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Role of County Psychiatric Leaders


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Role of County Psychiatric Leaders -- May 2012

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Role of County Psychiatric Leaders

  1. 1. Role of CountyPsychiatric LeadersRoger Peele, MD, DLFAPA 1
  2. 2. Outline 2
  3. 3. History of Counties - 1Pre-1066, England divided into shires.Post-1066, “county.”First county in US, James City County, 1636[NACo] 3
  4. 4. History - 2Since the 1770s, Americans have not wanted a king, have wanted authority close to the people.In 1800s, concept that county seats should be within a day’s buggy ride.[NACO] 4
  5. 5. History - 3Two roles of counties: 1. Administrative arm of the state or national government. 2. Local government. 5
  6. 6. History - 4Over the years, there has been an increase in:1. Greater autonomy from the state government.2. Rising revenue.3. Stronger political accountability.4. Widening range of services.[NACo] 6
  7. 7. Counties - Number48 states Alaska uses “borough” Louisiana uses “parish”Total number: 3028Most: Texas: 254Least: Delaware: 3 7
  8. 8. Counties – Size and PopulationArlington County, Virginia: 26 sq milesNorth Slope Borough, Alaska: 87,860 sq milesLoving County, Texas, 45 folksLos Angeles County, 9,848,011 folksMore than 2/3 counties have <50,000.[NACo] 8
  9. 9. County RolesHuge variance in priority of expenditures: In Virginia counties: 55% on education In New Hampshire: 67% on public welfare In Maine: 56% on public safety[NACo] 9
  10. 10. Source of Revenues3% from Feds [e.g., Payment in Lieu of Taxes (PILT)]33% from statesRest: from county sources, but states limit types of taxes counties can use. For example, a state might prohibit a sales tax or prohibit income tax.[NACo] 10
  11. 11. Range of IncomeHousehold income, Median, [2009]:Loudon County, Virginia: $110,643.McKinley County, NM: $30,366[NACo] 11
  12. 12. County Debt:Most urbanized counties: $500/residentMost rural counties: $172/resident[NACo] 12
  13. 13. County EmployeesAbout 4 of every 100 residents.[NACo] 13
  14. 14. Governance - 1Authority limited to what was granted by the state [“Dillon’s Rule” – 1868]“Home Rule,” [California – 1911] in which the counties have broad range of power to determine their organizational structure, what they can tax, and how they spend their money.[NACo] 14
  15. 15. Governance - 2As for counties part of urban areas, John F. Kennedy, about 1959, while still a Senator declared:“city governments cannot always assume sole responsibility for the solution to these pressing urban problems. I repeat, they cannot – our state governments will not – the federal government should not – and therefore you on the county level must.”[NACo] 15
  16. 16. Governance - 3In addition to the states pushing responsibility down to the counties, there has been a tendency to push responsibilities upward from cities and towns. Examples in increased responsibility: -- police protection -- jails and prisons -- public welfare 16
  17. 17. Governance - 4Consolidation of counties. NYC, 1898, has not been a common trend, less that 40.[NACo] 17
  18. 18. State Authorized County BoardsSome states have established countyboards and given the county boardconsiderable authority. For example inVirginia, Community Service Boards. InMaryland, County Service Agency. 18
  19. 19. Governance - 5In many states, a level has been created between the state and the county, “Regional” authorities. (E.G., East Carolina [NC] has nine counties reporting to it)[NACo] 19
  20. 20. Governance - 6Also, especially in urban areas, “Council of Governments,” at least 600, have been formed over the years, having specific authorities, e.g., transportation, housing.[NACo]
  21. 21. Governance - 7Community Mental Health Act of 1960s called for federal grants to go to “local” boards, specifically excluding any governments – so counties left out. 21
  22. 22. Governance - 8Revenue sharing between Federal Government and Counties initiated under Nixon and killed under Reagan. 22
  23. 23. Forms of Government - 1Commissioner form.Voters elect a multi-member board – sheriff, coroner - each member of which wield both legislative and executive authority.[NACo] 23
  24. 24. Forms of Government - 2County Administrator form has two styles:3. County Council selects the Administrator.4. County Administrator is elected by the county voters.[NACo] 24
  25. 25. Governance Tension state v countyWhile counties were assuming more responsibilities, they were not always given more authorities.[NACo] 25
  26. 26. Governance Tension rural v. urbanPartially resolved by Supreme Court, Reynolds v. Sims, 1964, “legislators represent people, not trees or acres. Legislators are selected by voters, not farms or cities or economic interests.”[NACo] 26
  27. 27. Economic DevelopmentA more recent interest of county governments has been economic development, e.g., approve hospitals to bring more Medicare money into a county.[NACo] 27
  28. 28. Health Authority• Thirty two states give counties Public Health Authority.[NACo] 28
  29. 29. Federal-State-CountyIn comparison to the federal government and state government, counties tend to be most flexible, the most locally responsive, and most creative.[NACo] 29
  30. 30. Advice to CountiesThink globally, act locally.[NACo] 30
  31. 31. Three Rights - GeneralIn conceptualizing the goals of those of us working in the public sector, useful to think of “rights.”• Freedom or Independence from the Disorder• Nondiscrimination• Access to their community 31
  32. 32. Rights and County Role1. Facilitate access to treatment2. Assure nondiscrimination3. Remove barriers and provide support to live in their community 32
  33. 33. Independence - 1Right of people with psychiatric illnesses to receive the most current treatments so that each person has the maximum independence from their illness that can be achieved with modern treatments. 33
  34. 34. Independence - 2Not the same as “least restrictive,” which is a negative goal. Medicine needs positive goals, such as being able to function independently.Test: Receiving treatment as defined by most authoritative standard of care and treatment. 34
  35. 35. Achieving Independence - 3-- Costs: medications, transportation, time a way from work.-- Lack of connection between primary care and psychiatric care. 35
  36. 36. Achieving Independence - 4Patient acceptance of treatment:-- Language barriers-- Address lack of awareness as to “mental illness” [as opposed to “bad”]-- Address stigma of patient, family and community-- Address misgivings about psychiatric treatments 36
  37. 37. Achieving independence - 5-- Addressing machismo that might include conceptualizing mental-health-related violence or conceptualizing alcoholism as manly, not an illness. 37
  38. 38. Achieving Independence - 5-- Apply techniques, such as motivational interviewing.-- Enhancing health literacy.-- Provide community-based educational programs, such as “fotonovelas.” 38
  39. 39. Achieving independence - 6Commitment to freedom.
  40. 40. Achieving Independence - 7Terms used:Customer/consumer/recipientProvider
  41. 41. Nondiscrimination - 1Right of people with psychiatric illnesses to have the same availability to care and treatment as is available for other illnesses. 41
  42. 42. Nondiscrimination - 2There are no exceptions.There are no added burdens for the patient or for their clinicians.Test: Is “mental illness” mentioned in a policy or regulation? If so, probably a discrimination. 42
  43. 43. Nondiscrimination - 3VigilanceExamples: Carve out of mental health. Multiaxial burden. 43
  44. 44. Nondiscrimination - 4American Psychiatric Association has taken position that insurance carve outs are inherently discriminatory.Issue now being addressed, does “parity” reach services, such as residential programs that do not have an equivalence in the rest of medicine.
  45. 45. Nondiscrimination - 5A mental health service carve out might not be discriminatory, might bring services beyond what is regarded as “medical” that are very important.
  46. 46. Access to their community - 1Right of people with psychiatric illnesses to live in their community. 46
  47. 47. Access to their community - 21. No barriers to access.2. Provided supports – education, job support, housing, etc. – that enhance ability to live in their community 47
  48. 48. Rights - SummaryCounties have the major role in assuring that people with psychiatric illnesses to live in their communities. This is especially true of those whose illness is disabling. 48
  49. 49. “Silo”County four-letter word.
  50. 50. Integration - 1“Integration” has many meanings”2. Integrate as to community.3. Integrate as to ethnic/culture4. Integrate as to family5. Integrate as to age [youth commonly integrated into family services]6. Integrate as to school or occupation, e.g., school-based, veteran-based
  51. 51. Integration - 26. Integrate as to institution, e.g., jail-based program.7. Integrate as to service, e.g., all clinics under one authority, all inpt units under one authority8. Integrate as to problem, e.g., substance- abuse program, eating-disorder program, juvenile-delinquent program. ID program.
  52. 52. Integrate - 39. Specialty based, e.g., psychiatric, psychologicalAny view on integration can be another view’s fragmentation.
  53. 53. Integration - 4Major integrative initiatives at this time:1. Integration of psychiatry into primary care.2. Dual-dx focused on two diagnoses: substance-abuse into the rest of mental health services.
  54. 54. Integration with Primary CareAPA website has identified some substantial programs, both focusing on depression:1. Institute for Clinical Systems Improvement [ICSI] developed DIAMOND with 9,000 in 62 medical groups in MN and WI,
  55. 55. Impact2. IMPACT uses Problem-Solving Treatment in Primary Care, a 6-8 sessions, counseling provided by staff with little or no prior mental health training.
  56. 56. Montgomery County, MD IntroductionSuburb of Washington, DCAbout a million people.Many ethic groups and recent immigrants [147 different languages found in survey of students in public schools.]The County’s Behavioral Health and Crisis Services serves between 8,000 – 9,000/year.
  57. 57. Montgomery County, MD 24 Hour Crisis Services - 124 hour crisis services.Triage and evaluations beds [6].Residential Alternative to hospitalization [8 beds]Outreach team to evaluate and, if necessary, begin the process to attain emergency hospitalization.24-Hour hotline [local NAMI program]
  58. 58. Montgomery County, MD 24-Hour Crisis Services - 2Provides support for major untoward events, e.g., homicide in a school.Lethal Assessment Program [LAP] by all of the police departments and sheriffs.Some years recently, no domestic homicides in the County
  59. 59. Montgomery County Access ProgramAssesses 2,000 individuals to mental health services.Has safety net program for those between referral and date of appointment.Referrals to settings with more independence, e.g., state hospital to residential, residential to independent housing.
  60. 60. Montgomery County, MD Community Support ProgramsCommunity Support Programs:1. Monitoring need for level of care to ascertain if the person is ready for more independent living. Monitors residential programs, more than one/day.2. Project for assistance in Transition from Homelessness, e.g., case management, screening, diagnostic treatment services, housing assistance.3. SSI/SSDI Outreach, Access, and Recovery {SOAR} program. Program to help SSI/SSDI people who are homeless [e.g., coming out of hospital; living is shelter attain desirable supports.4. For seniors, about 100 consultations to the County’s Aging and Disability Department
  61. 61. Montgomery County, MD Child & adolescent services1. Clinics in multiple sites provide treatment for children and adolescents.2. Evaluate students referred by the public schools. [96% are stabilized without referring to ERs]
  62. 62. Montgomery County, MD Adult ServiceAssertive Community Treatment [ACT] program. {Madison County model}Collaborates with local NAMI to increase their work with families and peers.Collaborates with community agency to counsel African immigrants seeking mental health services.Collaborates with veterans program to train clinicians as to PTSD, TBI, military culture, and other veteran issues. [Considering implementing telemental services.]
  63. 63. Montgomery County, MD Forensic Services1. Screen 9,000 individuals who are arrested, 200 assessments for suicidality.
  64. 64. Montgomery County, MD For AddictionsPrograms for people with addictions [about 800/year]: Outpatient clinic Treatment program includes treating the dual diagnosed. Methadone maintenance program Mental health court [100/year] Detox Residential Dual Dxed residential[Of those completing treatment, 87% have a decrease in their use of substances]
  65. 65. Montgomery County, MD Victim and Abuser Programs1. Programs for victims, provides clinical, legal, and police protection [2,000 year]
  66. 66. Montgomery County, MD Core Service Agency - 1County coordinates services among potential resources for people with psychiatric illnesses:Transitional sheltered housing [2]ERs [6]Hospital Inpt units [4]Partial Hospitalization programs [3]Senior program [1]
  67. 67. Montgomery County, MD Core Service Agency - 2MR/DD/ID program [1]Program for hearing impaired and mentally ill [1]Psychiatric Rehabilitation Programs [11]Vocational/Supportive Programs [5]Drop in center [2]Language capacity is stressed, most have Spanish-speaking capacity. One has capacity to speak 24 languages.
  68. 68. Montgomery County, MD Core Service Agency - 3For children, many of the same as adults are in the County. Also, a therapeutic nursery is available.
  69. 69. Montgomery County, MD with Local NAMI1. 24-hour line.2. Family educational programs3. Care-giver educational programs4. Peer programs for those who have a psychiatric disorder
  70. 70. Montgomery County, MD Advisory BoardsAlcohol and Other Drug Abuse Advisory CommitteeMental Health Advisory Committee.
  71. 71. LA County - 1The Los Angeles County Department of Mental Health (DMH), the largest county mental health department in the country, directly operates more than 80 programs 71
  72. 72. LA County - 2and contracts with more than 700providers, including non-governmentalagencies and individual practitionerswho provide a spectrum of mentalhealth services to people of all ages tosupport hope, wellness and recovery. 72
  73. 73. LA County -3Mental health services provided include assessments, case management, crisis intervention, medication support, peer support and other rehabilitative services. 73
  74. 74. LA County - 4• Services are provided in multiple settings including:2.residential facilities,3.clinics,4.schools,5.Hospitals, 74
  75. 75. LA County - 55.county jails,6. juvenile halls and camps,7. mental health courts,8. board and care homes,9. in the field and10. in people’s homes. 75
  76. 76. LA County - 6• Special emphasis is placed on addressing co- occurring mental health disorders and other health problems such as addiction. 76
  77. 77. LA County - 7The Department also provides counseling to victims of natural or manmade disasters, their families and emergency first responders. 77
  78. 78. LA County – Service Recipients - 1Service Recipients DMH’s services to adults and older adults are focused on those who are functionally disabled by severe and persistent mental illness, including those who are low- income. 78
  79. 79. LA County Service Recipients - 2Services to children and youth are focused on those who are uninsured, temporarily impaired, or in situational crises, seriously emotionally disturbed, and diagnosed with a mental disorder. 79
  80. 80. LA County – Service Recipients 3They include wards or dependents of the juvenile court, children in psychiatric inpatient facilities, seriously emotionally disturbed youth in the community, and special education students referred by local schools and educational institutions.
  81. 81. LA County – Recovery - 1• A Commitment to Recovery and Wellness• Recovery refers to the process in which people who are diagnosed with a mental illness are able to live, work, learn, and participate fully in their communities. 81
  82. 82. LA County – Recovery - 2• We are committed to providing education about mental health issues and how they affect individuals and families; and teach and promote self-advocacy. 82
  83. 83. LA County – Recovery - 1The Recovery Model is the framework for all adult services and is based on the belief that adults diagnosed with a mental illness can lead productive lives by seeking and maintaining meaningful relationships through employment, education, or volunteer work, and participating fully in their community. 83
  84. 84. LA County – Recovery - 3• We are also committed to encouraging individuals, families, and communities to share responsibility to support one another. 84
  85. 85. LA County – Recovery - 4• Wellness and Recovery Outcomes Our aim is to help our clients and families to:• Achieve their recovery goals;• Find a safe place for them to live; 85
  86. 86. LA County Recovery - 5• Use their time in a meaningful way;• Have healthy relationships;• Access public assistance when necessary;• Weather crises successfully; and• Have the best possible physical health.
  87. 87. LA County – Children -1Child Mental Health Services in Los Angeles County are targeted for children from birth to 15 who are seriously emotionally disturbed (SED) and have been diagnosed with a mental disorder. 87
  88. 88. LA County – Children -2• Our goal is to enable children with behavioral disorders to remain at home, succeed in school and avoid involvement with the juvenile justice system. 88
  89. 89. LA County – Children -3• A wide range of services are provided to these children and their families through a network of County-operated and contracted agencies across all eight service areas of Los Angeles County as well as several programs and services that are delivered Countywide. 89
  90. 90. LA County – Transition Age Youth - 1• DMH Services for Transition Age Youth• The Transition Age Youth (TAY) Division seeks to provide an array of mental health and supportive services for Seriously Emotionally Disturbed (SED) and Severe and Persistently Mentally Ill (SPMI) youth ages 16-25. 90
  91. 91. TAY - 2The TAY Division has identified a number of priority TAY populations to receive these services; along with a specific emphasis on outreaching and engaging TAY who are currently unserved and underserved.
  92. 92. TAY - 3These priority populations include the following:1. TAY struggling with substance abuse disorders;2. TAY who are homeless or at-risk of homelessness3. TAY aging out of the childrens mental health, child welfare, or juvenile justice systems;4. TAY leaving long-term institutional care; or5. TAY experiencing their first episode of major mental illness
  93. 93. TAY - 4• TAY ProgramsFull-Service Partnerships (FSP)Drop-in CenterEnhanced Emergency Shelters for TAYProject-Based Operating Subsidies for Permanent Housing 93
  94. 94. TAY - 5Probation Camp ServicesHousing Specialist ServicesTAY System NavigatorsCo-located Staff at Transition Resource CenteField Capable Clinical Services (FCCS)
  95. 95. LA County – Adults - 1Los Angeles County Department of Mental Health provides an array of mental health and supportive services for clients, between the ages of 19 and 59, who live with serious mental illness and co-occurring substance use disorders. Mental health services are available through directly operated and contract agencies throughout the County. 95
  96. 96. LA County Adults - 2Services typically provided in these agencies are: assessment, therapy, medication, case management/brokerage, crisis intervention, and other supportive services related to housing, prevocational and employment. 96
  97. 97. LA County Adults - 3These services are intended to reduce psychiatric symptoms, increase independent functioning and self-reliance so that individuals can achieve the fullest and most productive life possible.
  98. 98. LA County Director - 1• The Director also serves as the public guardian for individuals gravely disabled by mental illness, and is the conservatorship investigation officer for the County.• [NACo] 98
  99. 99. LA County Director - 2• The Director of Mental Health is responsible for protecting patients’ rights in all public and private hospitals and programs providing voluntary mental health care and treatment, and all contracted community-based programs.• [NACo] 99
  100. 100. San Francisco County - 1San Francisco County, as part of its Coverage Initiative Healthy San Francisco, has expanded its network of contracted community clinics and health centers and is seeking to build a seamless system of health, mental health and substance abuse services.
  101. 101. San Francisco County - 2• Stationing health workers at mental health clinic sites –– the flip side of employing behavioral workers in primary care settings –––is being successfully implemented at San Francisco’s Progress House where UCSF nursing students tend to the health needs of mental health residents.
  102. 102. San Francisco County - 3Click onto:
  103. 103. San Francisco County - 4• [Networks of Care :]• [ Network of Care For Seniors/People with Disa ]• [Network of Care For Mental Health]• [Network of Care For Kids]• [Network of Care For Children & Families]
  104. 104. San Francisco County - 5• [ Network of Care For Developmental Disabilitie ]• [Network of Care For Domestic Violence]• [Network of Care For Public Health]• [Network of Care For Probation Services]• [ Network of Care For Veterans and Service Me ]
  105. 105. Housing - 11. Institutional care.2. Hospital3. Halfway/residential/transitional facilities.4. Emergency Housing5. Supportive housing/special needs housing 105
  106. 106. Housing - 26. Affordable Housing [rental] a. subsidized b. unsubsidized7. Market rate rental8. Home Owenership 106
  107. 107. What is Housing First?• A mental health and housing services program based on the philosophy of consumer choice that offers people who are homeless and who have psychiatric disabilities immediate access to an apartment of their own, without “readiness requirements”.
  108. 108. Current System: To enter Housing and service programs you must climb the steps Permanent Housing Transitional Housing Drop-in, Shelter Outreach108
  109. 109. Housing First…levels the steps Outreach Permanent Housing and Support Services109
  110. 110. (NYC Survey of housing providers in 2005) • Clean time –92.5% of Providers require • Methadone – 11 % exclude • Insight into mental illness • Compliance with treatment • Criminal background – Sex offenders – 82% exclude – History of arson – 80% exclude • Credit checks110
  111. 111. Essential Elements of Housing First 1. Consumer Choice 2. Separation of Housing and Services 3. Recovery Orientation 4. Community Integration111
  112. 112. Responsibilities in Leased Based Housing • Expectations of tenancy • Rent payment • Quiet enjoyment (both tenant and their neighbors) • Maintaining apartment (HQS) • Financial Realities- planning/budgeting • Application process and timelines112
  113. 113. Disturbing statistic…Adults with serious mental illness who aretreated in public systems die, on average,20-25 years earlier than the generalpopulation (average age of 58 comparedto 78 for the general population). Joseph Parks, et al. (2007) “Morbidity and Mortality in People with Serious Mental Illness." National Association of State Mental Health Program Directors (NASMHPD) Report.
  114. 114. 7 % hepatitis 6 % cancer 5 % asthma/COPD•80% have substance use disorders• 3 %are smokers 75% and more hyperlipidemia• 24% hypertension• 9.2% diabetes• 9 % HIV positive
  115. 115. • 8 % seizure disorders• 7 % hepatitis• 6 % cancer• 5 % asthma/COPD• 3 % hyperlipidemia
  116. 116. Research Evidence• New York Housing Study• Comparing Pathways to Housing with Continuum of Care Programs in NYC• 36 month longitudinal outcomes
  117. 117. Participants Inclusion Criteria2. 15 days of the past month literally homeless3. 6 months of housing instability4. Major Psychiatric Diagnosis
  118. 118. Study Design- Longitudinal Random Assignment - N=225- Experimental (Pathways) 99- Control (Continuum) 126
  119. 119. Proportion of Time Stably Housed: 1 0.8Proportion 0.6 Experimental Control 0.4 0.2 0 th th th th th th e in on on on on on on el -M -M -M -M -M M as 6- 12 18 24 30 36 B TimeNote. Significant at 6-, 12-, 18-, 24-, 30-, and 36-month.
  120. 120. Percentage 0 5 10 15 20 25 B as el in e 6- M on th 12 -M on th 18 -M on th 24Time -M on th 30 -M on th 36 -M on th Percentage Heavy Substance Use Control Experimental
  121. 121. Substance Treatment Utilization in the Past 2 Weeks Substance Treatment Service Utilization Proportion of Services 0.3 0.25 0.2 Pathways to Housing 0.15 Continuum of Care 0.1 0.05 0-M h th 18 nt h 24 n t h 30 n t h 36 nt h 4 2 nt h 12 nt h 4 8 nt on o o o o o o o -M -M -M -M -M -M M 6- TimeNote. Significant at 6-, 12-, 18-, 24-, 30-, 36-, 48-month.
  122. 122. Washington DC Cost Estimates Washington DC Cost Estimates Cost per Day per Person $3,500.00 $3,085.72 $3,000.00 $2,500.00 $2,000.00 $1,500.00 $1,000.00 $435.37 $500.00 $67.12 $105.62 $80.62 $17.04 $0.00 l il l on ng r ta ia Ja lte pt pi is si e os os Pr ou Sh H lH H e ta v en rti po M p Su * Shelter amount does not include the increased use in services associated with shelter/street stay, including jail, emergency room services, and
  123. 123. Program Philosophy• Consumer Choice• Housing is a basic human right• Recovery is possible
  124. 124. Separation of Housing and Support Services  Housing: Scattered site independent apartments rented from community landlords  Treatment: Treatment and support services provided using Assertive Community Treatment (ACT) Teams, Housing Support Teams, Case Management, or other off-site services124
  125. 125. Community Integration • Housing that is normal housing- not a program • Housing where the services can walk away from the person who no longer needs them (or return if necessary)125
  126. 126. Consumer choice as a continuous process in Housing First programs • People continue to choose the type and sequence of services once housed. • Choices include the right to risk; people make mistakes and learn from that experience, dignity of failure • Continued practice in making choices leads to making the right choices and the126 experience of success
  127. 127. Integration with CorrectionSome counties have mental health[including substance-related disorders] withjails, prisons, community re-entry programs,and parole offices. Not just mental healthclinicians, but also case management.[e.g., Macomb County, MI] 127
  128. 128. Prevention - 1Focus tends to be on preventing addictions:In schools: Alcohol curriculum Tobacco curriculum Other drug curriculum Social skills building “Choices” graduation ceremonies with certificates 128
  129. 129. Prevention - 2Libraries: Resource centersLocal media. Example: SOS: Something of Substance, ½ hour program x 10[Suffolk County]Speakers bureau.County Guides. Example: Heroin Education Leads to Prevention (HELP)[Suffolk County] 129
  130. 130. Advocacy Organizations - 11. Those the County creates. A. Specific for mental health. Sometimes a subpart of mental illness 1] specific for addictions, 2] specific for intellectual disabilities 3] specific victims of trauma 130
  131. 131. Advocacy Organizations - 2• NAMI• Mental Health Associations• Parent-teachers Associations 131
  132. 132. Advocacy Organizations - 3Two roles:3.Inward directed: Advocate for directionsthey want the County to take.4.Outward directed: Advocate for County’sprograms. 132
  133. 133. Advocacy Organizations - 3Preference:Only one Advisory Board and refer alladvocates to that body, “as I have toassume they represent the community.”[Function of relationship with rest ofgovernance] 133
  134. 134. Professional OrganizationsCounty Medical Society, commonCounty Psychiatric Society, chapter of statedistrict branch, uncommonCounty psychological association,uncommonCounty social work association, uncommon 134
  135. 135. Standards - 1• Feds: – Medicare regulations – Medicaid regulations State regulations, common County regulations, uncommon 135
  136. 136. Standards - 2JCAHO: Hospitals ClinicsAmerican Psychiatric Association PracticeGuidelines. The word “Standards” avoided. 136
  137. 137. Medical Director Role - 11. Speaks to the psychiatric needs ofpatients with: a. the County’s clinicians, b. with County administration, c. with other relevant County agencies, e.g., police. 137
  138. 138. Medical Director Role - 2– D. Any external board/commissions that impact the work of the County’s mental health work.– E. With the state mental health authorities.– F. With regulatory bodies and accreditation bodies. 138
  139. 139. Medical Director’s Role - 3– G. With other bodies that may need to know the County’s psychiatric views and needs, such as professional society, lay organizations, educational institutions, and so forth.– H. With any organization or individual who believes the County’s clinical work is inadequate. 139
  140. 140. Roles of Medical Director - 42. Conduit for new developments,sometimes adding interpretations.3. Participation in policy development.4. Participate in non-clinical meetings, andkeep clinicians informed of the results towhere they will often not need to attend non-clinical meetings. 140
  141. 141. Medical Director’s Role - 55. Participation in program and in individualevaluations.6. Supervision of psychiatrists. May be aqualitative supervision as to their clinicalwork, not necessarily administrativesupervision of needs like scheduling.7. Recruitment of psychiatrists 141
  142. 142. Role of Medical Director - 68. Final say on clinical issues [should berare that such are taken out of hands of thefront-line psychiatrist.]9. Addressing legal issues, trying to obtainlegal assistance in how to reach clinicalgoals. [Usually best to ask attorneys “how,”not “whether.”] 142
  143. 143. Role of Medical Director - 710. Establishes the clinical values [hopefullyby hammering out a consensus]. a. Evidenced based? b. Recovery goal for all? c. Coercion has a role in providingclinical care? d. Costs are to be a determining factorin deciding on treatment? 143
  144. 144. Role of the Medical Director - 911. Use the physician-to-physician networkto resolve issues that would otherwise notbe well settled. Thus, the medical directorneeds to evolve a first-name-basis informalsystem with local clinicians, who can resolvean issue that seemed block by bureaucraticrules, an “old-boys network” of more thanboys. 144
  145. 145. Role of Medical Director - 1012. Assist the private sector through keepingthat sector informed as to clinicaldevelopments and informed as to resourcesthat help those clinics, hospitals andpractitioners be more effective in their workwith their patients. 145
  146. 146. Roles of Medical Director - styleManage on one’s feet.Create a sense of omnipresence in theorganization.Be seen.Be heard from. 146
  147. 147. Nursing HomesNursing homes, once a “de-institution”option, is now being seen as an institution.[NY Times, 12Sep2011] 147
  148. 148. Needs - 11. Greater recognition of the county’s role inserving the mentally ill. 148
  149. 149. Needs - 22. Very broad, automatic access to services. – Probably need standards of automatic access. Regulations that increase access. – Standards need empirical basis – should not depend on establishing standards on only a rational basis. 149
  150. 150. Needs - 31. A way to measure a county’s adequacy as to access of the mentally ill to that county’s communities. [Wheelchair analogy]. 150
  151. 151. Needs - 4Adults with serious mental illness who aretreated in public systems die, on average,20-25 years earlier than the generalpopulation (average age of 58 comparedto 78 for the general population). Joseph Parks, et al. (2007) “Morbidity and Mortality in People with Serious Mental Illness." National Association of State Mental Health Program Directors (NASMHPD) Report.
  152. 152. Needs - 45. A climate of innovation. There are manypeople with mental illness whose access totheir community is far less than ideal.Clinical and administrative innovationsshould be encouraged. 152
  153. 153. What Should the APA do?Establish an organization within the APA, abottom-up, democratic organization, tofacilitate communication of ideas,experiences, and bases for advocacy. 153
  154. 154. Disturbing statistic…Adults with serious mental illness who aretreated in public systems die, on average,20-25 years earlier than the generalpopulation (average age of 58 comparedto 78 for the general population). Joseph Parks, et al. (2007) “Morbidity and Mortality in People with Serious Mental Illness." National Association of State Mental Health Program Directors (NASMHPD) Report.
  155. 155. Risillience 155
  156. 156. PPA.. 156
  157. 157. NYLawsuits;2. 1980s: To have pts moved from state hospitals to least restrictive: many to nursing homes.3. 2009: Against warehousing in adult homes.4. 2011: Against warehousing in nursing homes
  158. 158. Integration with Primary Care - 1• Psychiatry & Primary Care Integration Across the Lifespan POSITION STATEMENT• Approved by the Board of Trustees, September 2010 Approved by the Assembly, May 2010
  159. 159. Integration with Primary Care - 21. Access to and payment for clinically appropriate services provided by psychiatrists should be included as an essential feature in medical/health home initiatives.
  160. 160. Integration with Primary Care - 32. Parity of benefits design for beneficiaries as well as parity in payment for all physicians, particularly psychiatric that does not discriminate by location of service or diagnosis should be provided.
  161. 161. Integration with Primary Care - 43. Psychiatrists should have choices of participation in a new health system, such as fully integrated clinicians and/or managers of the system, as collaborative care partners, and as consultants to it.
  162. 162. Integration with Primary Care - 54. The exact financial formula for these choices should be negotiated such that it is compatible with parity and nondiscrimination regarding both psychiatric patients and psychiatric physicians.A. Psychiatric Ass. policy statement [Eliot Sorel, M.D., Anita Everett, M.D. Roger Peele, M.D., Catherine May., M.D., Michael Houston, M.D., Hind Benjelloun, M.D., Kayla Pope, M.D.; and consultant, Jack McIntyre, M.D.]
  163. 163. Integration with Primary Care - 6American Psychiatric Association Ad Hoc Work Group Report on the Integration of Psychiatry and Primary CareThirty-two page document outlining potential resources, past models and the need to pursue this goal.[Authors: Anita Everett, M.D., Roger Kathol, M.D., Wayne Katon, M.D., Eliot Sorel, M.D. APA StaffIrvin Muszynski, J.D., and Mary Ward
  164. 164. Integration with Primary Care – 7Resource document [A Psychiatric Ass., 2009]:Integrated Care of Older Adults with Mental Disorders
  165. 165. Integration with Primary Care - 8Addressing Mental Health Concerns in Primary Care: A Clinician’s ToolkitAmerican Academy of PediatricsThis toolkit is a resource designed to help primary care clinicians in implementing algorithms to help guidance in enhancing mental health care.CD-ROM. 2010. $199.95.
  166. 166. NCCounty Resources [a website]: option=com_content&view=article&id=201&Itemid=126Orange County:Part of Orange-Person-Chatham Authority.Phone numbers of resources, e.g.: clinics, hospitals, programsHow to get Medicaid or Medicaid waiver.•
  167. 167. Outpatient Commitment – 1 AACP PositionThe AACP recommends that states and counties add features to their quality assurance monitors for providers to measure the effectiveness of IOC on adherence to treatment and on IOC’s reduction of dangerous behavior.. IOC must be shown to improve both measures beyond that which can be achieved by less coercive means.
  168. 168. Outpatient Commitment - 2The AACP cautions states and counties against implementing IOC where resources for services are insufficient to afford the committed outpatient the highest quality mental health care, as well as access to the basic resources of income support, housing, and physical health care. These localities risk providers’ utilizing IOC inappropriately.[]
  169. 169. Evidenced-based Practice - 1AACP Position Statement on Implementation of Evidence-Based Practice, December, 2005 ions/position_statements/evidence.aspx
  170. 170. NACo on ACA - 1• Resolution in Support of Provisions of the Affordable Care Act that Help County Safety• Net and Behavioral Health Programs• Issue: Essential need to implement key features of the Patient Protection and Affordable Care• Act of 2010 (ACA).• Adopted Policy: The National Association of Counties supports full funding for, and• implementation of, the provisions of the ACA that help counties meet the service needs of low• income and disabled populations.
  171. 171. NACo on ACA - 2• Specifically, NACo supports maintaining and expanding• affordable health coverage and benefits to uninsured and underinsured residents who rely on• county health care delivery systems – including the Medicaid maintenance of effort (MOE)• requirements and the scheduled Medicaid expansion. NACo also supports the ACA’s provisions
  172. 172. NACo on ACA - 3• American County Platform and Resolutions 2011‐ 2012• to improve care coordination to ensure that everyone has a medical/health home for efficient,• accessible and cost-effective care; to improve access to preventive care and health promotion, for• underserved populations; and to promote the use of peer supports and counselors, together with• effective care coordination that spans health and social support services.
  173. 173. NACo – SSDI 1• Resolution in Support of Reducing the 24-Month Waiting Period for Participants in Social• Security Disability Insurance• Issue: Coverage of the current 24-month gap in health coverage for disabled individuals• receiving SSDI.• Adopted Policy: NACo supports and urges passage of legislation to eliminate the 24-• month wai Adopted Policy: NACo supports and urges passage of legislation to eliminate the 24-• month waiting period for health care coverage, for those individuals who have worked and paid• in to the system and then become disabled, seeking assistance through SSDI. ting period for health care coverage, for those individuals who have worked and paid• in to the system and then become disabled, seeking assistance through SSDI.
  174. 174. • Resolution on Adapting to Aging Population• Issue: Aging population is increasing demands on county health and human services.• Adopted Policy: NACo supports legislation to allow for and encourage adaptation of• local government health services to an older and larger client base.• Background: As the “Baby Boomer” generation ages and enters retirement, the demand• for health and human services and the pressure on local governments to provide those services• will increase greatly.• It is imperative that our health systems begin now to adapt to the different demands,• needs, and methods of communication that these new populations will require. If our local• governments are to successfully provide the basic services demanded of them, it is essential
  175. 175. • Resolution on County Organized Health Systems• Issue: Local Administration of the Medicaid and Expanded Public Programs via• "County Organized Health Systems".• Adopted Policy: The National Association of Counties (NACo) urges Congress and the• Administration to remove current statutory prohibitions that prevent the establishment of• additional County Organized Health Systems (federally defined as "Health Insuring• Organizations"). NACo also urges the Centers for Medicare and Medicaid Services (CMS) to• adopt a policy of encouraging the formation of County Organized Health Systems as a means to• more effectively deliver Medicaid benefits at the local level.• Background: County Organized Health Systems (COHS) are locally established• independent publicly-run health plans that administer the Medicaid program, as well as other• publicly-funded health care programs for low income populations, in either a county or group of• counties. COHS plans have existed in California since 1983 and there are currently five plans• serving nine California counties and over 600,000 Medicaid beneficiaries.
  176. 176. -2• COHS plans are governed by boards or commissions appointed by County Supervisors,• and each plan develops its program to best suit the needs of the local community.• During the last 25 years, COHS plans have proven successful in terms of both costeffectiveness• (saving approximately 20 percent over fee-for-service Medicaid) as well as• improved service delivery to Medicaid beneficiaries (e.g. increased access to care, disease• management programs, and high immunization rates). COHS plans cover all Medicaid eligible• beneficiaries in their services areas and provide the entire spectrum of care - from prenatal care• to hospice. The expansion of the five COHS plans into four additional counties has shown that• the county based model can be effectively replicated in both suburban and rural• environments. Similar models also exist in 28 rural Minnesota counties.
  177. 177. • Resolution on Essential Support Services for Persons with Behavioral Health and• Developmental Disabilities• Issue: Close coordination across health and social service programs.• Adopted Policy: Care coordination across Federal programs that serve persons with• disabilities should be fully maintained for current beneficiaries and expanded appropriately to• serve the disability population newly insured through National Health Reform; social service• programs, particularly affordable housing and job training, should be expanded so that persons• with disabilities can become and remain fully independent in their home communities.• Background: Close coordination across health and social service programs is essential• to assure the effectiveness of care and supports for persons with disabilities. County behavioral• health and developmental disability authorities are concerned that federal care and support• programs should be available to persons with disabilities, including the newly insured, in the post• National Health Reform environment, and that care coordination should be available to make• them operate efficiently.
  178. 178. • Health services are less effective and more costly when needed social services are either• not available or are not coordinated well. This Resolution is an effort to address this problem• directly, both for the currently insured and the new populations to be insured through National• Health Reform.• These tools are also very important so that persons with disabilities can live independent• lives in their own communities.
  179. 179. • Resolution Supporting Efforts in the Prevention and Treatment of Obesity and Overweight• Issue: Reduce obesity and overweight and improve wellness.• Adopted Policy: The National Association of Counties recognizes obesity and• overweight as conditions that can persist from childhood to adulthood, that are associated with• chronic disease, and that cause preventable and premature deaths in adults, adolescents and• children. NACo supports local public health department leadership in obesity and overweight• prevention.• Background:
  180. 180. • Resolution on Persistent Health Disparities• Issue: Persistent health disparities.• Adopted Policy: NACo supports legislation to reduce health disparities and address the• social determinants of health, increase the diversity and cultural and linguistic competencies of• the health workforce, and improve environmental justice. This must include significant direct• federal funding for counties to implement programs designed to reduce disparities, by direct• service delivery and in partnership with providers.• Background: Disparities in health outcomes for vulnerable populations as defined by• race/ethnicity, socio-economic status, geography, gender, age, disability status, risk status related• to sex and gender have been well documented and are well understood by county officials.• These vulnerable populations disproportionately experience worse health and safety outcomes• across a broad spectrum of illnesses, injuries, and treatments. These disparities are likely to be• exacerbated during a prolonged recession.
  181. 181. • Resolution on Nurse Home Visitation Programs• Issue: Nurse Home Visitation Programs.• Adopted Policy: NACo recognizes the importance of evidence-based nurse home• visitation programs that serve low-income parents, pregnant women and young children. NACo• supports the premise that parents need access to public health resources to promote a healthy• environment for their families. NACo supports adequate funding including Medicaid funding• for all nurse home visitation programs that benefit families. [focus on children]
  182. 182. • Resolution on Nurse Home Visitation Programs• Issue: Nurse Home Visitation Programs.• Adopted Policy: NACo recognizes the importance of evidence-based nurse home• visitation programs that serve low-income parents, pregnant women and young children. NACo• supports the premise that parents need access to public health resources to promote a healthy• environment for their families. NACo supports adequate funding including Medicaid funding• for all nurse home visitation programs that benefit families.
  183. 183. • Restoring the Partnership for American Health: Counties in a 21st Century Health• System Full Partners: County governments are integral to Americas current health system and• will be crucial partners in achieving successful reform. At the most basic level, county officials• are elected to protect the health and welfare of their constituents. County governments set the• local ordinances and policies which govern the built environment, establishing the physical• context for healthy, sustainable communities. County public health officials work to promote• healthy lifestyles and to prevent injuries and diseases. Counties provide the local health care• safety net infrastructure, financing and operating hospitals, clinics and health centers. County• governments also often serve as the payer of last resort for the medically indigent. County jails• must offer their inmates health care as required by the U.S. Supreme Court. Counties operate• nursing homes and provide services for seniors. County behavioral health authorities help people• with serious mental health, developmental disability and substance abuse problems who would• have nowhere else to turn. And as employers, county governments provide health benefits to the• nearly three million county workers and their retirees nationwide. Clearly, county tax payers• contribute billions of dollars to the American health care system every year and their elected• representatives must be at the table as full partners in order to achieve the goal of one hundred• percent access and zero disparities.
  184. 184. • Local Delivery Systems-Access for All: NACo believes that reform must focus on• access and delivery of quality health services. Coverage is not enough. County officials,• particularly in remote rural or large urban areas know that even those with insurance may have• difficulty gaining access to the services of a health care provider, which can be exacerbated by• the severity of their illness. Insurance carriers participating in public programs should berequired to extend coverage into rural areas and to contract with local providers. Local delivery• systems should coordinate services to ensure efficient and cost-effective access to care,• particularly primary and preventive care, for underserved populations. County governments are• uniquely qualified to convene the appropriate public and private partners to build these local• delivery systems in a way that will respect the unique needs of individuals and their• communities. A restored federal commitment to such partnerships is necessary for equitys sake.
  185. 185. • Public Health and Wellness: NACo believes that a greater focus on disease and injury• prevention and health promotion is a way to improve the health of our communities and to• reduce health care costs. Disease and injury prevention and health promotion services can be• delivered by a health care professional one patient at a time. Local health departments, in• partnership with community based organizations and traditional health care providers, deliver• community-based prevention services targeted at an entire population. Population-based• prevention services can save money by keeping people healthy and reducing the costs of treating• unchecked chronic disease. These critical services include assessment of the health status of• communities to identify the unique and most pressing health problems of each community and• health education to provide individuals with the knowledge and skills to maintain and improve• their own health. The public health response to emergencies should be fully integrated into each• countys emergency management plan. Local public health considerations likewise should be• systematically integrated into land use planning and community design processes to help prevent• injuries and chronic disease. Policies are also needed to address health inequity, the systemic,• avoidable, unfair and unjust differences in health status and mortality rates, as well as the• distribution of disease and illness across population groups. Investing in wellness and prevention• across all communities will result in better health outcomes, increased productivity and reduce• costs associated with chronic diseases.
  186. 186. • Expanding Coverage: NACo supports universal health insurance coverage. Existing• public health insurance systems should be strengthened and expanded, including Medicare,• Medicaid and the State Childrens Health Insurance Program (SCHIP). As states and counties• attempt to shoulder their legislatively mandated responsibilities to provide care for the indigent• and uninsured, federal regulatory barriers should be removed to allow flexibility and innovation• at the local level. Restrictions on the expansion of County Organized Health Systems should be• lifted and they should be authorized to serve as a public plan option in their service areas.• Furthermore, in the effort to expand coverage, reformers should not forget that the coverage must• be meaningful, without imposing additional mandates on county governments. The benefit• package must be defined so as to provide the full range of services people need, including• prevention services, pharmaceuticals, dental, full parity for behavioral health, substance abuse• and developmental disability services. Barriers to cost-effective treatments, like living organ• donation, should be removed.
  187. 187. • Maintaining a Safety Net: NACo believes that the intergovernmental partnership• envisioned in the Medicaid statute should be restored and strengthened. Medicaid• reimbursement rates should be enhanced and increases to the Medicaid federal medical• assistance percentage (FMAP) should be passed through to counties contributing to the nonfederal• share. Local safety nets, supported by Medicaid and disproportionate share hospital• (DSH) payments, should not be dismantled to "pay for" universal coverage. We must not allow• the safety net infrastructure to be undermined. County hospitals and health systems provide• surge capacity, emergency and trauma services and other critical high cost services like neonatal,• HIV/AIDS and burn care. Safety net hospitals will continue to need extra support to carry out their missions, including addressing health disparities. Health care is not just coverage it is• also access and it is the safety net hospitals where translation services for hundreds of languages• can be found.
  188. 188. • DSH payments address two otherwise unreimbursed costs: (1) services provided to the• uninsured and underinsured; and (2) Medicaid reimbursement rates that pay less than the cost of• providing health services. It is too early to predict the net effect of Medicaid expansion and• reimbursement reform. In addition, unfortunately, there will always be some individuals who• will remain uninsured. These and other at-risk populations financed by DSH are unlikely to be• among the groups to be covered in the initial stages of reform. All individuals, including the• uninsured, should receive treatment and DSH supports that care. Therefore DSH payments• should not be phased out or down until health care reform is fully implemented and its effects on• DSH payments can be accurately assessed. Assumptions should not be made that DSH can be• cut by any arbitrary amount on some arbitrary timeline during the implementation of heath care• reform.
  189. 189. • Health Workforce: NACo believes that the health professional and paraprofessional• workforce must be supported and enhanced. It is important that we sustain training programs• and sites of service that enable us to develop a complement of health professionals that can• address the needs of a changing, growing and aging population.• Public hospitals have often been teaching hospitals. The sites of service include hospitals,• outpatient clinics, and community health centers. These settings provide access for patients• seeking care, and a diverse set of patient conditions and cultures that make for a comprehensive• learning experience. Reasonable medical education funding is an integral part of the business• model of these institutions.
  190. 190. • Every effort should be made to recruit, train, license and retain health professionals, and• allied professionals and paraprofessionals, on an expedited basis. A large body of evidence• supports the contribution of direct care staff, nurses and nursing assistants, to quality outcomes.• Funding for existing education and training programs - in secondary, post-secondary and• vocational educational settings - should be increased and targeted towards initiatives to expand• and diversify the health workforce. Partnerships between local economic developers and• workforce development professionals should be encouraged to meet growing health care sector• demand. Targeted incentives including scholarships, loan forgiveness and low-interest loan• repayment programs should be developed to encourage more providers to enter and remain in• primary care and public health careers. Primary care providers should be empowered to - and• compensated for - case management services.
  191. 191. • Health IT: The federal government should support the integration of health information• technologies into the local health care delivery system. NACo supports the Presidents goal of• implementing a nation-wide system of electronic health records in five years. NACo supports• efforts to promote the use of a range of information technologies to facilitate appropriate access• to health records and improve the standard of care available to patients, while protecting privacy.• This includes deployment of broadband technologies to the widest possible geographic footprint.• Other tools facilitate evidence-based decision making and e-prescribing. Using broadband• technologies, telemedicine applications enable real-time clinical care for geographically distant• patients and providers. Remote monitoring can also facilitate post-operative care and chronic• disease management without hospitalization or institutionalization.
  192. 192. • Long Term Care: Federal policies should encourage the elderly and disabled to receive• the services they need in the least restrictive environment. Since counties provide and otherwise
  193. 193. • support long term care and other community based services for the elderly and disabled, state• and federal regulations and funding programs should give them the flexibility to support the full• continuum of home, community-based or institutional care for persons needing assistance with• activities of daily living. Nursing home regulatory oversight should be reformed in order to• foster more person-centered care environments.
  194. 194. • Jail Health: Reforming Americas health care system must include reforms to its jail• system. Counties are responsible for providing health care for incarcerated individuals as• required by the U.S. Supreme Court in Estelle v. Gamble, 429 U.S. 97 (1976). This unfunded• mandate constitutes a major portion of local jail operating costs and a huge burden on local• property tax payers. The federal government should lift the unfunded mandate by restoring its• obligation for health care coverage for eligible inmates, pre-conviction. Furthermore, a true• national partnership is needed to divert the non-violent mentally ill from jail and into appropriate• evidence-based treatment in community settings, if possible. Finally, resources should be made• available to counties to implement timely, comprehensive reentry programs so that former• inmates have access to all the health and social services, including behavioral health and• substance abuse treatment, to avoid recidivism and become fully integrated into the community.
  195. 195. NACo• The National Association of Counties (NACo) is the national organization that represents county governments before the Administration and Congress. NACo provides essential services to the nations 3,068 counties. 196
  196. 196. NACBHDD - 1National Association of Counties Behavioral Health and Developmental Disabilities [NACBHDD] is the national voice for county and local behavioral health and developmental disability authorities in Washington, DC. 197
  197. 197. NACBHDD - 2Through education, policy analysis, and advocacy, NACBHDD brings the unique perspective of our members to Congress and the Executive Branch and promotes national policies that recognize and support the critical role counties play in caring for people affected by mental illness, addiction, and developmental disabilities. 198
  198. 198. NACBHDD - 3Newsletters: Covers legislative, regulatory, and judicial events including notices of grant possibilities and descriptions of publications related to mental health issues [includes substance related and intellectual disabilities]. 199
  199. 199. NACBHDD - 4Also at the NACBHDD website:-- Documents such as IOM reports.-- Presentations such as slides on new legislation-- Reports of NACBHDD Board meetings. 200
  200. 200. NACBHDD - 5• Ron Manderscheid, PhD• Executive Director• 25 Massachusetts Avenue, NW, Suite 500• Washington, DC 20001• Voice: 202-942-4296• Cell: 202-553-1827• E-Mail:• 201