Mental Health Services in Maine: A Blueprint for Action

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1 Mental Health Services in Maine: A Blueprint for Action Executive Summary Mental illness and services for people with mental illness and their families have been the focus of considerable debate for decades. Maine has been under court order (the AMHI Consent Decree) for 20 years because of a series of deaths at what was then, the Augusta Mental Health Institute. Despite years of effort and considerable attention, the terms of the decree have yet to be met. In the current economic climate, all spending is in question. Millions of dollars have been cut and more will be cut in Despite the overwhelming evidence that mental illness and substance abuse are the leading causes of illness and disability in the U.S. they are rarely mentioned within the context of healthcare reform and frequently mentioned when cutting is proposed. NAMI-Maine recognizes that its constituency individuals with serious and persistent mental illness (SPMI) and co-occurring disorders and their families is but one group of people with disabilities who are at risk because of the deteriorating economy. It is paramount to bear in mind that many people with mental illness are caught in a trap within a trap. First, these individuals exist in too- often abject poverty. 90% are unemployed. Those who could work cannot, for fear of losing MaineCare and the services it provides. Without services relapse to serious illness is guaranteed and serious illness would make them unable to work. Second, within that culture of poverty, those with a mental illness are increasingly unable to access the supports and treatment necessary for Recovery. Many cycle between their homes, involvement with the police, jail, the emergency room, and the street. There is no doubt that people with mental illness are disproportionately affected by the recent rounds of budget cuts and curtailments and no doubt that they are disproportionately represented in the correctional and justice systems when they are not able to access treatment. 1 Despite the overwhelming evidence that mental illness and substance abuse are the leading causes of illness and disability in the U.S. they are rarely mentioned in the context of healthcare reform and frequently mentioned when cutting is proposed. 1 NAMI Maine The Tipping Point. Pg. 10 1

2 This white paper is presented with that recognition and a willingness to work with any and all groups seeking to find common solutions. We can think of no other illness, that when left untreated, contributes so greatly to the cost of public safety. We cannot, however, think of any other population for whom the failure to provide treatment, supports and services has such a devastating impact not only on the individuals directly affected, but on costs and the entire service system. One contributor to this is the state s budget process, which looks at department by department spending, or program by program spending, but not how reductions in one place, increase spending in another as shown so clearly on Figure 1, page 13. We can think of no other illness that when left untreated, contributes so greatly to the cost of public safety. NAMI, as will become evident in this paper, is not interested in simply providing a laundry list of the problems. We are offering well reasoned solutions that we believe will save money and improve outcomes. They are based on years of collective knowledge and experience and with full cognizance of the risks and challenges ahead. NAMI fears that the state will react to effects and deficits, rather than address the underlying causes and conditions that make health care so very expensive. We offer this document in an effort to describe the problem AND offer solutions. Wherever we can, we have added information that estimates potential cost savings. NAMI believes we must: Assess the role of state operated services in the mental health system, focusing specifically on their effectiveness, efficiency, and cost. Assure that persons have access to appropriate community-based care when and where they need it. Develop and implement early screening and preventative services to reduce the occurrence and severity of mental health conditions and the need for more costly and more restrictive interventions. Collect and use meaningful performance data and focus on outcomes outcomes that provide timely access to effective services and services that improve the condition of the person over time. NAMI Maine believes that a shift in what we fund will result in significant savings. The chart below shows the cost of some of Maine s treatment settings for people with mental illness. The institutional costs are from the Maine State Government Annual Report, Medicaid costs are current hourly rates or average costs cited from national studies. NAMI recognizes that the cost of care for one person is entirely different from the cost of care for another. Illness, acuity, age, and number of episodes of illness all affect individual costs. The chart below offers only a broad-brush view of what we are spending now and how a realignment of priorities could result in significant savings. For example, we know that community supervision of a high needs, 2

3 high risk juvenile would cost more than $7/day, but we suggest that there would be other individuals on community supervision who would provide balance. Service Cost/person/year Action Savings Riverview $348,159 ACT 2 instead $338,159/person Dorothea Dix $455,555 ACT instead $370,555/person Charleston Correctional $28,890 Shift to $7/day/person $26,335/person Jail Bed $7,665 ($21/day state rate); $36,500($100/day jail cost) Shift to $7/day/person plus ACT team No savings at state rate; $23,945/person at jail cost Downeast Correctional $37,097 $34,542/person Maine Correctional $25,771 $23,216/person Maine State Prison $44,934 $42,379/person Mt. View $105,659 $103,104/person Long Creek $91,903 $89,348/person PNMI Bed $116,000 Supported housing with day treatment instead ACT Team $10,000 Instead of PNMI; $81,070/person $106,000/person Instead Dorothea Dix of $445,555/person Adult Day Treatment $34,930 ($15.95/hrx6x365) Peer instead Center $31,459/person Crisis Intervention $6,340 ($317/hrx20) Peer supports $2,869/person Emergency Room Visit $1038/visit Peer supports $1028/person Peer Support Center $9.51/visit 2 ACT is Assertive Community Treatment, an evidence-based model recommended by the federal government. It provides community-based, intensive home-based services to people who are severely ill. A team of workers provides services 24 hours a day to a small case load of individuals. 3

4 NAMI Maine is making twenty-five recommendations for reform listed below. In addition, NAMI cannot overstate our belief that the state must change, discontinue, as much as possible, its direct service role, and concentrate on funding, policy, and outcomes, rather than the provision of direct service. Recommendations: 1. Parity. To stem the tide of entry into MaineCare and retain more people in the private insurance market, enforce and retain Maine s current parity law for private insurance. 2. Single license. Use licensing policy to fully integrate the provision of mental health, substance abuse, and physical healthcare. Focus on integrated care delivered by a medical home. 3. Managed care. We recommend that the managed care provider that is selected by the Sate to manage MaineCare, contract only with providers who provide integrated care. We also recommend that contracts be driven by outcome measurements. 4. Medicaid Buy-in. Assure that it supports the maximum number of people to return to work and use it as a tool to move people back to the job market. 5. Vocational and Pre-vocational focus. Encourage MaineCare Section 17 3 services to focus on return to work, independent living, and non-professional supports and affiliations 6. Incentives. Policymakers must create incentives for the expansion of the clubhouse model and other pre- and vocational services. 7. Close DDPC. NAMI recommends that a plan for DDPC s closure be developed, with close attention paid to the transition needs of its patients. The development of cost-saving permanent supported housing and ACT type services is essential for this plan to succeed. 8. Section 17 services. Further reduce the need for hospital beds by expanding access to psychosocial supports. NAMI recommends that the 24 hour community-based crisis service system be supplemented by requiring that Medicaid Section 17 (community support services) be mobile and provided 24 hours a day using shifts. 9. Duplication of Effort. NAMI recommends that the state identify all state government delivered case management services to determine if they (l) cost more than privately delivered case management and/or (2) overlap with privately delivered case management. 10. Contracts. Link the contracting process and the single license recommended earlier to encourage community hospitals to provide local psychiatric beds for people in their communities. 3 Section 17 are MaineCare rules that govern and pay for home-based and intensive community supports for people with severe and persistent mental illness. These services are crucial to a person s ability to remain stable and out of crisis. 4

5 11. Incentives for landlords and providers. Encourage Section 17 providers to develop cooperative agreements with local landlords who offer housing to people who are receiving ACT, intensive case management, and other supports. Offer tax or other business-based incentives to landlords and providers who participate in these efforts. 12. Housing assistance. BRAP and Shelter Plus 4 care are cornerstones of assisting people to return to permanent housing following an illness or relapse or when family members can no longer maintain them in their homes. Funding for these programs must be a priority, as included in Court Master Wathen s recent report Revive Recommendations. The 1998 State Department of Corrections Community Corrections plan should be reviewed and its recommendations adopted. Funding for needed reforms/services included in that report could come from closing one or more of Maine s correctional institutions. This would require an assessment of prisoner risk levels and strenuous individualized planning for those at low risk. 14. Community Options. Evaluate the current Board of Corrections plan for the consolidation of jails and the prison system to make sure there is sufficient programming to reduce recidivism and sufficient attention to the needs of county jails. 15. Release Data. Use the data that was collected during the stand down in to assess the current status of inmates with mental illness and make a plan based on those numbers. 16. Action Team. Create a cross-system action team (corrections, mental health, substance abuse, etc.) that can be available 24-7 to develop, implement, and review plans of action for high-needs, high-risk inmates and those at risk in the community, to build cross system responsibility for outcomes. 17. Courts. Use the Kennebec Co-occurring Court as a model for how courts can address the needs of high-use, repeat offenders. Expand this model, which was started without new funding, to other Maine courts. 18. Review of reductions. Review internal DHHS reports that document how cuts have been proportioned across programs and services over the recent past and establish policy that will equalize those reductions, instead of targeting one class of disease/disability over others. 4 Shelter Plus Care is a 5 year federal housing subsidy for people who are homeless; BRAP is a general fund supported housing subsidy for people who are on waiting lists for Section 8 (federally subsidized) housing. 5 Court Master Wathen s June 25, 2010 report called for adding $995,000 for additional BRAP funding for FY 12 and beyond. 6 The Maine Department of Corrections did a one-day snapshot in Maine s jails, counting the actual numbers of inmates with mental illness. They called it the stand down. 5

6 19. Service review. Ensure that essential services are available to class and non-class members who meet the MaineCare clinical criteria for eligibility. NAMI recognizes that funding reductions will most certainly affect what services can be provided. We encourage DHHS to focus on evidence-based and promising practices, reduced variations in treatment practice, expanded availability of ACT and other treatments that produce cost-savings and improved health outcomes, and use of low-and no-cost, low-no barrier peer and family supports as effective and cost effective alternatives. 20. Housing and Vocational Supports First. The system that supports people with mental illness, must focus on housing and vocational supports first. 21. Accurate budgeting. Ensure that budget requests accurately reflect the documented needs, particularly the unmet needs of both class and non-class members. 22. Decree revisions. Encourage the Plaintiffs, Defendants, and Court Master to meet and consider modifications to the original decree so that it is responsive to current practice, needs and outcome-based service delivery. 23. Peer and Family Supports. Retain existing peer and family support services that provide direct support and enforce current requirements that service providers educate their clients about and refer them to these supports. Dedicate federal mental health block grant funds to these services. 24. Screening. Reinstate the school-based screening for young people for sucidality and behavioral health problems. 25. Access to psychosocial treatments. NAMI Maine recommends that policy makers make an effort to modify the regulations that guide what services are covered so that access to medications does not take precedence over access to psychosocial treatments and people are easily able to obtain both the medications they need and the treatment they need to remain stable. 6

7 A Blueprint for Action INTRODUCTION Maine and the nation face critical economic challenges. State revenue shortfalls have deepened and Maine has been forced to re-evaluate its programs and services, including those available to people with disabilities. Despite spending a significant portion of the state budget on healthcare and social services, the infrastructure developed over decades, is fragmented, in disarray and increasingly unable to meet the needs of growing numbers of people who are out of work and who have healthcare needs. Services can be delivered more effectively and efficiently. If we can t build the best mental health system, we can certainly build a better one. NAMI-Maine recognizes that its constituency individuals with serious and persistent mental illness (SPMI) and cooccurring disorders and their families is but one group of people with disabilities who are at risk. This white paper is presented with that recognition and a willingness to work with any and all groups seeking to find common solutions. We cannot, however, think of any other population for whom the failure to provide appropriate treatment, supports and services has such a devastating impact not only on the individuals directly affected, but also on costs and the entire service system. Services can be delivered more effectively and efficiently. If we can t build the best mental health system, we can certainly build a NAMI, as will become evident in this paper, is not interested better one. in simply providing a laundry list of the problems. We are offering well reasoned solutions, based on years of collective knowledge and experience, and with full cognizance of the risks and challenges ahead. NAMI fears that the state will react to effects and deficits, rather than address the underlying causes and conditions. We offer this document in an effort to describe the problem AND offer solutions. In December 2009, NAMI published a white paper, The Tipping Point, which cited four indisputable facts: 1. Mental illness and substance abuse are the leading cause of death and disability in Maine, most often in conjunction with other illnesses. 2. Mental health services in Maine are fragmented, disconnected and inaccessible to many. 3. Cutting MaineCare disproportionately affects individuals with mental health treatment needs. 7

8 4. The reduction of funding for mental health treatment, supports and services pushes more people into an already overburdened public safety system ultimately costing more than the early intervention and treatments that are not funded. NAMI is convinced that substantive system change will: Provide vital supports and services to individuals with serious and persistent mental illness (SPMI) and co-occurring disorders and their families; Create ongoing cost savings and improve quality of care and health outcomes; Improve service system efficiencies; Decrease the cost of and stress on jails, prisons, hospital emergency departments, municipalities, police departments, and homeless shelters; Strengthen and increase the use of peer and family provided services; Reduce the direct service role of government as much as possible, leaving policy development, funding, licensing, and outcomes oversight as their core function. Re-structure the community health system to be mobile and available 24 hours a day. NAMI recognizes that facing and overcoming the challenges ahead will take unprecedented determination and cooperative effort. The system currently in place is unworkable, inefficient and exorbitantly expensive. We have no choice but to rethink and rebuild Maine s mental health system; to do otherwise flies in the face of reason. Any short term gains in cost savings will, without a long term, well considered plan, result in costs that cannot be borne by the people of Maine. We are in crisis and we are at the crossroad. The choices we make now will determine our future. NAMI believes that we can make the right choices. A BRIEF HISTORY Reduce the direct service role of government as much as possible, leaving policy development, funding, licensing, and outcomes oversight as their core function. Maine Citizens with mental illness and their families have been the subject of discussion and debate for years. The Augusta Mental Health Institute was built in 1842, directly across the Kennebec River from the Capital. The site was specifically chosen so that the Governor and the Legislature would be able to monitor the wellbeing of AMHI s patients. Over the ensuing decades, new on-site buildings were commissioned to meet a perceived growing need for asylum-treatment. Census peaked at about 1,300 patients in the 1950 s. In the 1960 s, the increased use of psychotropic medications coupled with the growth of Medicaid funding provided the foundation for what we have come to think of as the community mental health system. By 1986, the community system was, then as now, fragmented and inadequate. The Stone Building at AMHI, designed to house 220 patients, ended up as a refuge and dumping ground. The census reached over 450 patients at one point contributing to the deaths of 10 residents and prolonged and expensive litigation. In 1990 the State entered into the AMHI 8

9 Consent Decree (Bates vs. DHHS). During this same time, a serious economic recession forced Maine and other states to shift funding of mental health services to Medicaid. Until the advent of disproportionate share mental health services were funded with general fund dollars. Once those costs shifted to MaineCare and disproportionate share 7, general fund dollars allocated to mental health disappeared into the deficit. Twenty years later, the State has yet to reach substantial compliance with the terms of the settlement agreement, even though most of the hospital beds are closed and the focus has shifted to a great extent to the community system of care. We will discuss the AMHI settlement agreement again later. Between 2006 and 2009, $48 million dollars was cut from the community mental health system THE PAST SEVERAL YEARS Between 2006 and 2009, $48 million dollars was cut from the community mental health system: programs have closed, there are just 92 inpatient beds at Riverview, people have lost their services, community mental health workers have lost their jobs, but no data has been collected to document the impact of these reductions. Yet, compelling changes are evident. In 2008 Maine s Attorney General studied the increased number of cases of the use of deadly force by police officers involved in psychiatric crises. Between 2004 and 2006, Maine conducted several studies of the needs of inmates in Maine s jails and prisons and the cost of caring for those with mental illness. 8 In 2010, Maine s First Lady and Maine s Chief Justice issued a call to action by forming the Juvenile Justice Task Force. Their report tells the tale: Maine cannot afford to lose one more of its young people to prison and jails, to homelessness, to hopelessness. Maine s response to juveniles in our communities is in urgent need of improvement. The future for disconnected youth, those who have dropped out of school is bleak. The Juvenile Justice Task Force envisions system-wide reform that will dramatically improve the futures of Maine s youth (June 2010, USM Muskie School of Public Service) 9. A multi-year effort to build treatments for youth with mental illness/emotional disorders has been deeply affected by cuts that closed residential beds for young people without putting something else in place and established state-run gate-keeping that further delayed or denied community-based interventions. NAMI staff is deluged with calls from clients and family members desperate for help. We talk daily to service providers, police department personnel, jail personnel, advocates and peer-organization members, among others, who express serious concern about the plight of the people they serve and an ever-growing frustration at their inability to meet their needs; this is 7 Disproportionate Share provides special federal funding to hospitals who treat significant populations of indigent patients , the Sentencing Commission Report; 2006, the Corrections Alternative Commission Report 9 75% of Maines incarcerated youth have mental health, substance abuse, and trauma related diagnoses. 9

10 particularly true for those who do not have MaineCare, those that are dual eligible (MaineCare and Medicare), and those that refuse treatment because they do not know they are ill. 10 After two decades of progress, with significant attention to meeting the terms of the Consent Decree, the mental health system so many have labored to develop, flawed though it is, is disintegrating. Interestingly enough, a warning about what could happen if the community mental health system was not adequate is contained in the state s 2000 plan to build the Riverview Psychiatric Center. That plan was clear, unless the community system of care increased, the number of beds at Riverview would be inadequate and jails will be full of inmates with mental illness and nowhere to treat them. 11 WHAT CAN BE DONE? PARITY AND INTEGRATED CARE Maine s parity law is one of the most comprehensive in the nation. But, people with small group and individual insurance (except for those enrolled in Maine s Dirigo Health) will spend, $25,000 on average for any mental health related illness in their family, while people with physical illness in their family will spend just $1, Despite our best efforts, full insurance parity has been elusive and families of and people with severe and persistent mental illness are often forced into the Medicaid system to survive. People with mental illness die 25 years sooner than their peers, primarily of untreated physical illness. There is a national movement to change the way that we conduct the business of treating illness that involves recognizing that mental and physical illnesses co-exist and deserve the same treatment. We cannot afford to do otherwise. Faced with budget deficits, states across the nation are cutting healthcare spending, including support for people with mental illness. Even in the Medicaid program, parity of care has been eroded. 13 More and more people with serious mental health needs, already living in poverty, go without treatment, but they do not go without service. We all pay the price one place or another. One place that clearly pays the price is our jails and prisons as shown on the chart below. 10 Anosognosia, is the clinical term for one of the symptoms of some psychotic disorders. It is the inability to recognize that distorted thoughts and perceptions are part of an illness and not real. 11 SMRT, Inc. The Maine Psychiatric Treatment Initiative: Civil and Forensic. Final Report. February 29, Surgeon General s Report on Mental Health Medicaid basic/non-categorical waiver does not include full parity for mental health and substance use disorders. 10

11 Figure 1 - Actual Maine Spending Despite the overwhelming evidence that mental illness and substance abuse are the leading causes of illness and disability in the U.S. they are rarely mentioned within the context of healthcare reform and frequently mentioned when cutting is proposed. Despite a national call for the provision of integrated treatment 14, this neglect contributes significantly to the increasingly prevalent diversion of those with mental illness to the already over burdened public safety and criminal justice systems as well increased cost and poor outcomes of treatment. Recommendations: 1. Parity. To stem the tide of entry into MaineCare and retain more people in the private insurance market, enforce and retain Maine s current parity law for private insurance. According to the AHRQ s Reducing Costs in the Health Care System: Research in Action, Issue 9, three years after a state enacted a mental health parity mandate AND introduced a managed behavioral health care plan, costs for mental health/substance abuse care dropped 39 percent. 2. Single license. Use licensing policy to fully integrate the provision of mental health, substance abuse, and physical healthcare. Focus on integrated care delivered by a medical home. Phase out dual licenses and offer a single license which requires all providers to cover substance abuse, mental health, and physical health treatment. Allow them to make internal decisions about how they provide this integration. Along with this initiative, the massive, contradictory, and costly regulations that govern the provision of mental health services must be streamlined and reduced. 14 The Institute of Medicine s Quality Chasm reports consistently call for the integration of care as crucial to improved health outcomes. 11

12 3. Managed care. We recommend that the managed care provider that is selected by the state to manage MaineCare, contract only with providers who provide integrated care. Transfer the state s gatekeeper role for juveniles to the managed care entity. We also recommend that incentives be used to promote the provision of evidence-based and promising practice treatments, including psychosocial and other home and community based services that are known to prevent hospitalization and foster recovery. Maintain and involve the existing peer and family advocacy and ombudsman agencies and involve them in oversight, data collection, and feedback about the new managed care system. Focus on shared cost savings models which have incentives for integrated care, consumer satisfaction, improved independence, health status improvements (ie. reduced use of tobacco), recovery milestones, and normalized natural and community affiliations. The Lewin Group s Medicaid managed Care Cost Savings: A Synthesis of 24 Studies, updated in 2009, notes: states Medicaid managed care cost savings are largely attributable to decreases in inpatient utilization. A study of preventable hospitalizations in California found that the rates of preventable hospitalization were 38 and 25 percent lower in managed care than in FFS for the Temporary Assistance for Needy Families (TANF) and SSI populations, respectively. In Ohio s PremierCare program, inpatient costs decreased 27 percent under capitated Medicaid managed care, from $76 PMPM to $55 PMPM. 4. Medicaid Buy-in. Maine has had a Medicaid buy-in program for a number of years. It is time to examine this program and assure that it supports the maximum number of people to return to work. If they cannot obtain health care benefits in the jobs they take, the buy-in program must be there so that they can return to work and afford the services they need. 5. Vocational and Pre-vocational focus. Inadequate attention is paid to helping people with psychiatric illness to work or return to work. NAMI recommends that the provision of case management, day treatment, and other skill building programs funded through Section 17, be re-designed to identify vocational engagement, independent living, and nonprofessional community engagements and affiliations as key outcomes that a provider must be able to perform to be able to continue billing. 6. Incentives. Policy-makers must create incentives for the expansion of the clubhouse model and other pre-vocational and vocational programming into existing peer support centers and other service centers and use the Buy-in program as one of a number of mechanisms to assist people to return to work. DOROTHEA DIX PSYCHIATRIC CENTER (DDPC) The Dorothea Dix Psychiatric Center, licensed for 100, houses approximately 58 patients, most, if not all, can be served on a much more cost effective basis with appropriate community resources. DDPC is antiquated, expensive, structurally inefficient, and, NAMI believes, no 12 Closing DDPC would save $26,422,207 per year; Placing 85 individuals with an ACT team would cost $850,000 per year.

13 longer necessary. This is not a reflection on the quality of care and treatment provided by DDPC s staff. In these times, however, we cannot afford, nor is it necessary to provide asylum. Although we recognize the significant delays that occur now for people deemed in need of a psychiatric hospital bed, we believe that adequate access to mobile community-based treatment and crisis beds would prevent the need for these hospital beds. 15 Recommendations: 7. Close DDPC. NAMI recommends that a plan for DDPC s closure be developed, with close attention paid to the transition needs of its patients. Closing DDPC would save $26,422,207 per year; placing 85 individuals with an ACT team would cost $850,000 per year. As with Riverview, the development of cost-saving permanent supported housing and ACT type services is essential. Further, we recommend that some of the money saved from closing the hospital be shifted to funding for housing first (discussed later) and ACT type services. In 1999, a study of capitated ACT services was published by Daniel Chandler, et al (Psychiatric Rehabilitation Journal, spring 1999, Vol. 22 no. 4). The conclusion was that with a capitated ACT system, the per person gross costs were 25% lower and the net costs were 67% lower than the comparison group receiving traditional services through Alameda County (Calif.). The largest savings came from the reduction in clients recycling through and lengths of stay in hospitals. 8. Section 17 services. Further reduce the need for hospital beds by expanding access to psychosocial supports. NAMI recommends that the 24 hour community-based crisis service system be supplemented by requiring that Medicaid Section 17 (community support services) be mobile and provided 24 hours a day. State contracts should be amended to require this at no extra cost. NAMI recommends re-deployment of existing staff using shifts to cover expanded hours of care and rates that allow agencies to offer incentives to workers who take difficult shift hours. The purpose of these expanded hours is to reduce the use of emergency rooms and to provide an alternative to their use, specifically, additional access to the kinds of preventative care that is offered by the existing array of community mental health service providers. 9.Duplication of Effort. NAMI recommends that the state identify all state government delivered case management services (mental health, child welfare, etc.) to determine if they (l) cost more than privately delivered case management and/or (2) overlap with privately delivered case management. A plan to eliminate duplications and purchase the most cost effective care should result. These savings should be used to close the deficit and improve care. COMMUNITY HOSPITALS 15 It is important to note, however, that as predicted in the 2000 report on the need for inpatient psychiatric beds in Maine, failing to assure adequate community supports are in place will only mean additional delays in obtaining or leaving a hospital bed at additional cost. 13

14 NAMI asserts that acute care mental health needs can be met by existing community hospitals if sufficient community resources exist and the need for long-term acute care can be reduced. Community supports and services are more effective and cost efficient than often unnecessary long term hospitalization. If properly funded and implemented, community supports and services deter readmissions. Managed care, now under development in Maine s Medicaid program, saves money by reduced use of hospital beds. NAMI believes this can only succeed if adequate community supports are available. Though there are exceptions, where long term in-patient treatment is necessary, this could be the exception not the rule if community-based services were available. Though NAMI is aware of many years of effort to more important effectively utilize community hospital psychiatric beds, this issue must continue to be pursued. Recommendation: 10. Contracts. Link the contracting process and the single license recommended earlier to encourage community hospitals to provide local psychiatric beds for people in their communities. HOUSING FIRST The lack of affordable housing is a major issue for Maine citizens with mental illness, forcing them to sleep on the streets, under bridges, and in teeming homeless shelters. Homelessness is a stark, bleak existence for anyone. For a person with a mental illness, the lack of safe, affordable housing can be destabilizing and result in a hospitalization. Recovery becomes a daunting effort. Jails become the safety net. Homeless people with mental illness are not the only ones affected. As demonstrated in two ongoing Cost of Homelessness studies by McLaughlin, Mondello, et al, homelessness for those with mental illness places severe strains on hospital emergency departments, police and jails. As the most recent Cost of Homelessness reports 16 clearly and convincingly show the positive effects of providing housing are astounding. In the Greater Portland area, the provision of affordable housing to 99 study participants resulted in an average annual savings of $12,000 per person. The aggregate cost savings were: A 50% reduction in Service costs; A 46% reduction in Health Care costs; A 49% reduction in Emergency Department costs; An 87% reduction in costs associated with Incarceration; A 53% reduction in Ambulance Transportation costs; Housing First is a paradigm shift; it is one of the most recommendations included in this report. 16 Mondello, M. The Effectiveness of Permanent Supportive Housing in Maine. 10/2009. Wheeler, S. etal. Cost of Homelessness Benefit of Shelter Plus Care

15 A 51% reduction in Police contact costs. The Rural Maine component of the study demonstrated slightly less but still highly significant cost savings in rural areas. The differences are attributed to demographics. Housing First is a paradigm shift; it is one of the most important recommendations included in this report. Permanent supported housing is a major factor in participants ability to secure and maintain employment, further promoting recovery by decreasing service dependence. It should also be noted that at the Riverview Psychiatric Center lack of permanent supported housing is a major factor in the inability of RPC to discharge some patients within a reasonable time after a determination that an individual is clinically ready for discharge. This affects both civil and forensic clients alike, although for somewhat different reasons. In both populations however, the inability to discharge a patient for want of housing results in the loss of beds for those individuals needing and awaiting placement at RPC. Currently, adult PNMI 17 (residential care) beds cost on average $116,000 per bed per year. NAMI Maine believes that some people prefer this model of care, are appropriate for this level of care, and should be allowed to remain in this setting. However, flexible in-home support models, that allow people with behavioral health conditions to maintain control over their own leases is less costly, has a higher association with recovery outcomes, and allows people to chose their service provider, rather than having to receive services in exchange for housing. NAMI Maine believes that making housing and employment a priority for the community mental health system and organizing community supports around these issues will improve outcomes, foster recovery, reduce isolation and dependence, and save money. Recommendations: 11. Incentives for landlords and providers. Encourage Section 17 providers to develop cooperative agreements with local landlords who offer housing to people who are receiving ACT, intensive case management, and other supports. Offer tax or other business-based incentives to landlords who participate in these efforts and incentives to the providers who help people to obtain and maintain independent housing. 12. Housing assistance. BRAP and Shelter Plus care are cornerstones of assisting people to return to permanent housing following an illness or relapse or when family members can no longer maintain them in their homes. Funding for these programs must be a priority, as included in Court Master Wathen s recent report 18. CORRECTIONS AND MENTAL HEALTH 17 PNMIs are private non medical institutions, a category of Medicaid funding that pays for residential care. 18 Court Master Wathen s June 25, 2010 report called for adding $995,000 for additional BRAP funding for FY 12 and beyond. 15

16 Maine s prison system holds just over 2,000 inmates, at least 16% of whom have Serious and Persistent Mental Illness (SPMI). A recent grant allowed data to be collected about jail inmates with mental illness 19 ; that data has not been released, but could inform service development. Treatment for inmates is inconsistently available at best and varies widely from county to county, jail to jail, prison to prison. The list of problems associated with failing to provide even minimally consistent treatment, services, pre and post incarceration supports proven to reduce recidivism is long. The situation, already dire, worsens daily as jails change their missions, lose approval to operate above capacity, and struggle to address the mental and other health needs of inmates. In fact, in recent years, jails have had twice the number of deaths that the Augusta Mental Health Institute did in the late 1980s. This issue has been exhaustively studied, reports have been issued and informed recommendations have been made. Even so, few of the recommendations about conditions for inmates with mental illness have been enacted and conditions in the jails and the prison remain inadequate. NAMI receives calls every day from family members who have a loved one in jail who is not able to continue the treatment that stabilized them in the community. Conversations with Sheriffs and correctional officers demonstrate the frustration that is felt by all families and officers alike. Many states are changing how they provide care and are creating re-entry and corrections-based step down services for inmates with mental illness. In 1998, Maine s Community Corrections Plan called for increased attention to treatment, testing, and supervision as the best means to reduce recidivism. The plan called for applying a restorative justice model to all community-based initiatives, managing low risk offenders in the community rather than building institutional capacity, and creating a strong, comprehensive aftercare component to enhance community reintegration and prepare for release. Graduated sanctions, coordinated with the courts, were the final component of a plan to keep more people out of jail and prison. At the time that report was written, it concluded that juveniles were obtaining needed services. Since then budget cutting and DHHS gate keeping have contributed to growing numbers of juveniles entering the justice system and increased police involvement for families who cannot cope with the needs of their children with mental health and substance abuse problems. The Juvenile Justice Task Force recommended improvements that would prevent young Mainers from justice system involvement. Some of those have been addressed by legislation and planning is underway based on that legislation. In addition, the state is now engaged in consolidating the county jails and the prison system. These changes have created additional stress on the correctional system, the jails, and first responders. As long as corrections, the justice system, and jails are the largest provider of care for people with mental illness, NAMI Maine considers them a significant element of the system of care for people with mental illness and co-occurring substance use disorders. The chart below shows the cost of institutional care in Maine. It is presented with the recommendation that the state plan to reduce the use of institutions and shift dollars to community corrections linked with Medicaid funded treatments and supports, where costs are lower and outcomes better. Institutional care is the most expensive and should be the last resort. 19 A Department of Justice grant received by the DOC, funded a stand-down and collected a day-long snapshot in Maine s jails identifying all inmates with mental illness and/or co-occurring substance use disorder. 16

17 Facility and Bed Count Annual Cost (06-07 data) Per person/year Riverview Psychiatric-92 $32,030,611 $348,159 Dorothea Dix Psychiatric -58 $26,422,207 $455,555 Maine Correctional Ctr.-525 $22,137,294 $25,771 Maine State Prison-859 $38,598,047 $44,934 Charleston Correctional - 95 $2,744,593 $28,890 Downeast Correctional -149 $5,527,450 $37,097 Mt. View Youth Ctr $14,052,739 $105,659 Long Creek $14,980,253 $91,903 Recommendations: 13. Revive Recommendations. The 1998 State Department of Corrections Community Corrections plan should be reviewed and its recommendations adopted. Funding for needed reforms/services included in that report should come from closing one or more of Maine s correctional institutions. This would require an assessment of prisoner risk levels, individualized planning for those at low risk and increased efforts to build needed skills for release. A 2008 report by George Mason University calculated the cost of community corrections at $7/person/day, significantly less than the cost of incarceration, even at the State s minimum jail bed rate of $21/day. 14. Community Options. Evaluate the current Board of Corrections plan for the consolidation of jails and the prison system to make sure there is sufficient programming to reduce recidivism. Allowing inmates to remain in a jail as close to their home community as possible, to receive needed re-entry and post-booking diversion support, and using restorative practices have promise in reducing recidivism. Examine the ability of the jails to provide integrated care to their inmates and work with the local community service providers to identify and address the reasons that some inmates with serious mental illness and cooccurring substance use illnesses return. Jails report the cost of care for inmates far exceeds the rate paid by the state this should be examined. 15. Release Data. Use the data that was collected during the stand down to assess the current number of inmates with mental illness and make a plan based on those numbers. 17

18 16. Action Team. Create a cross-system action team (corrections, mental health, substance abuse, etc.) that can be available 24-7 to develop and review plans of action for high-needs, high-risk inmates and those at risk in the community, to build cross system responsibility for outcomes. Re-deploy existing staff and seek volunteer experts to serve. 17. Courts. Use the Kennebec Co-occurring Court as a model for how courts can address the needs of high-use, repeat offenders. Expand this model, which was started without new funding, to other Maine courts. Consider placing re-assigning existing state case mangers to the courts to foster diversion and re-entry efforts. One economic analysis in Washington State concluded that drug courts cost an average of $4,333 per client, but save $4,705 for taxpayers and $4,395 for potential crime victims, thus yielding a net cost-benefit of $4,767 per client. Another economic analysis in California concluded that drug courts cost an average of about $3,000 per client, but save an average of $11,000 per client over the long term. The Multnomah County Drug Court was found to cost less than business as usual for drug offenders, because probationers typically have multiple failed treatment experiences that are very expensive but elicit few gains. Factoring in cost-offsets from reduced arrests resulted in net savings of $6,744 per participant and $12,218 when victimization was also accounted for. THE AMHI SETTLEMENT AGREEMENT The AMHI Settlement agreement (Bates, et al vs. DHHS) commonly referred to as the AMHI Consent Decree was signed in 1990, making it 20 years old. The agreement created a class comprised of all individuals who were patients at the Augusta Mental Health Institute on or after January 1, Those individuals are referred to as class members. With the closure of AMHI in 1995, the Riverview Psychiatric Center became its equivalent for the purpose of class member status. The settlement agreement requires DHHS to develop and maintain a comprehensive mental health system to meet the actual, individualized needs of all class members in accordance with specified principals, including, but certainly not limited to: The availability of services, including hospitalization, when necessary, as close as possible to the class member s home; The right of class members to live in the community of their choice; The right to an individualized support plan (ISP) that specifies the series to be provided; DHHS is required to develop, fund, recruit and support community services in the following areas: Housing Residential Support Services 18

19 Crisis intervention and resolution services Vocational opportunities and training Treatment options Recreational/social/avocational opportunities Transportation Family support services. NAMI recognizes that DHHS and the Legislature have made progress toward reaching compliance and that achieving compliance has proven a challenge in the best of times. We are concerned, however, that regardless of the availability of funding, budget requests do not reflect the actual needs of both class and non-class members. Moreover, within the class itself, there is an apparent disparity between class members who meet MaineCare eligibility criteria both clinically and financially and those who are clinically but not financially eligible. In his October 29, 2008 ruling, Dan Wathen, Court Master, wrote that prior to the Fall of 2007, DHHS provided grant funding (general fund dollars) to class members who met the MaineCare clinical criteria but not the financial eligibility criteria. Reductions in grant funding through curtailments and cuts, made those grant dollars increasingly unavailable. DHHS assured the Legislature that, through grant funding, services would remain available to all class members regardless of MaineCare eligibility. The same was not true for non-class members. The Master s ruling further notes certain service ineligibilities for non-class members who are clinically but not financially MaineCare eligible. Among services that would not be grant funded for financially ineligible non-class members was medication management. The ruling cites sub-paragraph 32G of the settlement agreement: Non-class members shall not be deprived of services solely because they are not members of the Plaintiff class, and paragraph 37, which requires that the Comprehensive plan verify with supporting data that in meeting class members needs, Defendant s shall not deprive non-class members of services solely because they are not members of the class. The ruling further cites a Maine Supreme Court decision that community based services be administered, supported and made available with an even hand In his June 11, 2009 report, the master refers to the above findings and writes: The Department now avoids discrimination by denying services to class members and non-class members alike. While NAMI believes that budget requests should be based on actual need, regardless of class member s status and that it is DHHS responsibility to develop a budget that addresses real need, we recognize that there has been and continues to be significant deficits. Of concern is a recent and continued focus on reducing the cost of care for mental and substance use illness, rather than a focus on the cost of treatment for all chronic, relapsing illness for which the state is responsible. Cancer, diabetes, heart disease, asthma all are MaineCare cost drivers. It is the 19

20 job of DHHS to review spending on illness and modify programs, policies, rates, and services equally for all who have serious illness. There has been a drop in spending on mental health in the last five years that has not occurred in spending on other diseases. While we endorse the purpose and provisions of the AMHI Settlement Agreement, we are deeply concerned that, in the midst of economic crisis and a $1,000,000,000 projected deficit, that the focus will, again, be on mental health and the consent decree. A way must be found to ensure adequate supports and services to all individuals living with chronic illness, including those with mental illness who meet MaineCare clinical criteria, regardless of financial eligibility. Recommendations: 18. Review of reductions. Review internal DHHS reports that document how cuts have been proportioned across programs and services over the recent past and establish policy that will equalize those reductions, instead of targeting one class of /diseasedisability over others. 19. Service review. Ensure that essential services are available to class and non-class members who meet the MaineCare clinical criteria for eligibility. NAMI recognizes that funding reductions will most certainly affect what services can be provided. We encourage DHHS to focus on providing evidence-based and promising practices, reduce variations in treatment practice, expand the availability of ACT and other treatments that produce costsavings and improved health outcomes and recognize low-and no-cost, low-no barrier peer and family supports as effective and cost effective alternatives. In addition, particularly as it relates to ACT and other evidence-based models, the state must assure that programs meet all national fidelity standards and have rates that make this possible. 20. Housing and Vocational Supports First. (See earlier section on housing and employment.) 21. Accurate budgeting. Ensure that budget requests accurately reflect the documented needs, particularly the unmet needs of both class and non-class members. 22. Decree revisions. Encourage the Plaintiffs, Defendants, and Court Master to meet and consider modifications to the original decree so that is responsive to current practice, needs and outcome-based service delivery. Ask the parties to review progress toward compliance to date and determine which components are essential to maintaining the health, safety and welfare of class members and non class members. PEER AND FAMILY SUPPORTS In its Advancing Peer and Family Supports Project year 1 final report (January 2010), NAMI and its partners, Amistad, Consumer Quality Initiatives (CQI), the Consumer Council System of Maine, and the Maine Association of Peer Support and Recovery Centers presented findings that demonstrate both the recovery enhancing and cost saving benefits of peer and family 20 Peer services result in the decreased utilization of more costly formal mental health treatment services.