Download response to the crisis

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