Adult Mental Health Services in Maine: Lessons from the Past; Hope for the Future. In: Maine Choices. Maine Center For Economic Policy, 1996

Adult Mental Health Services in Maine: Lessons from the Past; Hope for the Future Michael DeSisto, Ph.D., Outcomes, Inc. In: Maine Choices. Maine Center For Economic Policy, 1996 Maine Choices: 1997

Adult Mental Health Services in Maine: Lessons from the Past; Hope for the Future by Michael DeSisto, Ph.D., Outcomes, Inc. Introduction Maine is in the process of yet another major cycle of reform 1 in its mental health care system. Driven by a DMHMRSAS Consent Decree, the new reforms involve the further depopulation (downsizing) of the two State Mental Health Institutes and a major restructuring of the community mental health services system. The magnitude and implications of these changes have not been seen in Maine for 25 years. The context of these reforms include the State s continuing negative economic picture, and efforts by an Independent Governor to reorganize, reduce the size, and increase the performance outcomes of State government. The larger context for these changes is a society destabilized by lost economic security and the increasing use of violence to resolve conflicts. This chapter is organized into three major parts. First, the history and lessons from Maine s First Generation (1970 s) of depopulation and regionalization are presented, focusing on the Augusta Mental Health Institute (AMHI). Next, financial and policy trends over the past decade, which are characterized as a period of System Breakdown, are then analyzed. Major events during this period include: a general breakdown in the system in southern Maine resulting in a successful Class Action Suit and Consent Decree by AMHI patients; shifting most of the cost of running State institutions to the federal Medicaid program; and a general lack of public confidence in the system. Reasons for this System Breakdown do not appear to have been a lack of commitment of resources by Maine people, but instead a lack of continuity of policy, leadership, and a shared vision for the system. Finally, in Recent Developments, the paper outlines and discusses both the positive and negative aspects of current depopulation and regionalization efforts and other trends. Maine s First-Generation Depopulation Efforts 2 Figure 1 displays the AMHI average daily population and total admissions from 1946 to 1995. Annotations are used to show the timing of important policy and program events. 3 The trend throughout the period is a decreasing long-term care role and an increasing acute care role for the AMHI. The average daily population, total admissions, and length of stay data for a hospital are interdependent. This means that if there is a finite number of beds, and then there is an increase in admissions of involuntary patients who may have no other alternatives for hospitalization, the only alternatives are to reduce the length of stay for those who are admitted, discharge long-stay patients, or establish more beds. The data show that until 1961, AMHI had 1 Morrissey, J.P. and Goldman, H.H. Cycles of reform in the care of the chronically mentally ill. Hospital and Community Psychiatry, 1984 35(8), 785-793. 2 For a more detailed review of this period, as well as Maine s early involvement with mental illness, see DeSisto, M.J. et al., Perspectives in Rural Mental Health. A Comparison of Mental Health System Policy and Program development in Maine and Vermont. Augusta, ME. Maine-Vermont Project, 1991. 3 The post-war era was a period of rebuilding. Under the excellent leadership of Dr. Francis Sleeper, standards of care for patients and the skills and working conditions for workers were improved. Overcrowding of the hospital was reduced with new construction, and with Operation Out, which placed elderly patients in nursing and boarding homes. Modern drug treatment was introduced, which also helped reduce the census. Innovative psychosocial and community work programs increased public support for the institution. Maine Choices: 1997 2

mostly a long-term care role, with over 1700 patients, many of whom worked on the farm, in the laundry, on the grounds, and in the community. The acute care role of the hospital (admissions) was relatively small and stable, but increasing. The decision to accept voluntary admissions in 1961, and the statutory shift of the responsibility for admissions from local authorities to physicians, resulted in a dramatic increase in admissions and readmissions (See Figure 2), and shorter lengths of stay. By 1970, the Maine system was poised for a dramatic shift. Community Mental Health Centers were now established throughout the State 4, and Medicaid and other entitlements were now available. Governor Kenneth M. Curtis and new Commissioner William Kearns installed the first non-medical AMHI superintendent, 27 year-old Roy Ettlinger. His mandate was to depopulate the hospital, and armed with a clear policy direction and support from the Governor and Commissioner, he did just that. In the next five years, the population of the AMHI dropped from 1500 to 350 patients (See Figure 1). 5 6 7 The change was not simply a reduction of the census. It involved a paradigm shift for the hospital and the system from a medical or illness model to a social and egalitarian model. Formerly arranged by professional departments, the staff were reorganized into interdisciplinary treatment teams. Psychiatric aides became mental 4 Under the leadership of Mental Health Bureau Director William Schumacher, MD, Maine was one of the first States to develop a Statewide system of Community Mental Health Centers, and ranked second among States in per capita receipt of funds under the federal Community Mental Health Centers Act. See Federally-Funded Community Mental Health Centers Supported Under P.L. 94-63. Rockville, MD., 1983; National Institute of Mental Health. The Community Mental Health Services Network: A Statistical Profile. Rockville, MD., 1983; National Association of State Mental Health Program Directors. Funding Sources and expenditures for State Mental Health Agencies: Final Report of Revenue/Expenditure Results. Washington, DC, 1984 5 After family, the boarding home was the major placement resource for long-stay patients. For example, In 1972, the peak year of placement, 15.5% of the patients were placed in boarding homes, 3% in foster homes, 5.6% in nursing homes, and the remainder with family, friends, or in independent living. Currently 34% (631 persons) of people residing in boarding homes in Maine have a mental health history (See Maine Department of Human Services, Residential Care Facility Resident Characteristics, 1996). 6 Similar reductions in census took place at the Bangor Mental Health Institute during this period, so that the census for both hospitals decreased from about 2600 to 650. 7 Nationally, patients in State hospitals declined from a peak of 558,922 in 1955 to 137,000 by 1980 (Bassuk, E.L. & Gerson, S. Deinstitutionalization and mental health services. Scientific American, 1978, 238(2), 46-53). Mental health care was more available through mental health centers, and there was a 12-fold rise in outpatient care episodes, but this care was not being provided to former hospital patients. Most inpatient care continued to be provided in State mental hospitals through increasing admissions, and in residential care facilities and nursing homes. (Goldman,H.H., Adams, N.H. & Taube, C.A. Deinstitutionalization: the data demythologized. Hospital and Community Psychiatry, 1983, 34 (2), 129-134; Windle, C. & Scully, D. Community mental health centers and the decreasing use of State mental hospitals. Community Mental Health Journal, 1976, 12, 239-243). National concern that the new system was not meeting the needs of severely ill patients resulted in the Federal Community Support Program, the President s Commission on Mental Health (1978), and the Mental Health Systems Act (PL 96-398). This Act was repealed and replaced with Block Grants by President Reagan in 1980. A myth often used as an explanation of the failure of deinstitutionalization efforts is that the money did not follow the patients into the community. This explanation ignores the increasing and expensive acute care role of the State hospital which was not replaced in the community, the loss of patient labor which accounted for about a third of all work, and the increasing standards of care from payers, accrediting bodies, and from the public. Gerald Grob (The Forging of Mental Health Policy in America: World War II to the New Frontier. Journal of the History of Medicine, 1987, 42, 410-466; Mental Health Policy in America: Myths and Realities. Health Affairs, 1992, 11, 7-22) has pervasively debunked this myth, which may obscure more fundamental problems with shifting persons and services from institutions to the community. Maine Choices: 1997 3

health workers and were provided with college education opportunities and their own career ladder in the personnel system. Patients, formerly assigned to treatment units based on severity of illness and functional capacity, were now assigned to geographic units on the basis of their residence in one of five Community Mental Health Center Service Areas. Eventually, the system was to be regionalized by moving each geographic unit to the local community (and therefore the acute care role of the hospital), and the AMHI would be closed or become a longterm treatment center. 8 9 These changes were never realized. The Governor James B. Longley, an Independent who ran for office on a platform that government was inefficient, initiated a general cost-cutting effort that removed over a million dollars and over a hundred positions from the AMHI. 10 Administrators who had led the reforms under the prior administration resigned or were asked to leave. The new administration abandoned the geographic organization of the hospital for functional units based on age and severity. A single admission unit tried to manage the everincreasing admissions and readmissions, which were a clear indication that community elements of the system were not effective. The medical model was revived, but coordination and continuity with community agencies was lost. Another cost-cutting measure proposed by the new administration (1975) was to close the BMHI. This proposal divided system stakeholders along hospital and community lines, and would continue to have a major impact on mental health policy for the next decade. This proposal raised long-standing regional biases and was opposed by the entire Bangor community. The rationale was to use the savings for continued development of community programs, but was criticized for its lack of planning around the needs of individual patients. The proposal was soundly rejected by the Maine Legislature. However, long-standing wounds and divisions throughout the system remained. This event ended Maine s First Generation of depopulation. Overview. The policy continuity and early successes in depopulation and regionalization were derailed by changes in leadership and an unsuccessful attempt to close the BMHI. For the foreseeable future (through 1987), the Department of Mental Health would 8 There were other developments that facilitated the change. A Consent Decree won in federal Court against unpaid patient labor eliminated all industrial therapy. The hospital farm was closed. Based on the US Supreme Court (O Connor v. Donaldson, 422 U.S. 563, 1975) decision, Maine commitment laws were changed. Objective dangerousness and due process were required for initial and continued civil commitment. The admission of elderly persons and those with substance abuse was also discouraged. These actions resulted in an initial decline in admissions, but eventually enhanced the acute care role of the hospital, and created a new generation of short-stay, but frequently admitted patients in Maine and the nation (See Bachrach, L. A conceptual approach to deinstitutionalization. Hospital and Community Psychiatry, 1979, 29, 573-578). Figure 2 shows the increasing proportion of readmissions to overall admissions beginning in 1961 with voluntary admissions and again in the 1970 s and 1980 s after depopulation. 9 An Appropriations Committee study of the mental health system supported the general policy direction, and recommended the gradual transfer of all programs to regional mental health centers and the use of AMHI space for nursing homes, State offices, and the University. However, the report also expressed concern about the cohesiveness of the system, the lack of continuity of patient care, and the accountability for mental health centers, planning, and management for the system. Concern was also expressed about the aftercare and community living arrangements for former patients (See Maine Legislative Joint Standing Committee on Appropriations and Financial Affairs. Mental Health System Study: Interim Report. Augusta, ME, 1974). 10 Fuller, M.E. & Howard, M.A. A Brief History of the Augusta Mental Health Institute. Augusta, ME: Maine-Vermont Project, 1988. Maine Choices: 1997 4

remain committed to an important role and improvement of State hospitals 11 and to expanding residential, work, and social opportunities through the development of new agencies and services. Maine s system was rated 4th among the States by consumer representatives for its hospitals and community programs. 12 Statewide networks of family and consumer groups were nurtured. The system was now more pluralistic, but had no defined policy or statutory structure needed to integrate its elements. By 1986, admissions to the AMHI had reached unmanageable proportions, resulting in serious overcrowding. The suspension of voluntary admissions was a signal of impending crisis. System Breakdown Within a year, new Governor John McKernan wanted his own cabinet and asked for Commissioner Concannon s resignation. This marked the beginning of a breakdown in continuity of leadership as no less than eight changes in Commissioner would occur over the next eight years. At the same time, the resignation of Superintendent Garrell Mullaney in 1986 began a succession of eight different superintendents at the AMHI over the next eight years. The problems at the AMHI continued. The Legislature established a Commission to study the overcrowding. The new department administrators were unable to provide the necessary leadership. 13 The framing of the issues as a hospital overcrowding, understaffing, and underfunding revealed a lack of understanding that the hospital was part of a complex system, and that the rising and unstable admission pattern was evidence that the system was breaking down. 14 A series of events during 1987-88 brought AMHI from the American Psychiatric Association s Model State Hospital of the 80s to the Joe Blfstxkx 15 of State mental hospitals. First, Medicare decertification (1988) of the acute care units due to nursing shortages and poor medical records resulted in a significant loss of revenues. This was followed by five patient deaths (some heat-related), an investigation by the Justice Department, five more patient 11 Through the leadership of Superintendent Garrell Mullaney, the AMHI went on to develop model rehabilitation programs and in 1982 received an American Psychiatric Association Distinguished Service Award as a Model State Hospital for the 80 s for the overall excellence of its programs. 12 Wolfe, S. & Torrey, E.F. Care of the Seriously Mentally Ill: A Rating of State Programs. Washington, DC: Citizens Research Group, 1984. 13 Quality Health Care Resources, Inc. Consultant Report to Commissioner of Mental Health Susan Parker, April, 1989. This report was commissioned in 1988 when AMHI s Accreditation was threatened. The consultation was shared with the AMHI Legislative Oversight Committee and the Maine Commission on Mental Health, all established to help deal with the AMHI problems. A number of findings and recommendations were made. Most significant was the low staff morale resulting from a lack of strong, effective leadership at the Commissioner and Superintendent levels, and the need for organizational restructuring. 14 In Perspectives in Rural Mental Health (Footnote 2), this writer proposed that the seeds of these problems were sown over a 30-year period, and were the result of: (1) a lack of integration of the hospital and community system elements around the needs of specific patients; (2) unclear roles and responsibilities; (3) lack of a clear vision for the system; (4) lack of policy continuity; (5) program planning and system development unrelated to the expressed needs of specific patients; and (6) a lack of databased system monitoring. Unfortunately the history of government involvement with mental illness since World War II has been one of conflict and polarization between State and federal and hospital and community interests, with little consensus about who to serve and how (See Foley, H.A. & Sharfstein, S.S. Madness and Government. Washington, DC: American Psychiatric Press, 1983 for a review). 15 Torrey, E.F., Wolfe, S.M. & Flynn, L.M. Care of the Seriously Mentally Ill: A rating of State Programs. Washington, DC: Public Health Citizens Research Group and Alliance for the Mentally Ill, 1990. Maine s system was now ranked 11th (from 4th). Maine Choices: 1997 5

deaths, tentative non-accreditation by JCAHO, all culminating in a lack of public confidence, a Legislative Oversight Committee, and a Class Action Suit on behalf of AMHI patients. 16 For the first time in its 150-year history, at the request of the Governor, the AMHI was placed under the management of a Consortium of Southern Maine Hospitals. The problems at the AMHI were defined as staffing and resources problems, not leadership and system problems, which resulted in an infusion of over 10 million dollars and 200 staff between 1988 and 1991 (See Table 1). During the same period, expenditures for community services more than doubled. There was a great expansion of specialized residential, intensive case management, and crisis programs, and the creation of local hospital diversion programs to deflect hospital admissions. A new Commissioner, Robert Glover, was approved in 1989. Finally, in 1990, a Legislative Commission, guided by the Department of Mental Health, focused its attention on the entire system, recommending some clear values for continuity and integration and a regional system of local mental health boards 17 governed by primary and secondary consumers. 18 In the spring of 1992, the Maine legislature approved the establishment of two pilot regional administrative boards (one in Portland and one in Aroostook County) among the newly reconfigured five mental health services areas of the State. The lack of funding for these regional boards suggests that support for them was ambivalent and lukewarm. These boards, which had a majority of consumer members, no doubt threatened some providers and community members. Eventually, funds from the Robert Wood Johnson Foundation were used to establish the Portland board, which was eliminated with new legislation in 1996 to once again redefine the structure of the community mental health services system. 19 The period from 1987 to 1991 is a lesson for those who believe that more is always better. Increased spending did not yield a solution to the complex problems facing the mental health system. AMHI Consent Decree: A Case of Unable and Unwilling. The class action suit is a favored device to achieve institutional reforms because if the plaintiff s win, it is easier to convince the Court that system-wide relief is appropriate. 20 In the AMHI case, both plaintiffs 16 Filed on February 27, 1989. The scope of the Class were all patients at the AMHI on or after January 1, 1988, and all persons who would be admitted in the future. 17 Local boards are common in States that have county governments that manage human service and other programs for the State. 18 State of Maine Systems Assessment Commission. Draft Final Report. Augusta, ME, November 14, 1990. A decentralized system of local boards governed by consumers was also presented to the Legislature s Human Resources Committee by Commissioner Susan Parker. At this time, Local System Assessment and Planning Teams were meeting to inventory and plan new services using Maine s Community System Workbook (DeSisto, M.J. & Ridgway, P., 1986). This effort was derailed with new Commissioner Glover, who created a group of stakeholders to advise on a vision for the mental health system. To their credit, both Susan Parker and Robert Glover were strong supporters of consumer empowerment. Commissioner Parker instigated the Governor s Commission on Supported Employment. This collaboration of business, government, providers, and consumers and families received a three-year grant from the US Department of Education to design and implement a collaborative system of employment and supports for people with disabilities. This initiative succeeded in training consumers and employers needed skills and creating work for disabled people in natural job settings. 19 Momentum for consumer-governed local boards was lost when Commissioner Glover resigned in August, 1993. Roger Deschaises was appointed acting Commissioner until February, 1994. Susan Davenport was appointed and continued until February, 1995, when Melodie Peet was appointed by new Governor Angus King. 20 Levine, M., Ewing, C.P., Levine, D.I. The Use of Law for Prevention in the Public Interest. In Prevention: Toward a Multidisciplinary Approach. New York: Harworth Press, 1987, pp. 241-277. Of course, class actions are not without problems. Lack of consensus on goals or ideological anti- Maine Choices: 1997 6

and defendants saw the class action as an opportunity for broad system reform and the infusion of new resources and agreed to settle the suit through a Settlement Agreement called a Consent Decree. Once the parties accept an Agreement and it is ratified by the Court, it is enforceable. The AMHI suit was filed in Superior Court on February, 27, 1989. The class was certified by the Court on June 15, 1989. The Settlement Agreement was ratified by the Court on August 2, 1990. The defendants were to attain substantial compliance with all provisions of the Agreement by September 1, 1995. The Settlement Agreement 21 included two broad principles: (1) while the State had invested significant resources in the AMHI, that improvements in the care to class members could only be achieved by reducing AMHI s census and admissions, and reallocating AMHI s resources to community services as part of the development of a comprehensive mental health system; (2) that services should be developed on the basis of individualized needs with respect for the individual. By January of 1991, the defendants had to submit a plan for system development, including funding and timelines for development of system components. Development of the system was to be based on class members identified needs using information from an Individual Service Planning process. Non-class members were not to be deprived of services solely because they were not class members 22. Figure 3 shows AMHI admission, population, and staffing data from 1987 through 1996. Admissions began to decline in 1988, from 1447 to 646 by 1991, and then declining more gradually to their present level of 370. Similarly, the average daily population declined from 357 to 285 by 1991, and to 142 currently. Licensed beds have declined from 298 in 1991 to 133 currently. The decline in population slowed somewhat after nursing home units were closed, leaving only other long-stay patients with complex care needs. Despite declining admissions and population, staffing increased over the same period, but then declined with the beginning of the State s fiscal crisis in 1991. These initial reductions in admissions and population actually began before the class action was filed and prior to the Settlement Agreement without planning for dispositional alternatives. These policies continued with new Commissioner Glover and new Superintendent Linda Breslin 23. The Adolescent Unit, a program for persons with Borderline institutional biases may emerge. There may be disagreements between some plaintiffs and the attorneys around closing rather than improving the institution. Once settled, the defendant agencies may not be willing or able to carry out the order, or may not be able to get the necessary resources from other branches of government that are not parties to the suit. All of these issues have played out at one time or another during the AMHI Consent Decree. Lawyers for the plaintiffs in this case had already brought one of the most successful institutional reform cases (Wuori v. Zitnay, Civ. No. 75-80 (D. Maine 1975) con t sub nom Wuori v. Concannon) on behalf of Maine persons with mental retardation. With excellent leadership and commitment from Governor Brennan, Commissioner Concannon, and the legislature, the Court gave up active supervision of the case within a few years. The response to the AMHI decree has not yet been as successful for a number of reasons to be discussed later in this paper. 21 State of Maine, Kennebec, SS. Superior Court Civil Action, Docket No. 89-88. 22 Another problem with the Consent Decree as a means of system reform is that by definition, it creates a special class which receives priority for services, and may result in the creation of a two-tiered system. This argument was used continuously by the defendants for not implementing the Settlement Agreement. The Department of Mental Health has never operated on the basis of individual eligibility and still does not for non-class members. Managed care will no doubt bring individual eligibility for all served by the public system. 23 This writer, who was Chief of Psychology at the AMHI during the summer of 1989, actually drafted new admission policies for AMHI under Superintendent William Meyer, These policies made it more difficult for persons with only DSM Axis II disorders to be admitted. The discussion at the time was for the AMHI to take more control of its destiny by defining its own role in the system. There was an Maine Choices: 1997 7

Personality Disorder, and several on-grounds half-way houses were eliminated in 1989-90. Local community hospitals, police, jails, shelters, and welfare agencies were forced to utilize less than optimal alternate resources on an ad hoc rather than a planned basis. The continued lack of commitment, leadership, and follow-through after the Decree resulted in a public outcry, extensive media coverage of the plight of discharged patients, and another law suit, and an eventual Consent Decree from the City of Portland, supported by other municipalities, enjoining the Department not to release any more persons into the community until adequate services were in place. 24 On February 22, 1994, the plaintiffs filed a motion to the Court for contempt and enforcement of the Decree, stating that the Department had failed to comply with the Decree s basic requirements and would not meet the September 1, 1995 deadline for substantial compliance. The lack of adequate planning for the reduction of the AMHI census was among the issues raised, as was failure to implement Individual Support Planning, and failure to obtain adequate funding. 25 After a week long trial in July, 1994, Judge Bruce Chandler found the defendants in contempt. He stated that the Department had, in fact, operated as if there were no Court order in existence, had used the State s financial difficulties as an excuse, and had conducted downsizing without adequate planning and approval of the Court Master. Funding was not the problem. Instead, it was the lack of concerted effort to comply. 26 The Judge was also upset that millions of General Fund dollars to operate the AMHI had been replaced by the Department with federal disproportionate share Medicaid dollars without seeking Court approval. The defendants had failed to recognize that the class members were a distinct class governed by the Settlement Agreement whose needs must be given priority. The defendants continued to argue that the Court s order forced them to set up a privileged class of recipients and a two-tiered system. 27 The Judge responded that the defendants did not get it. The Court was not advocating for a two-tiered system, but that a one-tiered system could not be achieved by lowering the standards for class members in the Settlement Agreement. The Court was not preventing the defendants from providing services to others, but those persons were not under the Court s control. 28 There are many reasons for the Department s lack of compliance with the Decree. In addition to not understanding that they had responsibility for specific individuals, the mental health side of the Department had no community presence and therefore no capacity to plan, develop, and manage services around the needs of individuals. There were no State people on the ground to conduct assessments and to develop resources for specific individuals. Also, the infrastructure to gather and synthesize information about individual needs was very primitive. All of these factors contributed to the lack of will and ability to comply with the Consent Decree. immediate reaction of concern by community hospitals and providers, who had no dispositional alternatives. 24 City of Portland v. Davenport, Superior Court of Cumberland County. The Decree required parity of mental health services for class members and non-class members. This Decree was a hollow victory because this parity was to be exercised as resources were available. 25 State of Maine, Kennebec,ss. Superior Court Civil Action Docket No. CV-89-88. PLAINTIFFS MEMORANDUM OF LAW IN SUPPORT OF THEIR MOTION TO ENFORCE CONSENT DECREE AND FOR CONTEMPT, April 14, 1994. 26 State of Maine, Kennebec,ss. Superior Court Civil Action Docket No. CV-89-88. DECISION AND ORDER, September 7, 1994. 27 State of Maine, Kennebec,ss. Superior Court Civil Action Docket No. CV-89-88. DEFENDANTS MOTION TO AMEND DECISION AND ORDER, September 19, 1994. 28 The Judge ordered no less than 10 items of specific relief but no penalties. Maine Choices: 1997 8

It was as if the Department had learned nothing from the successful implementation of the Wuori v. Concannon Decree. The Department was back in Court in February, 1996, this time because of its own actions rather than inaction. New Commissioner Melodie Peet had decided in late October, 1995 to recommend to the Governor, the closure of AMHI by 9/30/96 and to redistribute funds for community resources. On 11/17/95, she presented a draft plan for the closure to the Productivity Realization Task Force. Plaintiffs, the Court Master, and some legislators were concerned about this precipitous action which was not discussed with them. Almost immediately, legislation was passed to remove the closing of AMHI from the Productivity Task Force proposal 29. The plaintiffs were back in Court before Judge Nancy Mills requesting contempt and sanctions. This time the Judge found that the Consent decree is met, at best, with indifference or misunderstanding or, at worst, with disdain. 30 The motion for contempt and sanctions was granted in the form of receivership which was stayed to give the Department a final opportunity to comply by submission of: (1) a final plan for implementation of the Settlement Agreement to the Court Master for approval by 3/18/96; (2) a plan to completing individual assessments of class members by 3/25/96; and (3) an evaluation of safety for discharge of patients at the AMHI for more than 150 days by 3/30/96. After this second trial, Governor King announced that the State would work collaboratively with the Court to implement the Consent Decree. Fiscal Overview. Table 1 shows Department of Mental Health expenditures for adult mental health programs from 1987 through 1995. Total expenditures have more than doubled over the period, from 41 million to almost 93 million. However, federal dollars, which accounted for only a small percentage of total expenditures in the beginning of the period, now account for about half of total expenditures. Some of the increase in federal financing of mental health programs resulted from both expansion and shifting the cost of existing community programs to the Medicaid program. However, most of the increase in federal financial participation was the result of shifting over 60% of the costs of running AMHI and BMHI to the Medicaid program during the State s fiscal crisis in 1992. 31 General Funds, which had increased 44% (from 41 million to 72 million) between 1987 and 1991, were simply de-appropriated (Figure 4). Use of 29 P.L., 1995, ch. 502, P-1 (effective November 30, 1995); Department of Mental Health and Mental Retardation. Report to Productivity Realization Task Force, December 11, 1995. 30 State of Maine, Kennebec,ss. Superior Court Civil Action Docket No. CV-89-88. DECISION AND ORDER, March 8, 1996. 31 OBRA (Omnibus Budget Reconciliation Act) 1986 allowed States to tax hospitals for Medicaid seed, which was in turn used to increase payments to hospital providers. Called Tax and Match Hospitals were repaid what they donated, and were able to recoup shortfalls from serving Medicare and Medicaid patients, and the States would be able to save General Fund dollars to spend on other programs, or de-appropriate these dollars. In 1987, OBRA gave States additional flexibility to define what were called Disproportionate Share hospitals (hospitals that were not recouping the costs of serving Medicaid patients). Most States, including Maine, used this opportunity to finance State hospitals (which served mostly poor people who lost their Medicaid coverage once admitted to the State hospital). For the first time, Medicaid was now involved in financing institutions for mental diseases (IMD s). In Maine, IMD s also included two private for-profit psychiatric hospitals. By 1995, disproportionate share dollars in Maine were 112 million, of which 32.5 million were for AMHI and BMHI, and 80 million in other hospitals. In 1994, Maine was ranked 6th among the States in the use of both Tax and Match and Disproportionate Share provisions. These programs were supposed to be eliminated in 1995, but have continued. Many State mental health authorities are now rolling their disproportionate share dollars into applications for Medicaid waivers. Maine Choices: 1997 9

disproportionate Medicaid dollars and the AMHI Consent Decree probably prevented cuts in total mental health expenditures and services during the State s fiscal crisis. However, the replacement of General Funds with Medicaid dollars is not without caveats. There are fewer more flexible General Funds in hospitals to use for community programs through downsizing. Funds for State hospitals are now part of the federal welfare debate. Also, in order to receive disproportionate share dollars, 1% of the acute care (Medicare) bed days at AMHI and BMHI must serve people over 65 and under 21. 32 In effect, the people of Maine, through the disproportionate share action, gave up much of the equity in its mental health system that was built up over 150 years. Unfortunately, as pointed out by Judge Chandler, none of these savings were used to help develop new services required by the Consent Decree. 33 During this period, there was a 70% increase in General Fund expenditures for community programs. By 1995, expenditures for community programs were 57% of General Funds (Figure 5) and 43% of total expenditures. Overall, compared to other States, Maine continued its higher expenditures for mental health services per capita compared to other States (ranked 7th with $67 per capita compared to $48 nationally in 1990; ranked 11th with $70 per capita compared to $55 nationally in 1993). 34 Overview. It was inevitable that Maine s system would break down. Once it did, the wrong problem-definitions, first hospital overcrowding and then resources without consistent leadership and a systems approach, were applied. Constant turnover of leaders resulted in many false starts at regionalization of the system and no shared vision among stakeholders about who and how local systems would be managed. Implementation of downsizing and reduction of admissions were conducted without adequate development of community alternatives based on individual class member needs. Leaders in the Department never internalized the requirements of the Consent Decree, and were unable or unwilling to implement individual case planning or work under the direction of the Court. Most of the General Fund equity in the system was de-appropriated when the cost of operating hospitals was shifted to the federal Medicaid program. On the positive side, prior to and during the State s fiscal crisis, there was a significant increase of funds and a great expansion of community resources and programs. Consumer involvement and empowerment was continued and expanded. Successive leaders began to think about the system as a whole. The Consent Decree showed that it was a historic document and would provide some continuity of direction for system policy and planning. Recent Developments New administrators bring new reforms. Like her predecessors, Susan Parker from New Hampshire and Robert Glover from Colorado, Commissioner Melodie Peet from Connecticut proposed a local, consumer and community-directed regional system. Unfortunately, her initial 32 As a result, AMHI maintains a psychogeriatric unit which admits elderly persons contrary to Consent Decree requirements. 33 Other visible signs of the erosion of equity in the system is the taking of hospital buildings and grounds for other State purposes, with little return for persons with mental illness. New hospitals could have been easily capitalized if only one dollar for each square foot of building space would have been dedicated for new construction. Instead, mentally ill persons and their families continue to be served in old, austere, outdated, stigmatizing buildings. 34 National Association of State Mental Health Program Directors Research Institute. Final Report: Funding Sources and Expenditures of State Mental Health Agencies: Revenue/Expenditure Study Results. Washington DC & Alexandria VA: NASMHPD, November 1992; October, 1995. Refers to all expenditures controlled by the State mental health agency. Maine Choices: 1997 10

tack, the creation of Local Service Authorities (LSA s), became another false start. LSA s were to be governed by consumers, parents, and families. They would be responsible for planning and managing adult and children s mental health services at the local and regional level. They were to have both administrative and clinical authority of regional services through a contract with the Department. The governing body for each LSA was to have at least a majority of members who were consumers, parents, and family members. The LSA would administer core clinical services, including medications, crisis services, a single point of entry and preadmission screening for hospitalization. They would also be responsible for allocation of resources, and overall local system development and information management. Eventually, the LSA s would be the local managed care agent. An extensive planning effort involving focus groups, and local and Statewide implementation groups was initiated. However, It did not take long for a change in this direction. Some providers and legislators expressed concern that the system would be governed by consumers and families. There was also some concern about how the LSA s, once establshed, would develop the capacity for all the roles and functions, for creating the infrastructure and staff to carry out these functions would cost money. Also, some key legislators opposed a system governed by consumers. 35 The change in strategy was another structural approach, but this time the State would direct a similar regional system with only advice from consumers, families, and providers. For the first time in Maine, a regional mental health structure was defined in statute. 36 Consumergoverned LSA s were abandoned for a top-down State regional office approach with State regional directors who report directly to the Commissioner. Twenty-four member Quality Improvement Councils (QIC) (12 member QIC s for each State hospital) accountable to the State regional director will assist the Department and providers with system planning and assessment through program evaluation teams made up non-providers. Local service provider networks (including State hospitals), accountable to the regional director and managed by a contracted or State-line position, will provide core crisis, case management, housing, outpatient/medication management, rehabilitation, and other services. The network manager will ensure that guidelines for network operations are met such as no rejects, no waiting list, 24 hour access, and relationships with police, welfare, schools, and other external systems. All of these components are consonant with central office structural changes abandoning discrete management structures for categorical groups (i.e. persons with mental retardation, children and adults) for three divisions: Systems Operations for all groups, Adminstration to integrate funding streams and manage operations, and Programs to conduct quality improvement activities. 37 This approach essentially expands and decentralizes the State s role into the region at significant cost. While some would argue that a transitional structural approach is necessary to build a local system, this approach may be the only current example in the nation of the influence/control of government expanding into local communities, and does not comport with 35 The fiscal problems of a Statewide consumer group, DREAMS, did not help. The Department did not accept its share of responsibility for these problems, which played out in the media, and supported the move from consumer governance to State governance of the regions. Except for the important governance issue, principles and elements of the regional system (single point of entry, no rejects, local area provider networks, etc.) are similar. 36 P.L. 1996, Chapter 691, S.P. 654, L.D. 1704. Mental Health and Mental Retardation-Community Mental Health Services-Quality Improvement Councils and Local Service Networks. 37 Department of Mental Health and Mental Retardation. Report to Productivity Realization Task Force, December 11, 1995. Maine Choices: 1997 11

recent trends to reinvent government. 38 Of course, this design could have been accomplished without the presence of the State in the regions. Once established, State offices will not be easy to dissolve. Consumer and family governance of the system has been abandoned for State control. Large providers, who have opposed the presence of the State in the regions since establishment of community mental health centers, while not in agreement, seem to have accepted this approach. Threatened by both LSA governance of the regions and the possibility of large managed care organizations moving into the public system, they have formed their own managed care organization (Behavioral Health Network of Maine, BHNM), which has received a contract to conduct assessments of AMHI Consent Decree class members. These developments are a positive sign that the relationship between providers and government leaders has improved, but perhaps at the expense of influence by consumers and families. The new Consent Decree implementation plan has an excellent definition of a System of care which includes local responsibility and a single point of entry for the system. 39 The development of the local service network should help create a coordinated network of services managed by the Department. In effect, the Department has set itself up to be the statewide MCO (managed care organization). Another possibility is that BHNM will become the MCO. Both options create the danger that the system will become too monolithic and ultimately restrict choices for consumers. A better approach would be to have truly locally-managed systems, with a different approach or model depending on the characteristics and wishes of each region. For example, in urban areas, more than one MCO could exist to give consumers some choice. In rural areas, there could be one MCO which would be governed locally. The outcomes for the different models or approaches could be compared. Finally, the approved plan to implement the Consent Decree, is a blueprint for a system of care. Table 2 shows that over 14 million dollars in new funding has been appropriated this year to create aspects of the system. Though not universal, significant program development efforts are more geared to the needs of specific class members. For the past 18 months, individual case planning and resource development have been more carefully constructed toward the needs of specific long-stay patients in the AMHI and BMHI as envisioned by the Consent Decree. The Plan calls for hiring over 100 new case managers and other front-line workers. Recent legislation has created special dedicated revenue accounts for reinvestment of funds through downsizing and maximization of Medicaid dollars. 40 Results from consumer focus groups commissioned by the Department have shown that consumers value health and recovery and want access to educational and other programs outside the mental health system. 41 42 A study of the case management practices in Maine 43 commmissoned by the Department have confirmed these findings. Implementation of the study s recommendations has the potential for making policies and practice more consistent with psychosocial principles of recovery 44 and life planning, and for increasing consumer access to transportation, recreation, work, and other community programs outside the mental health system. 38 Osborne, D. Reinventing Government. Reading, MA: Addison-Wesley, 1992. 39 Department of Mental Health, Mental Retardation, and Substance Abuse Services. Final Consolidated Plan for Implementing Settlement Agreement to AMHI Consent Decree, May 3, 1996. 40 Chapter 691, S.P. 654, L.D. 1704, Section 12; Chapter 697,H.P. 1284, L.D. 1764. 41 DeSisto, M.J. Consumer Focus Group Results: Preliminary Report. Outcomes, Inc., 1995. 42 DeSisto, M.J. Phase I Mental Health Statistical Improvement Program Report. Outcomes, Inc., 1996. 43 Rose, S.M., Mangum, J.A., Magill, A. Reviewing Case Management Practices in Maine. Center for Human Services, School of Social Work, Center Reports Number 6. 44 Anthony, W. Recovery from mental illness: the guiding vision of the mental health service system in the 1990 s. Psychosocial Rehabilitation Journal, 16(4), 1993, 11-23. Maine Choices: 1997 12

For over 50 years, the policy debate in mental health in Maine and the nation has been framed in dichotomies: institutions versus community; inpatient versus outpatient. These new developments have the potential to achieve a vision of deinstitutionalization: community integration for persons with prolonged mental illness. But these cultural reforms are very fragile. The vision will require local hospitals to assume the current involuntary acute care role of the State hospitals. 45 Recent adolescent suicides, horrible murders in Waterville and at the AMHI, have created new backlash from the public, some families, and have resulted in legislative inquiries, and bills for involuntary outpatient commitment. Public trust in the system is lacking. An Independent governor with no party affiliation makes the politics of governance unpredictable. Some important legislators seem to want only the short term gains of eliminating a State hospital without concern for the possible harm of such action. Sustaining these reforms will require more than structural reorganization. It will also require leaders who are able to: relate the meaning of the vision in a way that captures the imagination, enthusiasm, and commitment of others; build trust through constancy of purpose and reliability, and who take responsibility for everything that happens during their stewardship. Overall, the most compelling aspect of the new reforms is that they offer the potential for a cultural change that persons with mental illness and disability will be part of community life, and not shunned and banished to places far away from home. Recommendations 1. Given Maine s vast geography, which requires families and law enforcement to travel long distances, unless and until local hospitals assume the involuntary acute role currently provided by AMHI and BMHI, Maine will continue to need both of its State psychiatric hospitals. These involuntary services do not need to be provided at the AMHI or BMHI, but if they are not, some other State regional acute involuntary capacity is needed by the system at this time. Closing the AMHI or the BMHI without replacing this capacity would only create further hardship for families, communities, and mentally ill persons who need involuntary hospitalization. This cost of closing a hospital against the benefit of the remaining State general funds in each hospital (about 9 million) is too great. 2. Even though a major thesis of this paper is that the problems in Maine s mental health system are not the result of lack of funds, but instead continuity of policy and leadership, additional funds will be needed. The Consent Decree requires costly individual case planning and service resource development for all class members, including 150 long-stay patients with complex disabilities and needs. At the same time, the Department is trying to create a new system of care in the regions that will not discriminate against non-class 45 Recent legislation has removed some financial barriers by deregulating costs and revenues associated with involuntary care.(chapter 496 H.P. 1084, L.D. 1526). State Tort liability limitations have also been extended to hospitals which accept involuntary patients. But progress is slow. Of course, local non-profit hospitals now have many business opportunities for expansion to outpatient, long-term care, home-care, rehabilitation, etc., and may not want to take on risk or the stigma of serving involuntarily committed psychiatric patients. Maine Choices: 1997 13