Seven-state Public Mental Health System Comparison

WA treats fewer than half!
Additional sources of information used (continued)
Minnesota Department of Human Services – 2015 Legislative Session – "Strengthening Minnesota's mental health system," January 2015
New Jersey full disclosure of mental health system (vision, values, organization, structure, funding, resources, personnel, etc.) available on the Division of Mental Health and Addiction Services (DMHAS) web site
Oregon Health Authority, 2015-2018 Behavioral Health Strategic Plan, November 2014
Oregon Addictions and Mental Health – Bulletin, January 15, 2015, Pam Martin Ph.D. ABPP, Director
Utah's Division of Substance Abuse and Mental Health ANNUAL REPORT for 2014, dated January 2015

Oregon has taken the lead in the transparency and accountability of its mental health system

CT
KS
MN
NJ
OR
UT
WA
Clearly articulated mission/vision and values for SMHA and RSN's available on website







Annual report for SMHA including statistics for services performed at state and community level







Functional organization chart with names, titles, and contact information easily available from website







Provider performance to established benchmarks readily available from website updated quarterly





**

Waiting list for inpatient beds updated weekly and available on website







Monthly online newsletter with meaningful content







SMHA hot line to assist individuals experiencing difficulty getting care at the community level







Training, certification, and many community resources are available online

*
*




* Much of these mental health websites haven't been updated since 2013
** Updated annually
Connecticut leads the other six states in integrating the voice of the mentally ill into its planning

CT
KS
MN
NJ
OR
UT
WA
Are consumers and their families involved in SMHA policy making?
Yes, they serve on regional mental health boards
Yes, but informally
Involved in peer reviews and advisory groups
Serve on planning council and advisory committee
Represent 51% membership on advisory committees
Informally
Informally
Is consumer and family participation mandated by statute?
Yes
Yes
No
Yes
Yes
Yes
No
Does the SMHA fund the consumer's role in policy making?
Yes
Yes
Yes
Yes
No
No
No
The most successful mental health systems (CT, NJ, OR, & UT) have a robust mission/vision for their state's mental health system that combines the how with the what
CT
"To improve the quality of life of the people of Connecticut by providing an integrated network of comprehensive, effective and efficient behavioral health services that foster self-sufficiency, dignity and respect."
NJ
"An integrated mental health and substance abuse service system that provides a continuum of prevention, treatment, and recovery supports. . culturally-competent welcoming and well-trained workforce. . person-centered, person-directed, values consumer's dignity. . committed to professionalism"
OR
"Access to a full continuum of behavioral health services. . Equity for all, promotes community and prevents chronic illness, supports recovery and life in community, admissions and discharges to State hospitals performed in a timely manner."
UT
"Prevention, works, treatment is effective, and people recover. .[we] promote hope, health, and healing. . provide leadership, promote quality, build partnerships, ensure accountability, and operate effective education and training programs. .culturally and linguistically competent. . evidence-based"
The most successful mental health systems have the fewest layers between the Governor and the SMHA

CT
KS
MN
NJ
OR
UT
WA
Management layers between Governor and SMHA director
0 layers between
2 layers between
2 layers between
1 layer between
1 layer between
1 layer between
3 layers between
Medicaid Agency placement
Different department
Different department
Same department
Same department
Same department
Different department
Different department
Housing Agency placement
Different department
Different department

Different department

Different department

Different department

Different department

Different department

Office of the medical director
Within SMHA, Ezra Griffith, MD
No medical director within the SMHA
Within SMHA, Peter Miller, MD
Within SMHA, Robert Eilers, MD
The SMHA is located within OHA
No medical director within the SMHA
No medical director within the SMHA
Oversight body
State and five regional boards
Advisory council
Advisory council
Advisory council
Advisory council
Advisory council
Advisory council
*Advisory council as a minimum is required for states receiving federal block grants
So if not money, what accounts for the difference in performance of the public mental health systems?
Vision, Mission, & Tasks
People & Skills
Systems
Structure & Rules
Culture
Outputs
Access to care
Number treated
Remission rate
Readmission rate
Satisfaction
Inputs
Money
Facilities
Feedback
A systems model of organizational performance, e.g. Nadler, Tushman, Galbraith, Quinn, McKinsey, etc.
Washington* is at the median of spending on mental health for the seven states
Questions about the mental health service provider
Question
Yes
No
1. Greeted me with friendliness and warmth
69%
31%
2. Took a genuine interest in my situation
66%
34%
3. Got me the appointment when I needed it
49%
51%
4. Was open and forthcoming in answering my questions
57%
43%
5. Quickly assigned a qualified case worker
41%
59%
6. The mental health professional assigned to my case was competent and helpful
52%
48%
7. Worked collaboratively with me in planning my care
44%
56%
8. Provided effective medication and/or therapy for my needs
42%
58%
9. Provided timely follow-up to ensure effective long-term care
38%
62%
10. The care has provided a satisfactory outcome
44%
56%
Questions about the RSN's (county's) mental health representative
Question
Yes
No
1. Took a genuine interest in my situation
62%
38%
2. Took the time necessary to fully answer my questions
58%
42%
3. Seemed to genuinely care about my welfare
59%
41%
4. Supported my emotional needs as well as providing service
47%
53%
5. Treated me the way they would like to be treated
54%
46%
6. Provided information that met my need
45%
55%
7. Went out of their way to be helpful
45%
55%
8. Gave me assistance that led to a positive outcome
42%
58%
9. Connected me with other services such as housing and employment
26%
74%
10. Provided the assistance I needed
43%
57%
Customer Satisfaction Survey
Washington State Public Mental Health System – April 6, 2015
Part 1: County mental health services, questions 1-10
Part 2: Mental health service providers, questions 11-20
Part 3: Comments from respondents,

In the recent Mental Health America* report, Washington ranks very near the bottom
Overall Ranking
Adult Ranking
Youth Ranking
Washington #48
Washington #47
Washington #47
Ranking defined by highest prevalence of mental illness combined with
lowest levels of access to quality mental health care
*"Parity or Disparity – The State of Mental Health in America, 2015"
NJ leads the other six states in the adoption of evidence-based practices (EBP)
Type of EBP
Number of individuals served







CT
KS
MN
NJ
OR
UT
WA**
Assertive Community Treatment
265
-
1,992
2,340
621
36
N/A
Supported Housing
1,126
3,505
685
5,324
-
27
N/A
Supported Employment
2,885
1,382
294
1,930
968

N/A
Family Psycho-education
-
-
-
3,341
157
138
N/A
Integrated Dual Diagnosis Treatment
3,149
2,077
-
1,942
-
69
N/A
Illness Self-Management and Recovery
-
-
-
3,164
-
268
N/A
Medications Management
-
-
-
-
20,926
690
N/A
Therapeutic Foster Care
1,069
71

880
40

N/A
Multi-systemic Therapy
89
-
-
171
-
43
N/A
Functional Family Therapy
572
-
-
388
-
96
N/A
*Washington State did not report results of EBP survey to SAMHSA for 2013
Connecticut* and Utah* lead the seven states in completing consumer surveys to measure access to and quality of mental health care
Source: SAMHSA URS, page 19
*Connecticut and Utah make the results of their consumer surveys available as public information including results by service provider
Washington State in the national context
20% of Americans are affected by mental health and substance abuse disorders
While a sizable evidence base for effective interventions exists, there is a huge gap between what is known and what is actually delivered in clinical care
Mental health care providers across all states often lack training on evidence based psychosocial interventions
These interventions are often not available as part of clinical care for mental health and substance abuse disorders
Instead we have an over-reliance on pills – the quick fix
Some considerations in interstate comparisons of mental health systems
States vary in how broad or limited their client eligibility criteria are, so there is considerable variation in the number of mentally ill served as a percent of the total population
Some states restrict the use of SMHA funds to only provide services to individuals with a SMI or Serious and Persistent Mental illness with varying cut-offs for disability, while other states have no such impairment restrictions and provide service without accounting for ability to pay
WA reports having a mental health Severity Illness Requirement for SMHA services: "Requirements are specified in the Access to Care standards, including functional impairments and covered diagnoses. People in crisis can receive services regardless of income level." KS reports having no illness or income limits for persons to receive SMHA services.
States vary widely in terms of their expenditures of funds across all of state government
Some states such as CT merge Medicaid funding into the state's general fund
For the purposes of SAMHSA reporting, some states, including WA report on all clients served by the SMHA regardless of the source of funds (Medicaid or the state's general fund). Other states may exclude clients from its reports based on the funding sources that are included in the SMHA system.

Source: NRI – Analytics Improving Behavioral Health
State mental health expenditures (including Medicaid) by type of service

CT*
KS
MN
NJ
OR
UT
WA
On State psychiatric hospitals
$184.1M
$96.7M
$118.7M
$551.9M
$235.7M
$53.5M
$218.4M
On community programs
$542.7M
$262.4M
$837.4M
$1,280M
$477.2M
$150.5M
$553.4M
On prevention, research, training, and administration
$50.9M
$0.9M
$7.7M
$25.4M
$9.0M
$1.2M
$14.7M
% spent on children & adolescents, 0-17
N/A
39%
30%
16%
21%
30%
17%
*Connecticut's figures do not include spending on children's mental health care
Source: SAMHSA URS
Glossary


SMHA
State Mental Health Agency
SAMHSA
Substance Abuse and Mental Health Services Administration
NAMI
National Alliance on Mental Illness
MHA
Mental Health America
EBP
Evidence Based Practices
SMI
Serious Mental Illness (Adults)
SED
Severe Emotional Disturbance (Children)
NSDUH
National Survey on Drug Use and Health
URS
Uniform Reporting System (SAMHSA)
RSN
Regional Service Network (often a county); in some states may be referred to as a Local Mental Health Agency
Appendices
WA needs to adopt IOM's framework for evidence-based psychosocial interventions for mental health and substance abuse*
*Institute of Medicine, September 2015
Leadership
Committed and Engaged Governor and Legislature
Culture
Diversity
Compassion
Quality mindset
Commitment to
excellence in care
Physician-led
Fast response
Action
CIT
ACT
FEP
Anti-bullying
Supported
housing
Supported
Employment
24/7 ER for MI
Reentry
Integrated
Care
Workforce development
Mobile teams
Openness
Who we are
What we do
An effective mental health system requires the right leadership, culture, programs and support
WA needs to drive the adoption of proven quality measures among the care providers
Structure measures that guide implementation of mental health care
Assess provider's training and capability to deliver evidence-based psychosocial interventions
Guidance on infrastructure and best practices
Allow consumers to select providers with expertise needed for their condition
Process measures that link particular services to predictable outcomes
Outcome measures that provide great value to patients, families, clinicians, and payers indicating whether patients have improved or reached full symptom or disease remission – patient reported outcomes are integral to measurement based care
There are many evidence-based psychosocial Interventions that need to be expanded in WA
Psychotherapies (psychodynamic, cognitive-behavioral therapy, dialectical behavior therapy, interpersonal psychotherapy, etc.)
Community-based treatments (assertive community treatment, first episode psychosis, etc.)
Vocational rehabilitation
Housing and safety
Peer support services
Integrated care interventions
Why does this gap exist?
Limitations on insurance coverage and failure to expand Medicaid
Fragmentation of care (different systems of providers, separation of primary and specialty mental health care, different entities paying for care, etc.)
Poor coordination of care
Variability in training the mental health care providers
Lack of requirements that care providers be trained in evidence-based interventions
No equivalent to the FDA for psychosocial interventions
Lack of adequate quality measures for mental health care
New Jersey also leads the states in general satisfaction with public mental health care
*The positive outcome from OR's recent investment in mental health care will become evident in future surveys
Source: SAMHSA URS
New Jersey leads the states in consumer satisfaction with access to mental health services
*The positive outcome from OR's recent investment in mental health care will become evident in future surveys
Source: SAMHSA URS
New Jersey has the greatest number of youths 12-17 experiencing a major depressive episode in the past year, but WA is not far behind
Source: SAMHSA Behavioral Health Barometer 2014
WA treats fewer than half!

A Seven state public mental health system Comparison
2015 WSPHA Annual Conference
October 12, 2015, Fred Hume, Lauren Simonds
2015 WSPHA Annual Conference
Presentation Disclosure
No off label, experimental or investigational use of medications are discussed during this presentation.

I (we) have no interests of commercial services, products or support that requires disclosure

Acknowledgments
Tom Carter, MD, Carol Koepp, former NAMI Eastside Public Policy Chair, Dr. Francesca Martin, Solutions4Community, Lauren Simonds, Executive Director of NAMI Washington,and Dr. Ernest Hughes for their encouragement, assistance, comments, and review of material.
Dr. Sharon Larson, former Director, Division of Evaluation, Analysis and Quality (DEAQ), Associated Director for Science, and Center for Behavioral Health Statistics and Quality (CBHSQ), SAMHSA for encouragement and useful questions
Marc Zodet, Statistician, Center for Behavioral Health Statistics and Quality (CBHSQ), SAMHSA for guidance on comparing state mental health systems, and
NRI - Analytics Improving Behavioral Health, SAMHSA's contractor for the Universal Reporting System
Key points
Washington State has a mental health crisis – the State's mentally ill population is twice that of Bellevue – less than half are treated
The State's public mental health system provides limited access to quality care – patient outcomes are often unfavorable
Money alone won't fix the State's mental health "system"
Integration of health care services provides a real opportunity to address the State's mental health crisis
Additional sources of information used
Connecticut's Department of Mental Health & Addiction Services (DMHAS) (Overview, Services, Organization, Divisions & Offices, Regulations & Statutes) available from the website
Correspondence from Mary Kate Mason, communications director, Connecticut's DMHAS on behalf of Commissioner Pat Rehmer, March 4, 2015
Kansas – Governor's Mental Health Task Force Report, April 15, 2014
Kansas Health Institute Report – "Kansas mental health system under increasing stress – promise of federal and state reform initiatives remains unrealized" August 18, 2014
Minnesota, articles from the StarTribune, October 26, 2013, January 1, 2014, September 14, 2014 "Minnesota law pushing mental health system to a crisis point"
Correspondence from Marc Zodet, SAMHSA & SAMHSA's contractor NRI dated February 9, 2015


Background
Attendees at NAMI's Family-to-Family classes anecdotally describe many breakdowns in mental health care for those depending on the public "system" - "Were these horror stories widespread?"
At NAMI's WA convention last year, Dan Satterberg, the King County Prosecuting Attorney was blunt, "We have a criminal justice system in Washington; we don't have a mental health system."
In November SAMHSA released its Uniform Reporting System results by state. These data were analyzed and presented to NAMI Eastside Public Policy Committee on January 29, 2015
The committee decided that a subsequent more in-depth study should focus on seven states consisting of former and current leaders in mental health care and two of Washington's neighbor states
A customer satisfaction survey was conducted by NAMI WA among users of Washington's public mental health system in April of this year
These are the findings of those studies
Washington has more adults with serious thoughts of suicide in the past year than the other six states
Source: SAMHSA Behavioral Health Barometer 2014
Primary data sources include:



Uniform Reporting System – Output Tables, 2007 through 2014
Behavioral Health Barometers – 2014 for CT, KS, MN, NJ, OR, UT, & WA
2013 National Survey on Drug Use and Health (NSDUH) - Mental Health Findings
State Mental Health Agency (SMHA) Controlled Expenditures for Mental Health Services 2013*

Assessment #10 – State Mental Health Agency Expenditures, October 1, 2014
National Association of State Budget Officers
– The Fiscal Survey of States – Fall 2014
Institute of Medicine "Psychosocial Interventions for mental and substance abuse disorders," September 2015
*In partnership with the National Association of State Mental Health Program Directors, Inc.
Overview of the comparison states
State
Comments
Connecticut (CT)
Longstanding leadership in mental health care with high levels of satisfaction with access and quality of care; children's mental health care is separately integrated with children's services
Kansas (KS)
An early leader in mental health due to the work of Karl Menninger. State funding for the public mental health system has fallen by more than $20 million per year.
Minnesota (MN)
Once a leader in care, MN's mental health system was fragile from declining funding. There was a big gap in community-based services for the most intensive needs. This year the legislature approved $46M in new funding.
New Jersey (NJ)
A leader among the states in providing highest quality public mental health care. The system is accountable and transparent.
Oregon (OR)
A $40 million increase in State funding for the public mental health system in 2012 has resulted in a new state hospital and strengthened SMHA; the OR public mental health system now has high levels of accountability and transparency – similar neighbor of WA; 19% rural vs. 16% for WA
Utah (UT)
UT's Division of Substance Abuse and Mental Health has driven major improvements in mental health care in the past two years with high levels of accountability and transparency – near neighbor of WA
Washington has more adults with serious mental illness than any of the other six states
Source: SAMHSA Behavioral Health Barometer 2014

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Satisfaction with access to mental health services



Percent generally satisfied with quality of care


Mental health spending (all sources) per person treated



Percent of Total SMHA Clients Surveyed


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