 7,169,987 36,000 1,100,000 80,000 PROJECTED ANNUAL CAPACITY 200 200 350 750 900 10 18 400 4,626 600 144 200 TOTAL COSTS $ 13,905,272 *Diagnosis and Outpatient Treatment (including medication) by physicians, nurses, counselors and other professional staff. 37 Table 6. Satellite Programs by Cost SATELLITE CATEGORY HOSPITAL & CRIMINAL JUSTICE Mental Health Court CIT COMMUNITY-BASED CARE Case Coordination (3) staff Mental Health Core Services* Consumer-Run-Drop-In Center HOUSING Supportive Housing Specialist (2) TOTAL COSTS ANNUAL BUDGET $ 260,000 15,000 180,000 7,893,079 36,000 80,000 PROJECTED ANNUAL CAPACITY 200 350 400 5,168 600 200 $ 8,464,079 Table 7. Other System of Care Counties’ Programs by Cost ALL OTHERS CATEGORY COMMUNITY-BASED CARE Case Coordination (17) staff Mental Health Core Services* ANNUAL BUDGET $ 1,020,000 19,535,620 PROJECTED ANNUAL CAPACITY 2,000 12,400 TOTAL COSTS $20,555,620 *Diagnosis and Outpatient Treatment (including medication) by physicians, nurses, counselors and other professional staff. 38 APPENDICES 39 40 41 42 43 ABBREVIATIONS: ABBREVIATION ACT APS CSB CSP DBHDD DCH DHR DVR EBP EHR FPL FQHC GA GRH HIE HPSA HRSA ITR JAMA LCSW MH MICP MIERS NAMI nd SAMHSA SMI TANF DEFINITION Assertive Community Treatment American Psych System Community Service Boards Crisis Stabilization Program Department of Behavioral Health and Developmental Disabilities Department of Community Health Department of Human Resources Division of Vocational Rehabilitation Evidenced Based Practices Electronic Health Records Federal Poverty Level Federally Qualified Community Health Center Georgia Georgia Regional Hospital Health Information Exchange Health Professional Shortage Area Health Resources and Services Administration Intensive Treatment Residential Journal of American Medical Association Licensed Clinical Social Worker Mental Health Multipurpose Information Consumer Profile Monthly Income and Expense Reports National Alliance on Mental Illness No Date Substance Abuse and Mental Health Services Administration Serious Mental Illness Temporary Aid to Needy Families 44 Appendix – Best, Promising and Effective Practices Definitions Matrix Evidenced-Based Practices: From SAMHSA web site: http://nrepp.samhsa.gov/about-evidence.asp “approaches to prevention or treatment that are validated by some form of documented scientific evidence established through scientific research” Practice DEFINITION CITATION Crisis Stabilization Program Georgia DBHDD Website: This is a residential alternative to inpatient hospitalization, offering community-based psychiatric stabilization and detoxification services on a short-term basis. ASAM: “is an organized service that may be delivered by appropriately trained and certified staff, who provides 24-hour supervision, observation and support for patients who are intoxicated or experiencing withdrawal, with the aim for them to achieve initial recovery” SAMHSA: : Consumer/survivor-operated services are addressing and striving to meet the critical, self-identified concerns of consumers/survivors that are often overlooked in traditional treatment providing: mutual support, basic human needs, empowerment, public education, and rights protection” Supportive housing includes case management that includes designing the services plan, effective service delivery and community-building strategies, and preparing for the needs of tenants of supportive housing. Promising Practice recognized in most states SAMHSA website: http://mentalhealth.samhsa.gov/ SAMHSA: “Supported Employment is staffed by employment specialist as part of treatment team to help people with mental illnesses find and keep competitive employment within their communities.” Office of Applied Studies, Substance Abuse and Mental Health Services Administration: “Women and men differ in substance abuse etiology, disease progression, and access to treatment for substance abuse. Substance abuse treatment specifically designed for women has been proposed as one way to meet women's distinctive needs and reduce barriers to their receiving and remaining in treatment.” Best Practice -SAMHSA website http://mentalhealth.samhsa.gov/cmhs/CommunitySupport/toolkits/emp loyment/ Effective Practice: Office of Applied Studies, Substance Abuse and Mental Health Services Administration, Rockville, Maryland, USA The American Journal of Drug and Alcohol Abuse, Volume Social Detox Program Club Houses/Drop In Centers (Consumer Operated Programs): Supportive Housing Supported Employment Women’s Residential Program APIC ModelCommunity Re-entry from Jails SAMHSA: APIC-Assess, Plan Identify, & Coordinate – Drives active systems integration of criminal justice and mental health providers Best Practice: ASAM http://www.asam.org/ and CSAT: http://csat.samhsa.gov/publications.aspx Best Practice: SAMHSA website http://mentalhealth.samhsa.gov/publications/allpubs/SMA013510/sma01-3510-04.asp Best Practice: SAMHSA website http://homelessness.samhsa.gov/(S(5snsoy2druhsg4zhrwdopdnz))/Res ource/Toolkit-for-Developing-and-Operating-Supportive-Housing270.aspx http://www.informaworld.com/smpp/title~db=all~content= t713597226~tab=issueslist~branches=29 - v2929, Issue 1 2003 , pages 19 - 53 Best Practice – SAMHSA website http://mentalhealth.samhsa.gov/search.asp?q=mental+health+court&re strict=NMHIC 45 Appendix – Best, Promising, Exemplary and Effective Practices Definitions Matrix - continued Evidenced-Based Practices: From SAMHSA web site: http://nrepp.samhsa.gov/about-evidence.asp “approaches to prevention or treatment that are validated by some form of documented scientific evidence established through scientific research” Practice DEFINITION CITATION Intensive Case Management (Case Coordination) Defined by Perl & Jacobs (1992) - “The important activities of case management include, but are not limited to, assessment, continuous service planning, advocacy, benefits acquisition, service linkage, and monitoring” Best Practice - SAMHSA, NIAAA, and NIDA identified case management as a best practice through research by Perl & Jacobs, 1992 which funded fourteen demonstration projects Assertive Community Treatment (ACT) Groups treatment SAMHSA: Services that are customized to the individual needs of the consumer, delivered by a team of practitioners, and available 24 hours a day to prevent hospitalization and incarceration Best Practice -SAMHSA website http://mentalhealth.samhsa.gov/cmhs/CommunitySupport/toolkits/comm unity/ SAMHSA: Illness Management Recovery Groups- comprehensive – Delivered by professional staff to help people with psychiatric symptoms develop personal strategies for coping and moving forward in their lives. U.S. Department of Justice: A broad-based group of stakeholders representing the criminal justice, mental health, substance abuse treatment, and related systems and the community guides the treatment, planning and administration of the court. U.S. Department of Justice: A broad-based group of stakeholders representing the criminal justice, mental health, substance abuse treatment, and related systems and the community guides the treatment, planning and administration of the court. Modeled after Memphis CIT Model: Special trained officers to respond immediately to crisis calls 1. Ongoing training of CIT training to officers from local mental health and treatment professionals at no expense to the police force 2. Establishments of partnerships of police, National Alliance on Mental Illness, mental health providers, and mental health consumers Building on the Wraparound Milwaukee Wraparound system of care. Behavioral Aides are deployed to support consumers in their home for extended periods of time as a means for stabilization of symptoms and earlier interventions that help the consumer remain in their home and community versus hospitalizations. Best Practice- SAMHSA website http://mentalhealth.samhsa.gov/cmhs/CommunitySupport/toolkits/illness/ IMRpractinfo.asp Effective Practice: http://www.samhsa.gov/SAMHSA_News/VolumeXIV_2/index.htm Drug Court Mental Health Court Crisis Intervention Team (CIT) Behavioral Aides Effective Practice: Bureau of Justice Assistance, Office of Justice Programs, U.S. Department of Justice: http://www.ojp.gov/BJA/pdf/MHC_Essential_Elements.pdf Best Practice: NAMI & SAMHSA Evaluation Study citation: http://psychservices.psychiatryonline.org/cgi/content/full/50/12/1620 Exemplary Program by the President's New Freedom Commission on Mental Health. http://www.milwaukeecounty.org/WraparoundMilwaukee7851.htm 46 FOOTNOTES 1 Serious Mental Illness (SMI) is defined as a diagnosable “severe” mental disorder that meets the criteria specified in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) and includes psychotic disorders (schizophrenia), severe mood disorders (depression and bipolar), severe anxiety disorders (obsessive-compulsive and post-traumatic stress), severe attention deficit/hyperactivity disorders and severe eating disorders (anorexia nervosa). 2 Georgia’s Mental Health Gap Analysis: Building an Action Agenda Eleventh Annual Rosalynn Carter Georgia Mental Health Forum May 19, 2006. 3 Georgia Association Chiefs of Police, Mental Health and Law Enforcement Encounters: A Review of Current Problem and Recommendations (nd). 4 Chief Justice-Led Task Force to Promote Criminal Justice/Mental Health Collaboration-A Call to Action: Final Report and Recommendations. Presented to Chief Justice Leah Ward Sears, November 7, 2008. 5 Governor Sonny Perdue’s Mental Health Service Delivery Commission: Final Report. Delivered December 4, 2008. 6 Prevalence is the number of new and existing conditions (SMI) observed a point in time or during a period of time. 7 Op. Sit., Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). 8 Department of Human Resources, “Adults with Serious Mental Illness (SMI) Comparison of Estimated Need (Prevalence) to Consumers Served, FY2008” and “Adults with Substance Abuse Comparison of Need to Consumers Served, FY2008”; United States Census Bureau, Population Estimates on July 1, 2007 (released August 2008). 9 Kaplan, L., The Role of Recovery Support Services in Recovery-Oriented Systems of Care. DHHS Publication No. (SMA) 08-4315. Rockville, MD: Center for Substance Abuse Services, Substance Abuse and Mental Health Services Administration, 2008. 10 GeorgiaInfo – Georgia Counties Ranked by Population (2000 US Census) – georgiainfo.galileo.usg.edu/countypopulationrank.htm 11 Quesenberry, J., Suicides NAMI Region 5 Summit, 30 Day Readmission, Information Management Unit, Decision Support Section, GA Department of Human Resources, May 2009. 12 Georgia Department of Community Affairs, Homeless in Georgia 2008, July 2008. 13 California Psychiatric Association Sacramento, CA, White Paper on “Homelessness and Mental Health”, March, 2003. 14 Lamb, H.R., Weinberger, L.E. (1998). Persons With Severe Mental Illness in Jails and Prisons: A Review. American Psychiatric Association, 49:483-492. 15 Inmate Statistical Profile, Inmates admitted during FY 2009, GA Department of Corrections, Operations, Planning and Training Division, Planning and Analysis Section, pps. 49 and 51. August 24 2009. 16 Unpublished Report for the GA Department Corrections. J.L. Metzner, MD. Diplomate, American Board of Psychiatry and Neurology. 17 A White Paper Prepared by the Forensic Taskforce of the NAMI Board of Directors, Full Report, Decriminalizing Mental Illness: Background and Recommendations, page 5, September 2008. 18 California Psychiatric Association, Sacramento, CA, White Paper on Corrections and Mental Health, March, 2003. 47 19 County Jail Report – Primary Jail Capacity Data - January 2009. 20 (http://ww.dca.state.ga.us/development/research/programs/jailReports.asp) 21 Quesenberry, J., Suicides (International Self-Harm), 1993-2002. Information Management Unit, Decision Support Section, GA Department of Human Resources, May 2009. 22 CDC’s WISQARS website “Fatal Injury Reports,” downloaded January 24, 2008. 23 Pyke, J. (NA) Recovery: A brief overview. 24 Deegan P.E. (1988) Recovery: the lived experience of rehabilitation. Psychosocial Rehabilitation Journal, 11, 11-19. 25 Anthony, W.A. (1993). Recovery from mental illness: The guiding vision of the mental health service system in the 1990’s. Psychosocial Rehabilitation Journal, 16:11-23. 26 Anthony, W.A. (2004) Overcoming Obstacles to a Recovery-oriented System: The Necessity for State-level Leadership. US Department of Health and Human Services: Report to National Association of State Mental Health Program Directors National Technical Assistance Center for State Mental Health Planning. 27 National Council of Community Behavioral Healthcare (The National Council): SAMHSA Dialogue (2009) Advancing Health through System Reform. 28 The Georgia Supreme Court Report, Mental Health America Fall 2007 Newsletter. 29 Georgia Association Chiefs of Police, Mental Health and Law Enforcement Encounters: A Review of Current Problem and Recommendations (nd). 30 Gay, Derril, Public Policy Advisor, GACSB Association, Interview, State Hospital and Community Mental Health Safety Net System, August 2009. 31 Carol T. Mowbary, PhD; Amanda Toler Woodward, PhD; Mark C. Holter, PhD; Peter MacFarlane, Doctoral Candidate; Deborah Bybee, PhD., The Journal of Behavioral Health Services & Research, July 2009, Volume 36, Number 3, pages 361-371. 48