The Importance of Pursuing Mental Health Integration

Why Pursue Mental Health Integration?

It is the right thing to do: The NCCBH vision statement provides the foundation for our work: We are committed to creating and sustaining healthy and secure communities, achieved through a system that holds the needs of consumers paramount, regardless of their ability to pay.

Vital to this commitment is a network of organizations and advocates promoting services of unparalleled value.

NCCBH members primarily serve public sector consumers, those with severe and persistent mental illness or serious emotional disturbance-the needs of this population are often overlooked in primary care and integration planning. We must assure that their needs as well as the needs of the broader community are appropriately addressed.

Many people in the broader community now receive their behavioral healthcare in a primary care setting, and the gap between the medical and behavioral healthcare systems must be bridged: As noted by Robin Dea and many other commentators, there is:

“evidence that many, if not most, people coming into primary care are being treated for psychosocial problems, not organically based medical disease . . . evidence of medical cost offsets from treating behavioral health problems presenting as physical health problems in the primary care setting . . . the assumption that if adequate detection of early stage psychiatric illness took place in primary care, there would be some prevention of patients going to more severe episodes of major psychiatric illnesses . . . and primary care is where most people who have behavioral health problems are in fact seen.”

Some of the important findings from the research field include:

-The Epidemiologic Catchment Area (ECA) Study and articles based on this survey data, reported the finding that about 50% of care for common mental disorders was delivered in general medical settings. However, many subsequent studies have shown that these disorders may be undiagnosed or under-treated.
-Screening systems, treatment guidelines and provider education in primary care are necessary but not sufficient steps to ensure a difference in outcomes.
-Collaborative and stepped care has been shown to achieve outcomes that are better than “usual care”.

There is the opportunity for quality improvement of care within the primary care and specialty behavioral healthcare settings: Studies have shown that many people with depression stop taking their medications before the minimal time required to effectively treat an episode of depression. Patients at Group Health Cooperative who initiated medications for depression with their primary care physician and received targeted stepped up care and relapse prevention support were significantly more likely to adhere to adequate dosages of medication and to demonstrate a greater decrease in depressive symptoms.

Application of research findings such as these through adoption of evidence-based practices in both primary care and specialty behavioral health (BH) settings will result in better outcomes for consumers.

With the publication of Priority Areas for National Action: Transforming Health Care Quality, the Institute of Medicine’s 2003 follow up to Crossing the Quality Chasm: A New Health System for the 21st Century, a major opportunity and challenge has appeared for the public mental health system.

The Quality Chasm recommended the systematic identification of priority areas for national quality improvement; Priority Areas proposes twenty areas for transforming health care nationally. Included in this list are major depression (screening and treatment) and severe and persistent mental illness (focus on treatment in the public sector).

Their inclusion as priority areas, as well as the findings in the Interim Report from the President’s New Freedom Commission on Mental Health, with its observation that the system is “fragmented and in disarray-not from lack of commitment and skill of those who deliver care, but from underlying structural, financing and organizational problems” suggests that the time for new strategies is at hand.

Many people being served by public behavioral health services need better access to primary care: A rationale less frequently articulated for integration is that the specialty BH system, especially the public sector focusing on the severe and persistent mentally ill adult population (SPMI) and seriously emotionally disturbed (SED) children, serves a disabled consumer population with healthcare needs that are frequently under-addressed due to difficulties in obtaining medical services.

Most state Medicaid waivers related to coverage for physical healthcare have focused on enrollment of the TANF population into Medicaid managed care plans, leaving the disabled Medicaid population unable to adequately access care, or in better situations, reliant on “safety net” providers-community health centers (CHCs) or county delivered health services.

Community health centers serve people who need better access to behavioral healthcare. These “safety net” providers serve a broader scope of patients than just the Medicaid population. But many states have implemented mental health Medicaid waivers that focus the public mental health system on the SPMI/SED and Medicaid populations, with minimal levels of support for non-SPMI/SED or uninsured populations. Often there is not a good match of target populations between the two systems. If the Medicaid mental health program also has a highly managed service authorization and payment methodology, there may be additional barriers to reimbursement for mental health services.

This has led to frustration for “safety net” healthcare providers because they have difficulty obtaining behavioral health services for their non-SPMI/SED or uninsured patients. In a recent survey of CHC medical directors, 80% indicated that cost is the main barrier to behavioral health care for their uninsured populations. The recent financing and development of behavioral health services in CHCs addresses this frustration and is just the latest in a series of efforts to acknowledge that a large proportion of the population gets their behavioral health services in primary care.

Because behavioral health clinicians are a resource for assisting people with all types of chronic health conditions: Yet another reason for integration is the potential contribution of BH clinicians regarding behavioral and lifestyle change: providing interventions targeted at better management of chronic disease, supporting and “leveraging” the time of primary care providers through disease management programs.

Disease management activities focus on several areas: early identification of populations at-risk for costly chronic disease (e.g., asthma, diabetes), care interventions that utilize evidence-based practices, education-intensive orientations that focus on both patient and provider, care management and a coordinated approach across multidisciplinary treatment teams, and a method for systematic data collection that measures clinical and cost-effectiveness. Large organized healthcare systems, such as Northern California Kaiser-Permanente, implement their major disease management programs with specifically assigned nurses as care managers and educators.

However, many physicians in individual or group practices do not have access to this level of support unless they are in the network of a health plan with active disease management programs. In markets where primary care and multi-specialty groups have accepted accelerated risk, disease management approaches will be especially value-added.

We are in a time of significant public policy activity regarding financing of the national healthcare system and the uninsured population. As we approach the 40th anniversary of the founding of the community mental health center movement, the dialogue has returned us to our public health beginnings-serving the needs of a population.

The Health Resources and Services Administration (HRSA) Primary Care Integration Initiative is currently being implemented across the country. The HRSA initiative includes: identification of system issues related to integration and the development of related strategies; development of a service manual for CHC behavioral health services; development of BH intervention models for CHCs; and grants for establishing BH services in existing CHCs.

Newly funded CHC sites will be expected to provide dental, mental health and substance abuse services, either directly or by subcontract arrangements. CHCs are in the process of decision making about building their own BH services or contracting for BH services, as they prepare their grant applications. (The NCCBH website, www.nccbh.org, has a Primary Care Integration Resource Center with more details about the HRSA process.)

At the same time that HRSA is putting new BH resources into CHCs, reports are emerging from many states indicating that the public mental health system is funded at somewhere around half the level that is needed. In the private sector, the relentless downward pressure on behavioral health PMPMs has also reduced overall system resources, shifting cost from the private sector to the public sector.

Reports such as these were released prior to the current fiscal crisis in state Medicaid programs; rather than addressing the shortfalls, there are significant new reductions in BH services in many states. And, the implementation of managed care methods for Medicaid have made it difficult for some community based BH providers to continue to enact their mission of serving the needs of the population, regardless of ability to pay.

The implications for system-wide

How State Budget Cuts Impact Continuity of Mental Health Care

Continuity of care between the inpatient and outpatient settings continues to be a challenge. Current hospital payments assume that hospitals are actively involved through discharge and the transition to outpatient settings and advocating for payments for outpatient providers to assist in this process is viewed as duplicative. This undermines mental health care providers’ ability to smoothly transition clients between service settings.

Meeting the credentialing requirements for program services and mental health professionals has posed new challenges. Community behavioral health organizations employ professionals that may not meet private insurers’ credentialing standards (for example, 3 years of post-licensure experience). Community providers have addressed this through contractual arrangements in which quality assurance and supervision requirements substitute for these credentialing standards. Services are billed under a supervisory protocol in which the supervising professional’s national provider identifier is used.

Additionally, some programs offer services that rely on a combination of funding sources such as county, state, and private insurers. In these situations, counties sometimes want to limit private insurance clients’ access to these programs because a portion of the overall program is covered by the county.

Impact of State Budget Cuts on Mental Health Care -

In a dramatic turnabout that may foreshadow dilemmas faced by other states, the governor of Minnesota vetoed funding for the state’s mental healthcare program. The legislature would have extended the program for several months, as a compromise was negotiated to retain elements of coverage for the state’s mental health population – a hospital uncompensated care fund, medication/pharmacy, and “coordinated care delivery systems.” In the system, an accountable hospital-centered program paid a fixed amount to cover about 40% of the state’s mental illness population who elected to participate. As there is no reimbursement for outpatient clinic and all non-hospital services, providers and consumers now are scrambling to seek disability determination or enroll in Medicare type coverage after the six month state mental illness coverage enrollment period ends.

While these cuts are only effective as of June 1, 2010, it is expected that they will result in increases to the uncompensated care burden on hospitals and community safety net providers.

How Do We Minimize The Impact of Budget Cuts on Mental Health Care?

Many not-for-profit membership organizations representing community mental health and other service provider agencies throughout Minnesota have been working in coalition with national mental health groups on advocacy related to the state’s mental health program changes. Initially, advocacy efforts were focused on encouraging the state legislature to vote in support of expanding the state Medicaid program early to receive additional federal funding (as provided for in the national healthcare reform bill). Unfortunately, this proved to be politically untenable in the immediate future; however, a measure was passed to allow the governor to use executive authority to expand Medicaid coverage for mental illness patients.

While being actively involved in this advocacy process is vitally important to the community behavioral health system, national mental health advocacy medicaid organizations and their members are also evaluating ways in which they can optimize their business practices to meet this changing budgetary reality. Among other strategies, community behavioral health providers are working to develop partnerships with community hospitals to reduce the number of avoidable emergency department admissions and ease the transition from the inpatient to outpatient settings, supporting clients through the disability determinations process so they may become eligible for Medicaid as quickly as possible, and raising funds that will help to cover the cost sharing requirements for state sponsored mental health care and the enrolled clients that are unable to pay.

Through this two-pronged approach that includes both advocacy and pragmatic business considerations, it is hoped that the community behavioral health system will be able to develop new cost-effective ways of delivering services that will be well-positioned to withstand funding changes while taking advantage of new opportunities made available through national and state health care reform initiatives.

Easter Seals – Michigan is showcased in this four part special that aired on WDIV Channel 4 in May 2009. It looks at the sucessful mental health programs that have helped people in the community seek help and live productive lives.
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School Based Mental Health Services Reduce School Violence

We live in a complicated world requiring complex skills. We must prepare our children to cope and to compete. They need reading, social studies, science and math more than ever, but they also need social skills, problem solving, superior reasoning and good mental health. There is a societal need to reduce the incidence of violence in our schools, as well.

When children and teens are focused on problems at home or within themselves, they often do not do well in school. School success and good mental health are intrinsically tied together. Additionally, school success and good mental health are linked to life success. Identifying those youth who are in need of help can reduce suffering and improve mental health, school success, and life success. Good mental health aids development, learning, interpersonal relationships, and the ability to cope with stress more effectively.

Approximately 1 in 5 children & adolescents (20%) experience the signs and symptoms of a mental health disorder during the course of a year. These children are estimated to have severe emotional or behavioral problems that significantly interfere with their daily functioning. Yet, less than one-third of the children under the age 18 with a serious disturbance receive any MH Services. Often the services they do receive are inadequate or inappropriate (Children’s Defense Fund). Ten percent of children in any given classroom (3/30) are ready to learn at the curriculum level (Dr. Adleman & Dr. Taylor UCLA School Mental Health Project).?Only 16% of all children receive any mental health services. Follow through for children receiving mental health services in school is much greater than those referred to community services. Of the 16% that receive MH services, 70-80% receive that care in a school setting (healthinschools.org), yet less than 10% of all school districts in the United States currently have an established School Based Mental Health Program (Center for School Mental Health Assistance, Dr. Mark Weist 2001, University of Maryland).

To assess the effectiveness of school based mental health (SBMH) services in reducing emotional, school, home, and behavioral problems of youth, Robert Schmidt, MA and Kathryn Seifert, Ph.D. collaborated on the evaluation of outcomes for a SBMH program for a rural mid-Atlantic School district. Coordination of mental health services with educators, Department of Social Services, the Department of Juvenile Services, and the Development Disabilities program contributed to the program’s success.

The project began in 1999 with a Federal grant to the school district and the project is ongoing. Youth were referred to the project from teachers, guidance counselors, parents, student self-referrals and other agencies such as the Departments of Social Services and Juvenile Services and Law Enforcement. The student’s scores on the Devereaux, BASC, CARE and several school measures such as absenteeism, disciplinary referrals, violence related suspensions, and other suspensions were measured at the beginning of services and at the beginning and end of each school year.

From 1999 to 2004, 36% youth were referred because of symptoms of depression, 26% because of family problems, and 24% because of behavior problems. Examples of reasons for referral to the program included: crying in class, child can’t stay focused, student found out mom is terminally ill, youth’s parents going through divorce, and recent sexual abuse. There were 84 referrals to the program in 1999, compared to 437 students in 2002 and 239 students in 2003. Peak referral times were in October and February. Youth in the transition years of sixth and ninth grades were referred to the program most often. In 2000, 2,132 mental health sessions were provided, in contrast to an amazing 15,763 sessions in 2003.

A group of 632 students who participated in the program showed significantly improved attitudes toward teachers and school, mental health symptoms, and self-esteem during and after services. Students participating in SBMH in years one and two had significantly better school attendance (56 and 57% increase) when compared to non-participants (66 and 59% decrease). Additionally for the group of participants, absenteeism increased 44% before participation and decreased 53% during participation.

Students had a significant (40%) decrease in disciplinary referrals when compared to non-participants (20% decrease). Participants in years one and two had a significant decrease in suspensions (32% and 27%) from school when compared to non-participants (33 and 16% increases). Parents reported that their children were having significantly fewer problems after receiving services. Youth self-reported significantly improved commitment to school, interpersonal relationships and self-esteem, as well as fewer stress related problems. Students reported significantly reduced school maladjustment and clinical maladjustment and improved attitude toward parents and emotional well-being.

Evaluation of the success of the program revealed several key components. One important component was having a central school/mental health coordinator to be an organizer, ombudsman, problem solver, program evaluator, and coordinator of the two systems. Additionally, the mental health service must be an integral part of the school system, not just an adjunct or add-on. Mental health staff need to communicate and attend meetings with school personnel. Mental health professionals can provide workshops and consultation to teachers, guidance counselors, and administrative staff.

Funding for the project came from mental health third party billing and grant funding. Supplemental funds allowed mental health professionals to attend meetings, consult with school personnel, and provide services for children and youth who do not meet medical necessity criteria of their insurance companies. It is also important to include families as an essential part of the program.

In a time when all programs are struggling to cope with funding cuts, collaborative programs, such as this one can make services more efficient and cost effective. Many families of troubled youth are involved in more than one service, in addition to the school. Coordination of multiple services is beneficial to the families and helps improve outcomes for youth.

This project demonstrated that school based mental health services improved student well-being, behavior and school success, while showing a significant decrease in violence and other behavior problems at home and at school. The study is ongoing and a second site has been added.

Should Alcohol Taxes Pay for Mental Health Programs? Do the Math

Improving the Mental Health System

According to a news release that was dated May 9, 2006, the “Standing Senate Committee On Social Affairs, Science and Technology” in Canada recommended the creation of a Canadian Mental Health Commission that will be responsible for significantly upgrading the Canadian mental health system. As stated by Senator Michael Kirby, the Chair of the Committee, “The Senate Committee is committed to improving the range, quality and organization of health and support services that are required by the tens of thousands of Canadians who are living with mental illnesses and addictions.”

Funding The Proposed Change

Based on an extensive three-year study on mental health and addiction, the Committee determined that it will cost .36 billion over a 10-year period for this mental health system upgrade. Where will these funds come from? According to the Committee, the revenue will come from raising the excise tax on alcoholic drinks by 5 cents per drink.

Part of the rationale for the 5-cent increase per drink was obviously the goal of raising the needed funds for the proposed changes in the mental health system. Another justifying factor for the price increase, however, was the fact that since each alcoholic drink will cost more, Canadians will be more inclined to drink lower-alcohol products such as beer and wine instead of liquor.

Let’s Do the Math

At first glance, this proposal seems to make sense. Why shouldn’t those who drink help finance a program that will provide them with a better mental health system? Why not let those who are part of the “problem” become part of the “solution”? This logic seems sound until you do the math. If .36 billion is needed to help finance the upgraded mental health system, then how many drinks will have to be consumed in a ten-year period to reach .36 billion dollars? The answer: 107,200,000,000 drinks. That’s 107 billion, 200 million drinks.

To arrive at how many drinks this is per year, all we have to do is divide this number by 10 (for the ten-year program) and the result is 10,720,000,000. This is still a huge number that fortunately can be “massaged” even more. According to The World Factbook website, the population of Canada was estimated to be 33 million people in 2006. Dividing 10,720,000,000 by 33,000,000 equals 325. Putting this in terms that the average person can understand, every man, woman, and child in Canada will have to consume 325 alcoholic drinks per year for the next ten years to finance the new mental health system! Simply put, these numbers are not realistic.

More Flaws

The “logic” of this proposed mental health program also breaks down when it is examined more deeply. For instance, why would people drink lower-alcohol products such as beer if the increased excise tax applies to all alcoholic drinks? To help understand this better, let’s use an example. Let’s say that the average shot in Canada currently costs .00 and the average beer costs .00. Based on the proposed price increase, if Joe drinks an average of 5 shots per week, his weekly average alcohol expenditure will be .25. When the numbers are calculated, this figures out to be 1.7% more than Joe would have spent before the proposed tax increase. Let’s do a similar exercise with beer. Based on the projected price increase, if Pete drinks an average of 5 beers per week, his weekly average alcohol expenditure will be .25. When the numbers are calculated, this figures out to be 5% more than Pete would have spent before the proposed tax increase. The point: since the proposed price increase affects higher-alcohol products (such as shots) proportionately less than their lower-alcohol counterparts (such as beer), why would Canadians switch to lower-alcohol products?

Alcohol and Mental Health

Another question. What if tens of thousands of Canadians, realizing that drinking alcohol is not good for their “mental health,” significantly reduce their alcohol intake or quit drinking alcoholic beverages altogether? Where will the money come from to offset this lack of revenue? In a similar manner, what if thousands upon thousands of Canadians who drink alcoholic beverages decide that they don’t want to pay the extra excise tax and, as a result, stop drinking alcoholic beverages? If this happens, where will the government get the money needed to transform the mental health system? In other words, does the Canadian government have a realistic “plan B” for this major transformation?

A Logical Contradiction

From a different perspective, isn’t it rather ironic that those who drink alcoholic beverages will pay for the revamped mental health system? Isn’t there a contradiction in logic somewhere in this proposal? Stated differently, if tens of thousands of Canadians have mental illnesses or are addicted to alcohol or drugs, wouldn’t the government want Canadians to drink LESS alcohol in order to reduce the existing alcohol abuse, alcoholism, and alcohol-related mental health problems? Yet according to the current mental health proposal, from strictly a financial standpoint, it would appear that the Canadian government is banking the entire mental health system upgrade on historical data that strongly suggests that Canadians will continue to drink at their current or even higher levels of consumption.

Budgetary Miscalculations

What happens, for instance, if there are cost overruns in the proposed mental health system? There are, of course, two “easy” solutions to this problem: increase the excise tax on each drink or motivate Canadians to drink even more alcoholic beverages. Either “solution,” however, is predicated on the fact that in order to “work,” the upgraded mental health system needs to be funded by Canadians who continue to drink alcoholic beverages.

Conclusion

It appears logical to conclude that the Canadian mental health system is in need of a major overhaul. As with most comprehensive government programs, however, the issue of funding becomes a major obstacle to overcome. The proposed Canadian mental health system upgrade is no exception. Based on the reasons given above, it seems obvious that the Canadian government needs to come up with alternate sources of revenue generation for this worthwhile project. Indeed, to point out one of the major “flaws” in the current proposal, consider the following question: When is more drinking a “good thing?” Answer: when it finances a nationwide mental health system upgrade. Something tells me that Andy Rooney from “60 Minutes” would have a lot of fun with this.

Copyright 2007 – Denny Soinski. All Rights Reserved Worldwide. Reprint Rights: You may reprint this article as long as you leave all of the links active, do not edit the article in any way, and give the author credit.

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