The Debacle of The Debacle of Deinstitutionalization:Deinstitutionalization:

History and Politics of Community History and Politics of Community Mental Health CentersMental Health Centers

Christopher Welsh MDChristopher Welsh MD

November 25, 2008November 25, 2008

DisclosuresDisclosuresGrant from Magellan to study outcomes of IowaGrant from Magellan to study outcomes of Iowa’’s ACT s ACT teamsteams

““Whose idea was it that we give our investors Whose idea was it that we give our investors full disclosurefull disclosure??””

OverviewOverview

History of CMHCsHistory of CMHCs

CMHCs in IowaCMHCs in Iowa

CMHC for MidCMHC for Mid--Eastern IowaEastern Iowa

Role of PsychiatristsRole of Psychiatrists

Dorothea DixDorothea Dix 18021802--18871887

Suffered a debilitating Suffered a debilitating breakdown in her midbreakdown in her mid-- thirties. In hopes of a cure, in thirties. In hopes of a cure, in 1836 she traveled to 1836 she traveled to EnglandEngland, where she met men , where she met men and women who believed and women who believed that government should play that government should play a direct, active role in social a direct, active role in social welfare.welfare.

The Indigent Insane BillThe Indigent Insane BillPromoted a grant of land for the relief and Promoted a grant of land for the relief and support of indigent, curable and incurable insanesupport of indigent, curable and incurable insane

Provide asylums that would emphasize Provide asylums that would emphasize ““moral moral treatmenttreatment””

Emphasized humane treatment based on compassion Emphasized humane treatment based on compassion and care rather than assigning mentally ill people to and care rather than assigning mentally ill people to jails, poorhouses, or life on the streetsjails, poorhouses, or life on the streets

Orderly routine with social contact, exercise and work Orderly routine with social contact, exercise and work rather than efforts to rid the body of demonic rather than efforts to rid the body of demonic possession and corporal punishmentpossession and corporal punishment

President Franklin Pierce Vetoes President Franklin Pierce Vetoes the Bill in 1854the Bill in 1854

"If Congress has the power to make "If Congress has the power to make provisions for the indigent insane, the provisions for the indigent insane, the whole field of public beneficence is whole field of public beneficence is thrown open to the care and culture of thrown open to the care and culture of the federal government. I readily the federal government. I readily acknowledge the duty incumbent on us acknowledge the duty incumbent on us all to provide for those who, in the all to provide for those who, in the mysterious order of providence, are mysterious order of providence, are subject to want and to disease of body or subject to want and to disease of body or mind, but I cannot find any authority in mind, but I cannot find any authority in the Constitution that makes the federal the Constitution that makes the federal government the government the great almonergreat almoner of public of public charity throughout the United States."charity throughout the United States."

Asylums Supported by StatesAsylums Supported by StatesDix resumes her campaign, state by state, for Dix resumes her campaign, state by state, for the establishment of public asylums supported the establishment of public asylums supported by by statestate tax dollarstax dollars

Her advocacy led to the founding of 32 hospitals Her advocacy led to the founding of 32 hospitals in 18 statesin 18 states

Over time asylums changed from small Over time asylums changed from small therapeutic programs into large custodial public therapeutic programs into large custodial public hospitalshospitals

Concepts of "curability" were replaced by Concepts of "curability" were replaced by concepts of custody and chronicityconcepts of custody and chronicity

Era of the AsylumEra of the Asylum 1850s to 1950s1850s to 1950s

100 years of state based approaches100 years of state based approachesLong term institutional careLong term institutional care

Large hospitalsLarge hospitals

Custody rather than treatmentCustody rather than treatment

By the midBy the mid--1950s about 560,000 Americans 1950s about 560,000 Americans resided in state supported institutionsresided in state supported institutions

The average length of stay was measured in The average length of stay was measured in yearsyears

Many patients spent their entire lifetime in AsylumsMany patients spent their entire lifetime in Asylums

DeinstitutionalizationDeinstitutionalization Late 1950Late 1950’’ss

Many factors led to deinstitutionalizationMany factors led to deinstitutionalization

Journalistic exposJournalistic exposééss

Introduction of chlorpromazine which initiated the Introduction of chlorpromazine which initiated the psychopharmacologic revolutionpsychopharmacologic revolution

President Eisenhower's major study of the care of the President Eisenhower's major study of the care of the mentally ill populationmentally ill population

Mental institutions were often viewed as inhuman Mental institutions were often viewed as inhuman ‘‘‘‘snake snake pitspits’’’’ factories for the manufacture of madnessfactories for the manufacture of madness

Evidence of social and functional deterioration following longEvidence of social and functional deterioration following long--term care reinforced the notion that institutions caused term care reinforced the notion that institutions caused chronic disorderchronic disorder

Bedlam 1946Bedlam 1946LifeLife magazine exposmagazine exposéé

Pennsylvania's Byberry Pennsylvania's Byberry Ohio's Cleveland StateOhio's Cleveland State

"All of a sudden America sees these photos "All of a sudden America sees these photos that look like concentration camp photos. You that look like concentration camp photos. You see people huddled naked along walls, see people huddled naked along walls, strapped to benchesstrapped to benches…… and it really is this and it really is this descent into this shameful moment." descent into this shameful moment." -- Robert Robert Whitaker, author of Whitaker, author of ““Mad In AmericaMad In America””

World War IIWorld War IISeveral new ideas emerged with military Several new ideas emerged with military psychiatrypsychiatry

Proximity Proximity –– treatment should occur as close as treatment should occur as close as possible to where symptoms were exhibitedpossible to where symptoms were exhibited

Immediacy Immediacy –– early identification and treatment early identification and treatment lead to better outcomeslead to better outcomes

Simplicity Simplicity –– the major part of intervention the major part of intervention should consist of rest, nourishment, and social should consist of rest, nourishment, and social supportsupport

Expectancy Expectancy –– return to former functioning was return to former functioning was possiblepossible

Combat trauma in US Marine in Pacific theater, World War II. By Tom Lea. Army Art Collection, US Army Center of Military History.

Cocoanut Grove Fire 1942Cocoanut Grove Fire 1942

Cocoanut Grove FireCocoanut Grove Fire 19421942

Deadliest nightclub fire in Deadliest nightclub fire in United StatesUnited Stateshistoryhistory

Killed 492 people and injured hundreds moreKilled 492 people and injured hundreds more

Dr. Erich Lindemann, a Boston psychiatrist, Dr. Erich Lindemann, a Boston psychiatrist, studied survivors and their relatives and studied survivors and their relatives and published "Symptomatology and published "Symptomatology and Management of Acute GriefManagement of Acute Grief””

Laid the foundation for research in this areaLaid the foundation for research in this area

Created the first community mental health Created the first community mental health center in 1948center in 1948

The First CMHCsThe First CMHCsThe first CMHCs were principally devoted to The first CMHCs were principally devoted to consultation and education for community consultation and education for community agenciesagencies

Offered treatment to new groups of previously Offered treatment to new groups of previously untreated, acutely ill, and emotionally troubled untreated, acutely ill, and emotionally troubled patientspatients

Few persons with severe and chronic illnesses Few persons with severe and chronic illnesses were treatedwere treated

Mental Health Study ActMental Health Study Act 19551955

In 1955 Congress passed the Mental Health Study Act to In 1955 Congress passed the Mental Health Study Act to study the problems of mental illnessstudy the problems of mental illness

The final report (1961 Action for Mental Health issued by The final report (1961 Action for Mental Health issued by The Joint Commission on Mental Health and Illness)The Joint Commission on Mental Health and Illness)

Immediate care be made available to mentally ill patients in Immediate care be made available to mentally ill patients in community settingscommunity settings

Fully staffed, fullFully staffed, full--time mental health clinics be accessible to all time mental health clinics be accessible to all people living in the USpeople living in the US

Community based aftercare and rehabilitation services for Community based aftercare and rehabilitation services for mentally ill individuals be greatly expandedmentally ill individuals be greatly expanded

The KennedysThe KennedysIn 1961 John F Kennedy became presidentIn 1961 John F Kennedy became president

Personal family experience with mental disability Personal family experience with mental disability

Sister Rosemary Kennedy Sister Rosemary Kennedy At age 23 her father was told by her doctors that a cutting edgeAt age 23 her father was told by her doctors that a cutting edge procedure would procedure would help calm her "mood swingshelp calm her "mood swings””

We went through the top of the head, I think she was awake. She We went through the top of the head, I think she was awake. She had a mild had a mild tranquilizer. I made a surgical incision in the brain through thtranquilizer. I made a surgical incision in the brain through the skull. It was near the e skull. It was near the front. It was on both sides. We just made a small incision, no mfront. It was on both sides. We just made a small incision, no more than an inch." The ore than an inch." The instrument Dr. Watts used looked like a butter knife. He swung iinstrument Dr. Watts used looked like a butter knife. He swung it up and down to cut t up and down to cut brain tissue. "We put an instrument inside," he said. As Dr. Watbrain tissue. "We put an instrument inside," he said. As Dr. Watts cut, Dr. Freeman put ts cut, Dr. Freeman put questions to Rosemary. For example, he asked her to recite the Lquestions to Rosemary. For example, he asked her to recite the Lord's Prayer or sing ord's Prayer or sing "God Bless America" or count backwards. ... "We made an estimate"God Bless America" or count backwards. ... "We made an estimate on how far to cut on how far to cut based on how she responded." ... When she began to become incohebased on how she responded." ... When she began to become incoherent, they rent, they stopped. stopped. -- James W. WattsJames W. Watts

The lobotomy reduced her to an infantile mentality that left herThe lobotomy reduced her to an infantile mentality that left her incontinentincontinent and and staring blankly at walls for hours and her verbal skills were restaring blankly at walls for hours and her verbal skills were reduced to duced to unintelligible babbleunintelligible babble

She lived out her life in a Wisconsin institution and died at thShe lived out her life in a Wisconsin institution and died at the age of 86e age of 86

JFK Address to Congress 1963JFK Address to Congress 1963 ““A Bold New ApproachA Bold New Approach””

A national mental health program to assist inA national mental health program to assist inthe inauguration of a wholly new emphasisthe inauguration of a wholly new emphasisand approach to care for the mentally illand approach to care for the mentally ill

Focus on comprehensive community care Focus on comprehensive community care

We need a new type of health care facility; one which will We need a new type of health care facility; one which will return mental health care to the mainstream of American return mental health care to the mainstream of American medicine, and at the same time upgrade mental health medicine, and at the same time upgrade mental health servicesservices

I recommend, therefore, that the Congress: I recommend, therefore, that the Congress: Authorize grants to the states for the construction of Authorize grants to the states for the construction of comprehensive community mental health centerscomprehensive community mental health centers

Authorize short term project grants for the initial staffing cosAuthorize short term project grants for the initial staffing coststs

CMHC Construction Act of 1963CMHC Construction Act of 1963

The Mental Retardation Facilities and CMHC The Mental Retardation Facilities and CMHC Construction Act signed on October 31, 1963Construction Act signed on October 31, 1963

Ended 109 years of federal noninvolvement in Ended 109 years of federal noninvolvement in state services for the mentally illstate services for the mentally ill

Congress refused to authorize funds to hire staff Congress refused to authorize funds to hire staff for CMHCsfor CMHCs

Less than a month later President Kennedy was Less than a month later President Kennedy was assassinatedassassinated

CMHC Construction Act of CMHC Construction Act of 19631963

President Johnson signs amendments in President Johnson signs amendments in 1965 that provide staffing grants1965 that provide staffing grants

Accomplished out of sentiment for JFKAccomplished out of sentiment for JFK

In 1965 mental health catchment areas of In 1965 mental health catchment areas of 75,000 to 200,000 people all over the 75,000 to 200,000 people all over the country began applying for federal grantscountry began applying for federal grants

Program based on federal seed money Program based on federal seed money grantsgrants

Local communities applied for federal funds that Local communities applied for federal funds that declined over several yearsdeclined over several years

Alternative funds like thirdAlternative funds like third--party payments were party payments were expected to replace declining federal grantsexpected to replace declining federal grants

Rise of the CMHCRise of the CMHCProvide five essential servicesProvide five essential services

Inpatient servicesInpatient services

Outpatient servicesOutpatient services

Day treatmentDay treatment

Emergency servicesEmergency services

Consultation and education services Consultation and education services

Ensure continuity of care between the servicesEnsure continuity of care between the services

Be accessible to the general populationBe accessible to the general population

Serve people regardless of their ability to payServe people regardless of their ability to pay

“…“…a reasonable volume of services to the indigenta reasonable volume of services to the indigent””

New RequirementsNew Requirements No New FundingNo New Funding

In the early 1970In the early 1970’’s Richard Nixon tried to discontinue the program s Richard Nixon tried to discontinue the program but was rebuffed by the Democratic Congressbut was rebuffed by the Democratic Congress

In 1974 Gerald Ford vetoed the extension of the Community MentalIn 1974 Gerald Ford vetoed the extension of the Community MentalHealth ActHealth Act

Existing centers were supported by congressional continuing resoExisting centers were supported by congressional continuing resolutions lutions until a new bill could be developed until a new bill could be developed

In 1975 another extension was also vetoed by Ford on the groundsIn 1975 another extension was also vetoed by Ford on the groundsthat it was too expensive but Congress overrode the veto by a withat it was too expensive but Congress overrode the veto by a wide de marginmargin

Congress passed amendments that added more requirements for the Congress passed amendments that added more requirements for the mental health centers but did not appropriate the funds necessarmental health centers but did not appropriate the funds necessary to y to pay for the newly required services or to cover even half of thepay for the newly required services or to cover even half of the country country in the time frame initially envisionedin the time frame initially envisioned

Services for children, the elderly, and chemically dependent perServices for children, the elderly, and chemically dependent persons as well sons as well as rehabilitation, housing, and preventive servicesas rehabilitation, housing, and preventive services

Failure to Meet GoalsFailure to Meet GoalsAfter 1975 no new construction was attempted due After 1975 no new construction was attempted due largely to prohibitive costslargely to prohibitive costs

Actual federal dollars were reduced while inflation more than Actual federal dollars were reduced while inflation more than doubled the cost of construction and staffing costsdoubled the cost of construction and staffing costs

Most CMHCs were focused on primary and secondary Most CMHCs were focused on primary and secondary prevention programsprevention programs

Crisis clinics and hot lines to prevent mental illnessCrisis clinics and hot lines to prevent mental illness

Staff more interested in insight oriented psychotherapy than in Staff more interested in insight oriented psychotherapy than in case management and rehabilitation case management and rehabilitation

Severely mentally ill persons leaving state hospitals did Severely mentally ill persons leaving state hospitals did not receive follownot receive follow--up services necessary to live in the up services necessary to live in the communitycommunity

CMHCs and CMHCs and DeinstitutionalizationDeinstitutionalization

Between 1955 and 1980 theBetween 1955 and 1980 thepopulation of state mental hospitalspopulation of state mental hospitalsdropped from 558,000 to 140,000 dropped from 558,000 to 140,000

Were these people better off out of state Were these people better off out of state hospitals?hospitals?

Funds from the states that were supposed to follow Funds from the states that were supposed to follow patients from the hospital into the community did not patients from the hospital into the community did not provide sheltered housing and treatmentprovide sheltered housing and treatment

Poverty, homelessness, and criminalization resultedPoverty, homelessness, and criminalization resulted

Community Support Community Support ProgramsPrograms

CSPs were the NIMHCSPs were the NIMH’’s response to the unmet needs of the CMIs response to the unmet needs of the CMI

By 1982 most of the states had received some sort of community By 1982 most of the states had received some sort of community support planning help for CMHCssupport planning help for CMHCs

Case managementCase management

Psychosocial rehabilitationPsychosocial rehabilitation

Supported livingSupported living

Supported workingSupported working

Crisis careCrisis care

New evidenceNew evidence--based practices (EBP)based practices (EBP)

Assertive Community TreatmentAssertive Community Treatment

Reassessment of theReassessment of the CMHC ProgramCMHC Program

1977 Presidential Commission on 1977 Presidential Commission on Mental Health chaired by First Mental Health chaired by First Lady Rosalyn CarterLady Rosalyn Carter

Persons with chronic mental illness Persons with chronic mental illness who had been deinstitutionalized who had been deinstitutionalized lacked the basic necessities of life lacked the basic necessities of life including adequate housing, clothing, including adequate housing, clothing, and foodand food

Half of the people released from large Half of the people released from large mental hospitals were being mental hospitals were being readmitted within a year of dischargereadmitted within a year of discharge

National Mental Health National Mental Health Systems Act of 1980Systems Act of 1980

An effort to reinvigorate the CMHC program and redirect An effort to reinvigorate the CMHC program and redirect it to those with chronic mental illnessit to those with chronic mental illness

Restructure federal, state, and local relationships allowing theRestructure federal, state, and local relationships allowing thestates more control of the management and distribution of states more control of the management and distribution of federal funds coming to local programsfederal funds coming to local programs

Give priority to vulnerable groups such as the chronically Give priority to vulnerable groups such as the chronically mentally ill, children, adolescents, and the elderlymentally ill, children, adolescents, and the elderly

Signed one month before Carter lost the election to Signed one month before Carter lost the election to ReaganReagan

Withdrawal of Federal GovernmentWithdrawal of Federal Government ““New FederalismNew Federalism””

Reagan promises to reduce government Reagan promises to reduce government waste and regulation and to return waste and regulation and to return responsibility for many social programsresponsibility for many social programsto the statesto the states

The Omnibus Budget Reconciliation Act of 1981The Omnibus Budget Reconciliation Act of 1981

Repealed the Mental Health Systems Act of 1980Repealed the Mental Health Systems Act of 1980

Eliminated all of the federal initiatives of the previous 18 yeaEliminated all of the federal initiatives of the previous 18 yearsrs

Eliminated all of the 10 federal regional offices of NIMHEliminated all of the 10 federal regional offices of NIMH

Lack of capacity to supervise and provide technical assistance tLack of capacity to supervise and provide technical assistance to o surviving federal CMHCssurviving federal CMHCs

Withdrawal of FederalWithdrawal of Federal GovernmentGovernment

OBRA 1981OBRA 1981Withdrew direct federal grant support from CMHCsWithdrew direct federal grant support from CMHCsand replaced it with block grants to the statesand replaced it with block grants to the states

Returned primary authority to states to decide howReturned primary authority to states to decide howand to whom mental health services should be provided and to whom mental health services should be provided

Ceased to make official use of the term Ceased to make official use of the term ““community community mental health centermental health center”” to describe a unique entityto describe a unique entity

Only 754 of a possible 1,500 eligible catchment areas Only 754 of a possible 1,500 eligible catchment areas nationwide had applied for and received funding for CMHCsnationwide had applied for and received funding for CMHCs

CMHCs increased fees and reduced staffing and CMHCs increased fees and reduced staffing and servicesservices

Waiting lists developedWaiting lists developed

Service quality decreasedService quality decreased

MedicaidMedicaidCreated in 1965 to provide health insurance for Created in 1965 to provide health insurance for lowlow--income parents, children, seniors, and income parents, children, seniors, and people with disabilitiespeople with disabilities

Supplemental Security Income established in Supplemental Security Income established in 1972 provided welfare to those disabled due to 1972 provided welfare to those disabled due to mental illnessmental illness

By the 80's all CMHCs switched to Medicaid and By the 80's all CMHCs switched to Medicaid and away from block grant moneyaway from block grant money

CMHCs of TodayCMHCs of TodayCMHCs have survived but service priorities and the locus of contCMHCs have survived but service priorities and the locus of control have rol have changedchanged

CMHCs remain the only option for mental health treatment for lowCMHCs remain the only option for mental health treatment for low income income uninsured peopleuninsured people

CMHCs have had to use revenues from a patchwork of funders to coCMHCs have had to use revenues from a patchwork of funders to cover the ver the costs of caring for uninsured and underinsuredcosts of caring for uninsured and underinsured

Paying patientsPaying patients

Federal governments Federal governments

State governments State governments

Local governmentsLocal governments

Fund raisingFund raising

Availability of services have steadily decreased in the last tweAvailability of services have steadily decreased in the last twenty yearsnty years

Individuals often sit on waiting lists for extended periods or aIndividuals often sit on waiting lists for extended periods or are turned awayre turned away

CMHC programs and deinstitutionalization were implemented CMHC programs and deinstitutionalization were implemented without evidence of effectiveness of treatments and without a sowithout evidence of effectiveness of treatments and without a social cial welfare system for the disabled mentally illwelfare system for the disabled mentally ill

Communities lacked availability ofCommunities lacked availability of

Supported housingSupported housing

Community treatment approachesCommunity treatment approaches

Vocational opportunitiesVocational opportunities

Income supports Income supports

Many became homelessMany became homeless

Many became incarceratedMany became incarcerated

Out of the AsylumOut of the Asylum Into the CellInto the Cell

CMHCs could not handle the hugeCMHCs could not handle the hugenumbers of patients who had beennumbers of patients who had beenreleased after spending months orreleased after spending months oryears in the large institutionsyears in the large institutions

“Nowhere in our society is the debacle of deinstitutionalization felt more than in our criminal justice system. America’s jails and prisons are now surrogate psychiatric hospitals for thousands of individuals with the severest brain diseases.”

Treatment Advocacy Center Briefing Paper. Criminalization of individuals with severe psychiatric disorders. 4/2007

1010--16% of US inmates have serious psychiatric illnesses 16% of US inmates have serious psychiatric illnesses like schizophrenia, bipolar disorder and disabling like schizophrenia, bipolar disorder and disabling depressiondepression

HindsightHindsight

HindsightHindsight““Many of those patients who left the state hospitals never Many of those patients who left the state hospitals never should have done so. We psychiatrists saw too much of should have done so. We psychiatrists saw too much of the old snake pit, saw too many people who shouldn't the old snake pit, saw too many people who shouldn't have been there and we overreacted. The result is not have been there and we overreacted. The result is not what we intended, and perhaps we didn't ask the what we intended, and perhaps we didn't ask the questions that should have been asked when developing questions that should have been asked when developing a new concept, but psychiatrists are human, too, and we a new concept, but psychiatrists are human, too, and we tried our damnedest.tried our damnedest.””

Dr. Robert H. Felix, past director of the NIMH and a major figurDr. Robert H. Felix, past director of the NIMH and a major figure e in the shift to CMHCsin the shift to CMHCs

HindsightHindsight''The psychiatrists involved in the policy making ''The psychiatrists involved in the policy making at that time certainly oversold community at that time certainly oversold community treatment... the policies were based partly on treatment... the policies were based partly on wishful thinking, partly on the enormousness of wishful thinking, partly on the enormousness of the problem and the lack of a silver bullet to the problem and the lack of a silver bullet to resolve it, then as now.'' resolve it, then as now.''

Dr. John A. Dr. John A. TalbottTalbott, past president of the American , past president of the American Psychiatric AssociationPsychiatric Association

HindsightHindsight““The result was like proposing a plan to build a The result was like proposing a plan to build a new airplane and ending up only with a wing and new airplane and ending up only with a wing and a taila tail…… Congress and the state governments Congress and the state governments didn't buy the whole program of centers, plus didn't buy the whole program of centers, plus adequate staffing, plus longadequate staffing, plus long--term financial term financial supports.supports.””

Dr. Jack R. Dr. Jack R. EwaltEwalt, directed the staff of the Joint , directed the staff of the Joint Commission when it was founded in 1955Commission when it was founded in 1955

CMHCs in IowaCMHCs in Iowa

Iowa is a prime example of what President Iowa is a prime example of what President Bush's New Freedom Commission on Mental Bush's New Freedom Commission on Mental Health meant when it reported that the nation's Health meant when it reported that the nation's mental healthcare system is "fragmented and in mental healthcare system is "fragmented and in disarray." It must be among the most convoluted disarray." It must be among the most convoluted mental health systems in the country.mental health systems in the country.

For individuals who are not Medicaid eligible, the state's 99 coFor individuals who are not Medicaid eligible, the state's 99 counties unties provide services, through a combination of state funds and countprovide services, through a combination of state funds and county y funds, derived primarily from local taxesfunds, derived primarily from local taxes

Iowa's counties follow a policy known as "legal settlement" whicIowa's counties follow a policy known as "legal settlement" which h requires that individuals be county residents, and free of the nrequires that individuals be county residents, and free of the need eed for mental health services for at least a year before their new for mental health services for at least a year before their new county county is responsible for paying. These restrictions often lead to inoris responsible for paying. These restrictions often lead to inordinate, dinate, potentially catastrophic delays in getting services when they arpotentially catastrophic delays in getting services when they are e needed.needed.

Iowa's mental health system is in serious trouble. The state neeIowa's mental health system is in serious trouble. The state needs to ds to move forward with a bold restructuring of its mental health systmove forward with a bold restructuring of its mental health systemem……

Transforming the Mental Health Transforming the Mental Health System in Iowa System in Iowa -- March 2007March 2007

We have 99 counties making 99 different decisions.We have 99 counties making 99 different decisions.

Some provide little or no mental health assistance short of Some provide little or no mental health assistance short of institutionalization.institutionalization.

Some provide a significant and inclusive array of services.Some provide a significant and inclusive array of services.

The result is grossly unfair, with service based on geography The result is grossly unfair, with service based on geography rather than need.rather than need.

Who is Eligible for County Who is Eligible for County Funded Mental Health Services?Funded Mental Health Services?

Counties fund services at CMHCs for low income uninsured peopleCounties fund services at CMHCs for low income uninsured people

Counties designate Central Point Coordinators (CPCs) to serve as single points of entry into the mental health system

Determine who is eligible for county funded services

Determine which services will be provided

One of the only state mandated services for those with mental illness is inpatient treatment

Outpatient psychiatry, psychotherapy and medications are optional

Each county has different criteria for determining who is eligibEach county has different criteria for determining who is eligible for servicesle for servicesClinical CriteriaClinical Criteria

Financial CriteriaFinancial Criteria

Legal Settlement CriteriaLegal Settlement Criteria

Clinical CriteriaClinical Criteria

Primary diagnosis ofPrimary diagnosis of

Mental IllnessMental Illness

Chronic Mental IllnessChronic Mental Illness

Mental RetardationMental Retardation

Brain InjuryBrain Injury

Developmental DisabilityDevelopmental Disability

Does not include a primary diagnosis of substance use Does not include a primary diagnosis of substance use disorderdisorder

Financial EligibilityFinancial Eligibility Criteria (Johnson County)Criteria (Johnson County)

Income that is equal to or less than 250% of the Income that is equal to or less than 250% of the federal poverty levelfederal poverty level

Single person $26,000/yearSingle person $26,000/year

Two person household $35,000/yearTwo person household $35,000/year

Resources that are equal to or less than $2,000 Resources that are equal to or less than $2,000 for a singlefor a single--person household or $3,000 in for a person household or $3,000 in for a multimulti--person householdperson household

Legal Settlement CriteriaLegal Settlement CriteriaMust have legal settlement in a County to get County fundingMust have legal settlement in a County to get County funding

If a client does not have legal settlement in the County where tIf a client does not have legal settlement in the County where they hey reside, services can still be fundedreside, services can still be funded

County of legal settlement will be billedCounty of legal settlement will be billed

OrOr

State payment program will be billedState payment program will be billed

Albert Bierstadt's Oregon Trail, 1869

What does Johnson County What does Johnson County Cover?Cover?

Initial psychiatric or therapy evaluation and as many therapy anInitial psychiatric or therapy evaluation and as many therapy and psychiatry d psychiatry appointments as needed for 90 daysappointments as needed for 90 days

After 90 daysAfter 90 daysOne psychiatric visit per quarter for medication managementOne psychiatric visit per quarter for medication management

Up to two therapy sessions per monthUp to two therapy sessions per month

GenericGeneric medications in six classesmedications in six classesAnticonvulsantsAnticonvulsants

AntidepressantsAntidepressants

AntipsychoticsAntipsychotics

ParkinsonParkinson’’s medicationss medications

SedativeSedative--hypnoticshypnotics

StimulantsStimulants

Lab work not coveredLab work not covered

CMHCs in IowaCMHCs in Iowa

Number of CMHCs in Iowa = 32Number of CMHCs in Iowa = 32--42?42?

Definition of a CMHCDefinition of a CMHC

CMHCs provide local outpatient services to CMHCs provide local outpatient services to mentally mentally needyneedy individuals residing or working individuals residing or working in a catchment areain a catchment area

No clearly defined mandated or core servicesNo clearly defined mandated or core services

CMHCs in Iowa 2008

Mid-Eastern IowaIowa City

Abbe CenterCedar Rapids

BridgeviewClinton

Vera FrenchDavenport

Counseling AssociatesKeokuk

HillcrestDubuque & Jackson

ResCareFairfield

HillcrestWashington

RichmondAmes

Black Hawk-GrundyWaterloo

Southern IowaOttumwa

Berryhill CenterFt. Dodge North Iowa

Mason City

BackboneManchester

Northeast IowaDecorah

Center AssociatesMarshalltown

Covenant ClinicWaverlyNorthwest BH

/SeasonsSpencer

Creative LivingRock Valley

SiouxlandSioux City

PlainsLeMars

West IowaDenison

Psychiatric AssocCouncil Bluffs

MyrtueHarlan

Southwest IowaAtlantic (no BG)

West CentralAdel

Eyerly BallChild GuidanceCrossroads

CrestonWaubonsieClarinda

CapstoneNewton New Directions

Oskaloosa

TamaToledo

PoweshiekGrinnell

ResCareMuscatine

CounselingServices &Howard Center (No BG)Sac City

Cedar Valley/PathwaysWaverly

Burgess MHCMonona

Behav Health Southern IALeon

Lucas Cty Health Center Chariton

Davis County Health(No BG)

Alegent BHMissouri Valley

Community Mental Health Center Community Mental Health Center for Midfor Mid--Eastern IowaEastern Iowa

507 E. College Street 505 E. College Street

CMHC for MidCMHC for Mid--Eastern IowaEastern Iowa4040thth AnniversaryAnniversary

Private nonPrivate non--profit agencyprofit agency

Serves Johnson, Cedar, Serves Johnson, Cedar, and Iowa Countiesand Iowa Counties

Serves 2,500 individuals, Serves 2,500 individuals, couples, and familiescouples, and families

CMHC for MidCMHC for Mid--Eastern IowaEastern Iowa List of ServicesList of Services

Psychiatry Psychiatry -- 3.5 FTE3.5 FTE’’ssCounseling and PsychotherapyCounseling and PsychotherapyIntensive psychiatric rehabilitation servicesIntensive psychiatric rehabilitation servicesPlay therapyPlay therapyHomeless Outreach (PATH)Homeless Outreach (PATH)School Liaison ProgramSchool Liaison ProgramSupported Community LivingSupported Community LivingClubhouseClubhouseFamily Services (PACE Program)Family Services (PACE Program)Emergency ServicesEmergency ServicesConsultation and EducationConsultation and Education

CMHC for MidCMHC for Mid--Eastern IowaEastern Iowa Funding SourcesFunding Sources

33% services covered by Johnson County33% services covered by Johnson County33% Medicaid 33% Medicaid 23% Private insurance23% Private insurance20% Medicare20% Medicare9% services covered by the State Payment 9% services covered by the State Payment ProgramProgram8% services covered by other8% services covered by othercountiescounties

CMHC for MidCMHC for Mid--Eastern IowaEastern Iowa Diagnoses of ClientsDiagnoses of Clients

Depressive Disorders 49% Depressive Disorders 49% Anxiety Disorders 16%Anxiety Disorders 16%Bipolar 11%Bipolar 11%ADHD 8% ADHD 8% Schizophrenia & Psychotic Disorders 6%Schizophrenia & Psychotic Disorders 6%Schizoaffective Disorders 3%Schizoaffective Disorders 3%PTSD 2%PTSD 2%Autistic Spectrum 1%Autistic Spectrum 1%Impulse Control 1%Impulse Control 1%Other 4%Other 4%

Role of the Psychiatrist at Role of the Psychiatrist at CMHCsCMHCs

Role of the PsychiatristRole of the PsychiatristAt first, CMHCs were primarily directed by psychiatristsAt first, CMHCs were primarily directed by psychiatrists

CMHCs led by psychiatrists

1971 >50%

1980 <20%

1985 < 8% (Knox 1985)

Emphasis at CMHCs put on prevention and social Emphasis at CMHCs put on prevention and social engineeringengineering

““Psychiatrists were considered too elitist, too expensive, and toPsychiatrists were considered too elitist, too expensive, and too o removed from the realities of social changeremoved from the realities of social change”” Sharfstein, S. S. (2000).Sharfstein, S. S. (2000).

Relegated to medication managementRelegated to medication management

Role of the PsychiatristRole of the PsychiatristNumbers of psychiatrists, psychologists and Numbers of psychiatrists, psychologists and nurses decreasednurses decreased

Numbers of master's level workers increasedNumbers of master's level workers increased

By the 80By the 80’’s a number of changes led to a s a number of changes led to a moderate increase in psychiatrists at CMHCs moderate increase in psychiatrists at CMHCs

Discharged mentally ill patients needed psychiatric Discharged mentally ill patients needed psychiatric evaluations and adequate treatmentevaluations and adequate treatment

Growth of psychopharmacologic treatmentGrowth of psychopharmacologic treatment

Medical issuesMedical issues

Role of Psychiatrists TodayRole of Psychiatrists TodayMedication checksMedication checks

1515--30 minutes30 minutes

LeadershipLeadership

Grant to support Medical DirectorsGrant to support Medical Directors

Psychiatric shortagePsychiatric shortage

TelemedicineTelemedicine

Circuit RidersCircuit Riders

Resident RotationResident RotationStarted July 2007Started July 2007

Residents rotate half day/week for 6 months in Residents rotate half day/week for 6 months in the 3the 3rdrd year at Midyear at Mid--Eastern Iowa CMHCEastern Iowa CMHC

Exposure to the CMHC environment and teamExposure to the CMHC environment and team

Community Psychiatry TrackCommunity Psychiatry Track

ConclusionsConclusionsThe CMHC program was developed toThe CMHC program was developed to

Provide mental health services to all who need them regardless oProvide mental health services to all who need them regardless of financial meansf financial means

Provide care to the seriously mentally ill leaving state hospitaProvide care to the seriously mentally ill leaving state hospitalsls

CMHCs were unable to meet the demands of deinstitutionalization CMHCs were unable to meet the demands of deinstitutionalization due todue toInadequate fundingInadequate funding

Lack of coordination with state mental hospitalsLack of coordination with state mental hospitals

Absence of a support system for the chronically mentally illAbsence of a support system for the chronically mentally ill

Today CMHCs continue to be the mental health safety net for the Today CMHCs continue to be the mental health safety net for the uninsured and uninsured and underinsured in designated catchment areasunderinsured in designated catchment areas

Funding for services comes from a Funding for services comes from a complicatedcomplicated patchwork system of insurers patchwork system of insurers including federal, state and local government agenciesincluding federal, state and local government agencies

CMHCs and care of the mentally ill are at the mercy of the politCMHCs and care of the mentally ill are at the mercy of the politics of the eraics of the era

The CMHC system in Iowa is no exceptionThe CMHC system in Iowa is no exceptionFunding of services at CMHCs varies significantly by countyFunding of services at CMHCs varies significantly by county

No set of core services at CMHCs are mandatedNo set of core services at CMHCs are mandated

Change We Can Believe In?Change We Can Believe In?Identify core safety net services and require that Identify core safety net services and require that CMHCs provide those services in order to be CMHCs provide those services in order to be accreditedaccredited

Remove county property tax dollar caps and Remove county property tax dollar caps and determine funding responsibility for safety net determine funding responsibility for safety net servicesservices

Implementation of EBPsImplementation of EBPs

Emergency Mental Health Crisis Service SystemEmergency Mental Health Crisis Service System

Address Workforce ShortageAddress Workforce Shortage

ReferencesReferencesCutler, D. L., Cutler, D. L., BevilacquaBevilacqua, J., & McFarland, B. H. , J., & McFarland, B. H. (2003). Four decades of community mental health:(2003). Four decades of community mental health:A symphony in four movements.A symphony in four movements. CommunityCommunityMental Health Journal, 39Mental Health Journal, 39(5), 381(5), 381--398. 398. Dixon, L., & Goldman, H. (2004). Forty years of Dixon, L., & Goldman, H. (2004). Forty years of progress in community mental health: The role of progress in community mental health: The role of evidenceevidence--based practices.based practices. Administration and Policy inAdministration and Policy inMental Health, 31Mental Health, 31(5), 381(5), 381--392. 392. Feldman, S. (2003). Reflections on the 40th anniversary of the UFeldman, S. (2003). Reflections on the 40th anniversary of the US community mental S community mental health centers act.health centers act. The Australian and New Zealand Journal of Psychiatry, 37The Australian and New Zealand Journal of Psychiatry, 37(6), (6), 662662--667. 667. NAMI. Grading the States: A Report on America's Health Care System for Serious Mental Illness, published March 1, 2006.Sharfstein, S. S. (2000). Whatever happened to community mental Sharfstein, S. S. (2000). Whatever happened to community mental health?health?Psychiatric Services (Washington, D.C.), 51Psychiatric Services (Washington, D.C.), 51(5), 616(5), 616--620.620.U.S. Department of Health and Human Services. U.S. Department of Health and Human Services. Mental Health: A Report of the Mental Health: A Report of the Surgeon GeneralSurgeon General——Executive SummaryExecutive Summary. U.S. Department of Health and Human . U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services AdministratServices, Substance Abuse and Mental Health Services Administration, Center for ion, Center for Mental Health Services, National Institutes of Health, National Mental Health Services, National Institutes of Health, National Institute of Mental Institute of Mental Health, 1999. Health, 1999.