SNAPSHOT:

Maine's Mental Health System

Disability Rights Maine 24 Stone St, Suite 204 Augusta, ME 04330

800.452.1948 ● advocate@drme.org

May 2017

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Contents Introduction ..................................................................................................................................... 3

Survey Methodology ....................................................................................................................... 4

Demographics ................................................................................................................................. 5

Housing ........................................................................................................................................... 7

DRM Analysis ............................................................................................................................ 7

Consumer Housing Comments ................................................................................................... 8

Employment .................................................................................................................................... 9

DRM Analysis ............................................................................................................................ 9

Consumer Employment Comments. ......................................................................................... 11

Mental Health Services ................................................................................................................. 12

DRM Analysis .......................................................................................................................... 12

Consumer Mental Health Services Comments ......................................................................... 14

Medication Management .............................................................................................................. 14

DRM Analysis .......................................................................................................................... 14

Consumer Medication Management Comments. ...................................................................... 15

Crisis ............................................................................................................................................. 16

DRM Analysis .......................................................................................................................... 16

Consumer Crisis Services Comments. ...................................................................................... 17

Peer Support .................................................................................................................................. 18

DRM Analysis .......................................................................................................................... 18

Consumer Peer Support Comments. ......................................................................................... 18

Transportation ............................................................................................................................... 20

DRM Analysis .......................................................................................................................... 20

Consumer Transportation Comments. ...................................................................................... 21

Recommendations and Conclusions ............................................................................................. 23

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INTRODUCTION Disability Rights Maine, Inc. (DRM) is an independent, private, nonprofit agency that protects and advocates for the rights of Maine citizens with disabilities. In 2016 Disability Rights Maine conducted a survey intended to be a non-scientific snapshot in time of the Maine mental health system. The intent of the survey was to go directly to consumers to learn of their experiences regarding mental health services in Maine. DRM’s goal in conducting this survey was to ensure DRM’s advocacy in the mental health system for both resource development and the quality of services continues to reflect the actual needs of those accessing those resources. This report presents the results of that survey that was conducted throughout Spring-Fall 2016. DRM Managing Attorney Kevin Voyvodich conducted a number of outreach visits around the state during this time period to directly distribute this survey to consumers. The report will consist of the statistical results with DRM comment and analysis and consumer anecdotal experience and commentary for each of the relevant sections. Then, it will provide conclusions and recommendations. The hope is that going forward this snapshot can help to inform advocates, state officials, and policy makers of questions to ask and potential strategies on how to create a quality, consumer driven, mental health system.

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SURVEY METHODOLOGY DRM conducted this survey in a number of different mediums and forms. Below is the methodology that DRM used in conducting this non-scientific snapshot in time of consumer access to and availability of services: 1. DRM geared the questions to the AMHI Consent Decree1 reporting of unmet needs. DRM

used the categories of unmet needs to create the categories of questions. 2. DRM had hired a professional to screen the questions for consumer accessibility and validity. 3. DRM had the survey available online, on both the DRM Website and the Consumer Council

System of Maine website, for pickup by providers, consumers, and consumer groups. Further, DRM conducted outreach with the surveys throughout the state.

4. DRM conducted in-person survey distributions at the 2016 Hope Conference, peer centers, and a crisis stabilization unit.

5. DRM conducted in person outreach with surveys at the following locations: Augusta, Bangor, Biddeford, Caribou, Livermore Falls, Portland, Presque Isle, and Rumford.

6. After receiving 230 surveys, DRM hired a professional analyst to review and compile the data.

1 Information on the AMHI Consent Decree can be found here: http://drme.org/assets/brochures/CD-Presentation.pdf

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DEMOGRAPHICS DRM Analysis

In examining the current statistics, two areas particularly stand out. One is the lack of any response from Washington County. In Washington County there was no clear hub for DRM to have conducted in-person outreach related to the survey.2 DRM obtained at least one response from every other county in Maine. This leads DRM to question whether there are potential resource or service gaps in Washington County which lead to a less cohesive mental health service system in that area. The most recent available Consent Decree reporting unmet needs data combines the major service center of Penobscot County with Hancock, Washington and Piscataquis Counties which leads to the conclusion that a greater examination of Washington County mental health resources may be needed in order to examine any potential service/resource gaps for that population.

The second data element that stands out is that 61% of those that provided their age were 40 or over, including 32% being over 50 years old. In looking at this data, one question that bears

2 http://www.maine.gov/dhhs/samhs/mentalhealth/wellness/documents/PeerRecoveryCenterContactList.pd

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45

50

Respondent Analysis (County)

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further examination is what effect the aging of those accessing mental health services in the community will have on this system. This is consistent with the population of Maine as a whole.3 A question that this creates is how the mental health system will respond to this population’s aging in combination with their need for mental health services. Studies earlier in the decade have shown that there is a national workforce shortage.4 This leads to a question of how those services in Maine compare to the national averages. Further examination of that specific issue was outside the scope of this survey but appears needed.

3 “Maine’s population has the highest median age in the United States.” http://www.maine.gov/dhhs/oads/trainings-resources/documents/STATEPLANONAGING2016-2020DRAFT.pdf. 4 https://www.samhsa.gov/capt/tools-learning-resources/mental-health-substance-use-older-adults.

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70

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Respondent Analysis (Age)

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20-29

30-39

40-49

50-60

61 and Over

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HOUSING DRM Analysis A number of issues stand out in this data. First, 34% of those who completed the survey did not live in their own home or apartment. This is despite the survey not specifically targeting hospitals or residential facilities. In 2015, a report to the Maine Legislature by the Maine State Housing authority cited the lack of affordable housing in Maine for low income individuals.5 The agency for Substance Abuse and Mental Health services has cited lack of access to housing as a barrier to recovery.6 It is important to highlight that a relatively high number of individuals do not live in their own house or apartment. Secondly, of note was the underutilization of the Bridging Rental Assistance (BRAP)7 vouchers, particularly in the homeless population where it is most needed. There is clearly a disconnect between the 42 individuals on a waiting list for housing assistance and only 5 individuals identified as using the BRAP program. The potential underutilization of this program for individuals with mental illness may bear further examination.

5 http://digitalmaine.com/housing_docs/15/. 6 http://www.maine.gov/dhhs/samhs/mentalhealth/housing/brap/. 7 Id. “BRAP is designed to assist individuals with housing assistance for up to 24 months or until they are awarded a Housing Choice Voucher (aka Section 8 Voucher), another federal subsidy, or alternative housing placement.”

65.4%

12.6%

4.2%

0.9% 0.9%

12.6% 3.3%

Housing Analysis (Place of Residence)

Own House/Apartment

Family/Friends

Group Home

Nursing Home

AssistedLiving Facility

Homeless

Other

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Consumer Housing Comments: The following is a sample of comments from consumers. "Not enough affordable housing." (Various iterations of this comment were made by

multiple respondents)

"It's such a long wait and the method of contacting should be worked on." ""Low income" housing can be very expensive to people on disability benefits. Not

enough section 8 vouchers available." "In Portland there isn't enough [housing] and [it's] too expensive."

"The forms are very complicated to fill out when trying to get assistance. Each place has

their own form and takes time to fill them all out. [It] would be nice if they could have one standardized form."

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Homeless OwnHouse/Apartment

Family/Friends

Nursing Home AssistedLiving Facility

% o

n W

aitin

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ist f

or H

ousi

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ssis

tanc

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Living Status

Waiting List for Housing Assistance

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EMPLOYMENT DRM Analysis The number of people who currently want to be working is 112 or 65% of those who answered the question. This is striking when compared to knowledge about job programs that could assist individuals returning to work. Many were not aware of the variety of employment services offered. The majority of “unemployed” respondents wanted to work (56%).8 Many unemployed individuals appear to be volunteering (based on comments). 45% of individuals in their own apartments/houses were working. That is much higher than any other housing category, including group homes. The second highest employment rates were for those “living with family or friends” at 30%. Then group homes in third, at 22%. Why aren’t more people in group homes employed? When examining the awareness number individuals in groups homes want to work at the same levels as those in independent housing, have the same awareness of vocational rehabilitation,9 yet fewer people in group homes are working. There is also data leading to the appearance of a correlation between housing and employment. 75% of individuals who were homeless wanted to be working, but 96% were unemployed.

8 The survey asked about consumer awareness of certain employment related services. Respondent numbers on awareness of services are: Vocational Rehabilitation 104, Career Planning Assistance 47, Benefits Counseling Services 44, Ticket-to-Work Program 47, Job Search Skill & Services 46, Employment Services 56, Clubhouse Services 36. 9 54% awareness of vocational rehabilitation services in their own apartment and house versus 56% awareness in a group home.

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5

10

15

20

25

Employment Analysis (Currently Employed)

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Yes, 65% No, 10%

No Response, 26%

Do You Want to be Employed?

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15

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30

Employment Analysis (Unemployed Who Want to be Working)

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Consumer Employment Comments: The following is a sample of comments from consumers. “I volunteer in five or six positions right now and I am currently waiting to hear back

from two employers.” “I volunteer over 30 hours a week.”

“Finding employment with a mental illness is nearly impossible unless you want to

volunteer.” “I need to work on going back to school before I try to go back to work.”

“Waiting to hear from benefit person. Hope I'm not doing all this training for nothing - if

I am 1 cent over - I lose! Don't know yet if it's worth the bother.” “There is a breakdown in disability that makes it nearly impossible to get out from under

and able to work, despite the available programs if you are disabled and a parent. You can't afford to work and lose benefits besides the money, to cover the cost of your health.”

“Opportunities are fewer than people realize. Many do not understand the caustic nature

between services and employment /volunteering.” “Jobs are scarce. I filled out 80+ apps last year.”

“I have physical, mental, and developmental disabilities. Not much help for people with

all three.” “Using the Career Center is very overwhelming and complicated. Every time I went in

for a class, it was not useful for me. When I asked questions, I was referred to my VR counselor. The processes were very slow so that by the time I got services, I was not doing well from the stress of not working. When people are ready to work is when they need the assistance. Having everyone go through a process at VR is difficult as well. Wasted a lot of time taking tests and classes before actually getting me set up with an agency to begin working on finding a job.”

“I have been on a waiting list for 4 years. I have been asking for job assistance since

2007. I still do not have help, as I am told there is no help in the Penobscot area.” “Just lost my job due to my memory loss. Not sure what I could do for work.”

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MENTAL HEALTH SERVICES DRM Analysis In examining the responses in this section three issues stood out: individual experiences with services, denials of services, and whether a consumer is referred to other services when attempting to access services. Of those who responded, 23% of those individuals had experienced some type of wait time for services, including 15 individuals who waited 3 months or more for services. Additionally, denials of services appear relatively common (see the denials section). This leads to the question of whether individuals are being appropriately linked with the correct services or are being denied based on other factors. Another data point is that of the 43 individuals waitlisted for services, fewer than 50% or 15 individuals stated that they had been referred to other services while waiting. This leads DRM to question whether it is lack of availability of alternative providers or the lack of incentive for providers to refer to a different, currently available service.

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3-6 Months 6-12 Months More Than a Year

Mental Health Services Analysis (Wait Times)

Case Management

Daily Living Support Services(DLS)

Assertive Community Treatment(ACT Team)

Community Support Services

Community Rehab Services

Peer Support Services

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0

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10

15

20

25

30

35

Mental Health Services Analysis (Denials)

Case Management

DLSS

ACT Team

Community SupportServices

Community RehabServices

Yes, 15

No, 22

Mental Health Services Analysis (Were you referred to other services while

waiting?)

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Consumer Mental Health Services Comments: The following is a sample of comments from consumers. “There needs to be more assertive care - individual care. The system expects a disabled

person to manage their own care, be it medical, housing, or money management.” “I am currently homeless and have to go to the ER for my medication. The wait for

counseling and med management is over 3 months.” “We NEED section 17 and community integration.”

MEDICATION MANAGEMENT DRM Analysis 22% of the respondents reported that they had at some point been on a waitlist for medication management services. Maine is a rural state with a large number of people living in those rural areas compared to the rest of the country.10 Of the 74 respondents who were on some type of waitlist for medication services 47% of those individuals reported waiting over a month for those services. Medication management can be a key service for those with serious and persistent mental illness.11 A side by side comparison of two counties using a provider ratio tool created by the Robert Wood Johnson Foundation, one that is a service hub and one that is not, shows that there can be disparities in provider availability based on the rural nature of Maine.12 DRM questions any cut in rates for medication services and believes that any consideration of cutting Medicaid rates for medication management in particular should be considered carefully due to the core nature of this service. Further, wait times and lack of rural availability lead to a conclusion that providers need strategies to reach rural consumers effectively.

10 http://www.maine.gov/dhhs/mecdc/healthy-maine/documents/HealthyMaine2020_2-25.pdf “In the United States, 653% of all counties are in Nonmetropolitan or Rural counties, yet only 16.7% of the nation’s residents reside in them In Maine, 11 of the 16 counties (or 68.8%) are in nonmetropolitan counties with 4.6% of residents living in these areas.” 11 http://www.mayoclinic.org/diseases-conditions/mental-illness/basics/treatment/con-20033813. 12 http://www.countyhealthrankings.org/app/maine/2016/compare/snapshot?counties=23_005%2B23_011%2B23_025 (Comparison of Mental Health Provider rations in Kennebec 240:1 versus Somerset counties 620:1).

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Consumer Medication Management Comments: The following is a sample of comments from consumers. “When I moved to Augusta from Portland I kept my doctor because he is awesome, he is

a geriatric psychiatrist which are hard to find and from my professional experience I know a good doc is harder than a needle in a haystack, so my wife drives me to Portland to see him. They are scarce in Kennebec.”

“Was receiving services close to home (about 10 miles away). That provider left the

agency and they did not replace her. Had to travel to Bangor which takes about 45 min and if I am more than 5 minutes late, they reschedule. This is not helpful! Ended up changing providers. Another issue is getting transportation for these 15 minute appointments-MaineCare balks at providing this for such a short appointment.”

“Sometimes I have to wait for medication approval from DHHS and I have to go off my

medication for some time like a week or 2.” “My psychiatrist at our local mental health center has retired with no replacement. I see a

nurse practitioner once every three month - mostly for med management.” “I have always traveled for psychiatric services. To find someone who I can see for more

than 15 minutes, is not a pill pusher and I can have a relationship is very hard to find. It is worth it to travel, but wish there were more providers that did more than just

Over a Month, 47% Less than a Month,

53%

How Long Have You Been Waiting for Medication Management?

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prescribing.” “My clinician stopped seeing adults so I stopped receiving services and stopped being

medicated.” “Without MaineCare there is no way to afford the medication.”

CRISIS SERVICES

DRM Analysis According to the most recent report from DHHS regarding Crisis Services, 65.3% of all initial face-to-face contacts were in the Hospital Emergency Departments.13 According to those who answered this question in the survey, 49% expressed that it was only somewhat or not helpful. This leads DRM to question what could change in the crisis system to both improve client experience and prevent possible unnecessary hospitalization. Further, according to the same report cited above from the Department, 56.3% of adult crisis interventions end up in the Emergency Department within 8 hours of the initial contact with crisis services. While this number is not directly connected with the 49% cited from this survey, it does lead DRM to question whether a decrease of crisis interventions in hospital emergency departments would lead to a better consumer experience. The Federal Substance Abuse and Mental Health Services Administration cited mobile crisis as having an advantage over facility environments.14 All of the above factors lead DRM to ask whether crisis services could be improved to safely resolve crises more consistently in a lesser restrictive environment? Consumer feedback on Crisis Stabilization units was generally positive in the comments section and according to SAMHSA, can have positive outcomes as well.15

13 http://www.maine.gov/dhhs/samhs/mentalhealth/consent_decree/august-2016/section-12_Crisis_Report_Qtr4-2016.pdf. 14 http://store.samhsa.gov/shin/content/SMA09-4427/SMA09-4427.pdf “Mobile outreach services, which have the capacity to evaluate and intervene within the individual’s natural environment, have inherent advantages over facility-based crisis intervention.” 15 Id. “When intervention within an individual’s normal living environment is not feasible, hospitalization is not the inevitable alternative; for many individuals facing civil commitment, consumer-managed crisis residential programs can represent a viable, more normalized alternative that produces good outcomes.”

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Consumer Crisis Services Comments: The following is a sample of comments from consumers. “I think the CSU are helpful and many crisis workers are very helpful.”

“The crisis service was very helpful. They talk with you.”

“If you talk or vent, they tend to just to stick you in the hospital which is not helpful.”

“Telephone crisis service put me on hold.”

“I believe the significant delay in response availability is a significant disservice to

consumers. Crisis workers are not able to assess while a person is still in crisis. They generally arrive after the person in crisis has exhausted themselves and presents as calm. They encourage consumers to go to an emergency room, incurring additional expenses while not telling them this will drop them to the bottom of the priority list as they are in a safe place, resulting in a much longer wait.”

“Crisis is the last thing I want to happen. I would fear being admitted and medicated

against my will. I always try to utilize other options instead.” “I wouldn't have gotten the help I need if they were not there. But the wait time creates

its own stress.” “ER/ICU crisis was helpful in the recommendation of a stabilization unit rather than

hospital.” “When I received services the wait was long.”

Somewhat/Not Helpful, 49% Helpful, 51%

Were the Crisis Services Helpful?

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PEER SERVICES DRM Analysis DRM sees a trend in all of the peer support numbers that individuals want peer support, want more information on types of peer support, and 69% of those who responded would try peer support if it were available in their area. The one anomaly is that the positive responses to the quality of the warmline were equal to the somewhat or not helpful responses. This may simply be due to the small sampling as a larger study showed specific positive results for warmline users.16 The consumer responses below also show a significant number of positive experiences with peer support.

Consumer Peer Support Comments: The following is a sample of comments from consumers.

“It is very helpful.”

“I think it’s great that there are people out there willing to do that work.”

“Peer support sounds good and I'd like to learn more about it. I'd like to participate in

Peer Support soon if possible.” “I would like to see more peer support. Such as a peer buddy program.”

16 https://www.ncbi.nlm.nih.gov/pubmed/21768081 Sustaining recovery through the night: impact of a peer-run warm line. This study surveyed 480 warmline callers over 4 years finding a positive impact of warmline services for consumers.

Yes, 69%

No, 31%

Would You Try Peer Supports if They Were Available in Your Community?

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“Others would if they knew what it actually is at its core. It has been the one most

influential life transforming recovery lasting element in my life.” “It is helpful to me.”

“Get good support at social club and socialization.”

“Social club is very helpful to people in our area. Good Support.”

“My peer support center is a lot of help to me. Like being there for me when I am in

crisis.” I have enjoyed coming to make friends, peer support, activities, and learning.”

“I enjoy going as I meet peer members, do activities, and travel.”

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TRANSPORTATION DRM Analysis Out of 173 who responded to the question of access to the MaineCare NET (Non-Emergency Transportation) transportation,17 only 37% state that they have access to this form of transportation. This leads DRM to question what the current barriers are to use this service. DRM further questioned transportation received from case managers, group home, nursing home, and hospital staff. Only 40% of consumers surveyed reported receiving assistance with transportation from any one of the other providers18 Examination of current rates paid in this setting that include transportation costs is needed to see if there potentially more access to transportation from providers in these settings. Further, the quality of these services bears close monitoring as seen in the comments and criticisms from consumers in the section below.

17 http://www.maine.gov/dhhs/oms/nemt/nemt_index.html 18 Case managers 39%, Residential 12%, Nursing Home 2%, Hospital Staff 11%

No, 62%

Yes, 38%

Do You Have Access to MaineCare NET Services?

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Consumer Transportation Comments: The following is a sample of comments from consumers. “When I have appointment to go to the hospital I have at times no rides.”

“I'm happy to have my own car because [the transportation provider] transportation is

very unreliable. I've been left at appointments for as long as 2 hours and picked up 10-15 minutes before an appointment - it was a 50 minute trip.”

“The bus is helpful.”

“The group home and my peer support and my rehab support gets me around.”

“I walk.”

“Our transportation system in Maine is non-user friendly.”

“No transportation in our area.”

“Not always available when my appointments are scheduled.”

“Buses should be run later.”

“I would like more options for rides for services I may need to go to.”

0%2%4%6%8%

10%12%14%16%18%20%22%24%26%28%30%32%34%36%38%40%

Received Transportation Services from Providers

Case Manager

Residential/Group Home Staff

Nursing Home Staff

Hospital Staff

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“Sometimes it's hard to get in the van because of my weight.”

“If I didn't have support of family, I wouldn't have reliable transportation.”

“I have staff that takes me to appointments, shopping, peer support club and to work. My

mom takes me when I have no staff.” “I have a worker that takes me around and I have my mom to take me when I have no

staff.” “I take RTP for appointments, but my Catholic Charities worker takes me to the store,

etc.” “If I could get someone to sit in the passenger seat (who has a license) and practice

driving to the “city” with me it would help. I can't because I already have a valid license. I just need a bit more support in this area to help me through anxiety.”

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RECOMMENDATIONS AND CONCLUSIONS Based on the above statistics and the anecdotal information and DRM’s analysis of this information, DRM makes the following recommendations regarding further necessary information, areas needing additional focus for resource development, and potential areas for quality improvement within the system based on consumer feedback:

1. Demographics: Further exploration of rural counties, in particular, Washington County. Due to

the lack of any peer center or other clear mental health service center it was difficult to obtain any data from those regions and none was received via other mediums such as the internet and mail. This leads DRM to recommend that specific rural counties such as Washington and Piscataquis County be closely examined to determine the current unmet needs for mental health resources.

The survey respondents were largely represented by those over 40 years old. As stated in the analysis, Maine as a whole is an aging state. Consumers of mental health services are also aging and will need specialized services in conjunction with their mental health services. DRM believes there needs to be an increased focus on geriatric services for individuals with mental health issues. The focus needs to on those with both medical and mental health needs being integrated into the least restrictive appropriate environment. Given the Olmstead requirements of community integration and the AMHI Consent Decree requirements of living in the least restrictive appropriate environment, all avenues of quality, accessible, integrated mental and physical healthcare should be explored. Unfortunately SAMSHA reports a national workforce shortage for this population.19 Therefore Maine needs to strategize on how to develop these resources.

2. Housing: The BRAP program must be better utilized. The numbers in this section suggest

that there is an underutilization of the BRAP voucher particularly in the homeless population. Better education about housing subsidy programs and outreach to target populations is needed going forward to address statewide unmet needs.

Based on the housing numbers, consumer anecdotal information, and the report by the Maine State Housing Authority to the legislature in 2015, all possible avenues to affordable, accessible housing should be explored going forward.

19 https://www.samhsa.gov/capt/tools-learning-resources/mental-health-substance-use-older-adults.

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Consumers in group homes and other restrictive environments must be assisted in moving to lesser restrictive environment. Many people are living in unnecessarily restrictive environments for decades.

3. Employment: Discussing employment during treatment planning meetings must be documented

and reported to SAMHS Agencies must collect data on which clients are working, how many hours, how

much they earn, and submit this info to SAMHS Agencies must provide more training and information for all agency staff on

employment services available to their clients. Agency staff often discourage clients interest in work and provide incorrect information on employment services. Agencies must strengthen their ability to have good conversations about jobs and work, not discourage interest with incorrect/incomplete info. 20

The state should target specific MH agencies and counties with lower awareness numbers for training.

Lack of access to health care is a major employment barrier. All opportunities for increased access to healthcare should be pursued.

4. Mental Health Services:

One area warranting increased attention is the need for agencies to refer out to other agencies to increase when they do not have the service capacity. DRM recommends that requirements be in place that they must refer to other agencies if they are the initial contact point.

The AMHI Consent Decree requires that all class members be approved for a termination of service under paragraph 69. DRM recommends any data collected related to this or any other type of tracking of discharges is used to improve quality of services and reduce involuntary discharges from services.

DRM currently monitors the Department’s efforts to decrease client wait times under the AMHI Consent Decree. DRM recommends continued focus on decreasing service wait times for critical adult mental health services.

20 Some helpful training programs already exist. For example, Maine Medical Center’s Benefits Counseling Program did a series of trainings for residential staff, support staff, etc. and it was super popular and well received. It was called a “benefits navigator” training, and aimed to encourage more positive discussions about employment by helping staff figure out how to answer basic questions, understand resources, and reduce misunderstandings about work and benefits.

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5. Medication Management

Any rate cuts to medication management services should must closely examined to see how it will affect access to this critical service. In particular, before any rates are cut, the direct effect on rural areas of Maine should be examined.

Wait times for medication management services should be examined more closely to determine how to both reduce wait times, and prioritize those with severe and persistent mental illness leaving institutions who require this service in order to live in the least restrictive appropriate environment.

6. Crisis Services

DRM recommends that crisis services be examined with a goal of reducing the first contact with crisis services being in the emergency department.

Alternative crisis contact points should be explored. Mobile crisis and other alternative crisis contact points should become a priority for the adult mental health system.

Alternatives to hospitalization such as short term, voluntary crisis units should become a priority to see if further resource development should occur.

Crisis agencies should be held to standards that require consistent successful outcomes for clients that reduce utilization of hospitalization.

7. Peer Support

DRM recommends that consumer and peer groups be provided with additional resources in order to increase peer education and resource outreach efforts. Consumers in this survey consistently stated they wanted more information about peer support and would like to access this peer support in their community.

8. Transportation

Transportation barriers to the Maine Care NET transportation should be studied and improved access to Maine Care recipients should be implemented.

Based on consumer feedback the quality of contracted transportation services must be improved.

Services such as community integration that have a certain amount of travel built into their current Maine Care rates should provide. Currently consumers are denied transportation even though it is a provided service.