League of Women Voters of Montgomery County, MD, Inc. Fact Sheet February 2002
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MONTGOMERY COUNTY'S PUBLIC MENTAL HEALTH SYSTEM
HOW IT'S WORKING FOR ADULTS
In response to a public outcry about problems in the public mental health system, the Montgomery County Council on July 17, 2001 appointed a Blue Ribbon Task Force on Mental Health. The Task Force was asked to investigate and to submit a final report in early February 2002. The LWVMC Health Committee was already at work on a study of mental health services for adults in Montgomery County's public system. While our study is completely independent from that of the Task Force, its preliminary observations and recommendations jibe with many of ours and are integrated into our report.
Our study is in effect an expansion on the one completed in June 2000, which dealt with the problems and a few successes in programs for children and adolescents with mental illnesses. While the problems in the structure and funding of Maryland's Public Mental Health System (PMHS) are common to the whole program, we found that there are problems with the adult mentally ill that are unique. Those fall into three broad categories - legal aspects including how the justice system deals with the mentally ill, housing and the homeless, and the availability of money to pay for medications, out-patient visits to providers, and residential treatment when necessary.
Since the advent of the use of psychotropic drugs great progress has been made in the treatment of the mentally ill. Many patients with organic brain disorders, such as bi-polar (manic-depressive), schizophrenia and depression, can now lead relatively normal lives. Although new and improved medications and treatments are constantly being developed, many of the mentally ill find their side effects intolerable. Others, when on medication, feel so well they don't believe they need them any more. Problems occur when they elect to go off medication - frequently setting up a cycle of homelessness, physical deterioration, jail - often for non-violent offences, and then hopefully a return to treatment. To prevent the cycle from recurring, these people need support from advocates, whether family/professional, or both. Too often none is available.
A REVIEW OF THE STRUCTURE OF MARYLAND'S PUBLIC MENTAL HEALTH SYSTEM
The Maryland Department of Health and Mental Hygiene (DHMH) on July 1, 1997 implemented a new system of health care services for persons on Medicaid, the federal/state program that provides health care for the indigent. With this change, all persons who had been on Medicaid, and some in the "gray zone" (the uninsured, sometimes referred to as the "working poor") were moved into managed care. Those receiving mental health services were also included.
A new Public Mental Health System (PMHS) was created under the Mental Hygiene Administration (MHA) based on a fee-for-service financial structure. Maryland Health Partners (MHP), an administrative service organization, was contracted to expedite access to care, to determine eligibility, to authorize services and payments, and to monitor system utilization across the state. It authorizes mental health services for those eligible for PMHS. Nine clinics serve approximately 3000 persons. Currently, we have been told, there is no waiting list for mental health services, but that there could be a delay in scheduling the first appointment.
From the beginning, there were problems in the way providers were compensated under this system. Fees were set too low - and in some cases still are. Another stumbling block is that under this system the provider is only compensated for hours he or she spends working directly with the patient. Appointments scheduled, but not met - "no shows" - not uncommon with this population, are not compensated - nor are consultations with significant others in the patient's life. Many providers have had difficulty handling the new billing system. Several providers have expressed a preference for the previous "grant" system, in which they were given "grants" of money and were allowed discretion as to how to use them appropriately.
MHP has been said to be poor about processing claims and slow in making payments. The Task Force found MHP's administrative costs to be ten times as high as that of Medicare. Both MHA spokesmen and providers attribute some of the problems to the billing system. We are told that the state is now willing to give generous technical help to clinics on billing, and is working with a committee of providers to simplify the entire billing system.
Early on, MHP developed a rather long list of private providers, each of whom was willing to see a few public mental health patients. This list proved to be somewhat illusory. Many providers found these clients difficult to work with, and often poor about keeping appointments. Problems with delayed compensation were another issue. The Task Force heard a story about a client who called fifteen providers on this list before finding one who would see her/him.
Medicare, the Federal program that covers many medical expenses for the elderly, also covers some disabled. Some of the severely mentally ill fall into that category. Medicare pays only fifty percent of the Medicare approved amount - with the patient expected to pay the balance. For many patients the co-pay is too high. Providers hesitate to take them because their compensation is so low. The Task Force found that the co-pay structures fall far short of covering the cost of both Medicare and gray zone clients.
The Task Force found that the fee-for-service system imposes a costly administrative burden on the provider agencies, who must get prior authorizations, submit bills, and negotiate the complex system of administrative hurdles to get those bills paid. The Baltimore Capitation Project was represented to the Task Force as an example of effective and cost effective service delivery, stimulating discussion as to whether it would be a feasible system for Montgomery County.
FUNDING SOURCES
State: The state of Maryland is legally responsible for funding mental health services within the state. The Governor's budget spells out the amount. The Legislature can only cut projected expenditures, but has no authority to add monies to any part of the Governor's budget. Advocates for the mentally ill, i.e. the National Association for the Mentally Ill (NAMI) and the Mental Health Association, say that Governor Glendenning's budgets have consistently failed to adequately fund mental health services. Part of the problem is a state system designed to treat 40,000 patients in which approximately 80,000 have shown up.
The Mental Hygiene Administration (MHA), which oversees these services, has received criticism for not allocating enough funds. Its spokesmen, in turn, attribute many of the problems to inadequate billing by providers - problems for which MHA is now offering help.
County: County officials have found themselves in difficult positions. Knowing that funding for public mental health services is a state responsibility, when it is inadequate, must they step in with county monies to meet the needs of some of their most vulnerable citizens?
The Core Service Agency under Mental Health Services within Montgomery County's DHHS is responsible for managing and monitoring these services at the local level. The state provides fee-for-service payments to the clinics and private providers who see Medicaid and gray zone patients. Since the changes in 1997, the county has continued to fund the two clinics in Silver Spring for which it could not find a private provider - Montgomery County Child and Adolescent Mental Health Center and the Silver Spring Multicultural Center.
In April 2001, the County Council approved a special appropriation to expand Mobile Crisis Team hours, services at the Men's Emergency Shelter, case management throughout the homeless system, and the County Access Team. The County Executive's FY 02 approved budget designated $6,404,670 for mental health services. In addition, the County Council appropriated additional funds to provide short-term support to the county's nine out-patient clinics. In September, after clinic representatives in emotional pleas outlined the tentative nature of their then current fiscal situation, the Council approved still another special appropriation, bringing the total of supplemental monies appropriated by the County to $870,000.
The bankruptcy and closure in 2001 of CPC Health, which had been the county's largest provider of mental health services, was a wake-up call for county officials. Its failure was said to have been based on not only the problems in the system encountered by other providers, but also upon badly managed finances, and inadequate record keeping and billing. Present DHHS managers now require accountability of existing providers by measuring outcomes, and demonstrations that the business sides of their operations are well managed. And the department is willing to help them.
The department is also looking for other ways to leverage county dollars spent on mental health. For instance, they have found that if a patient has dual diagnoses - e.g. substance abuse and mental illness - case management can be charged to sources that fund treatment for addiction. They seek other strategies.
Early in January 2002, Threshold Services, the county's second largest provider of mental health services, announced that it would go out of business in early April - or sooner. Later in the month, spokesmen for several clinics testified before the County Council that their clinics were also in precarious financial condition and implied that they also could go out of business if they did not receive almost immediate help. Within a week, County Executive Doug Duncan and the secretary of Maryland DHMH Georges C. Benjamin announced that the county and the state would each appropriate an additional $500,000 this year to shore up the clinics. The news was greeted with appreciation. But many advocates look on the relief as temporary unless problems in the system are corrected. It would seem that both county and state agencies are now positioned to collaborate in an effort to find solutions..
TREATMENT - OUT-PATIENT, IN-PATIENT, AND RESIDENTIAL
Medication and case management are believed to be the keys to keeping mentally ill adults functioning in the best way possible. The county has contracts with a number of private providers to provide these services. The importance of these services in both human and financial terms cannot be overstated. According to MHA's numbers, the average annual cost of serving individuals with severe and long-term mental illnesses in the community is $16,729 per consumer. The average cost to taxpayers of serving an individual in a state hospital is $180,000.
The Affiliated Sante Group is Montgomery County's largest provider, serving more than 1000 clients in the Silver Spring and Wheaton areas. Sante provides a variety of mental health services, both clinic and residential - and does some crisis intervention with homeless individuals.
Other private providers include Threshold Services, Community Connections, Inc., Family Service Agency, Inc., Montgomery General Hospital, St. Luke's House, Inc., Washington Adventist Healthcare, the Reginald S. Lourie Center for Infants and Young Children, and Washington Assessment and Therapy Services. All except the latter are non-profit. No clinic is operating in the black, but a number of providers are able to do so by providing a range of services, some of which are more richly funded, seeking grants, and fundraising.
In-patient services
Potomac Ridge, and Suburban, Washington Adventist, and Montgomery General Hospitals will accept psychiatric patients for limited stays. The Springfield Hospital for the Mentally Ill in Howard County is the state hospital serving Montgomery County for the severely mentally ill needing hospitalization. The hospital dropped its bed capacity from 310 in 2000 to 270 in 2002. It is operating at 100 percent capacity every day, causing it to divert Montgomery County admissions to other state facilities, sometimes resulting in less than optimal aftercare planning and the likelihood that a person will cycle in and out of the hospital.
The Crisis Center
The County itself runs and funds the Crisis Center - an attractive and comfortable space at 1304 Piccard Drive in Rockville. It is open 24 hours a day, seven days a week and can accommodate up to six patients. At least one master's prepared therapist is on duty at all times. A full time psychiatrist frequently sees the patient the day of admission. There are twenty-four full time professional staff members and four to six support staff. All staff members are cross-trained.
The center will see anyone in need, including "gray zone," and the uninsured. There is no charge for the initial evaluation. Patients with insurance are assisted with appropriate referrals. In addition to walk-in crisis assessments, the center provides short term psychiatric stabilization. Patients may stay for up to three days, and then can be seen as out-patients for four visits. Staff will assist them to find long term therapy, if needed. The Center is the point of entry for single adult homeless.
The Mobile Crisis Team works out of the Crisis Center. Members frequently accompany police called to deal with a psychiatric crisis. They are available from 8:00 a.m. until midnight for acute situations where the client is too unstable to come to the center. Police, trained in working with the mentally ill, deal with situations that occur when the Crisis Team is not on duty. They can bring a disturbed person to the Crisis Center at any time of the day or night.
Assertive Community Treatment Team
The ACT team goes out into the community and works with the severely, persistently ill - often mentally ill, often homeless. They may follow a person for an extended period of time.
MENTALLY ILL AND HOMELESS
Stable housing is critical to treatment and stabilization of the mentally ill. If a person is on the streets, case management, the hallmark of treatment for these people, is next to impossible.
It is estimated that fifty percent of the homeless in Montgomery County are mentally ill. Loss of jobs, eviction, and inadequate income - the same reasons other people become homeless - are the most common causes. With all of the difficulties related to their illnesses - lack of shelter is often their primary problem.
New (2002) data from the Montgomery County Coalition for the Homeless indicates that the county has an inventory of 314 beds in shelters for homeless adults with serious mental illnesses, substance abuse problems, or with a dual diagnosis of the two. It cited an unmet need for 440 additional ones. Presently there are 65 beds available to families in which one parent has one of the three diagnoses listed above. It estimates that there is a need for 245 more.
The Coalition for the Homeless places seriously mentally ill persons in one of four "safe havens" when possible. These are shelters specialized for their care. However, when space is not available in these, mentally ill homeless are placed in those serving the general population.
The benefits of "safe havens" specialized for the mentally ill are apparent when one looks at services that are usually available. Ideally they include targeted case management, group therapy, consultation with a psychiatrist, transportation to medical appointments, linkages to social services, help with application for benefits including Medicare and Medicaid, help finding housing, and follow-up after it is found.
Finding homes for these people is difficult. Low-income housing in Montgomery County is always a problem, because it is in short supply. For the mentally ill it is particularly difficult. The Housing Opportunities Commission (HOC) won't authorize housing for persons with criminal records. For the mentally ill, this is an additional barrier because many have spent time in jail - often for minor offenses. (See Detention Center later in the Fact Sheet.)
A related problem is finding homes for persons ready for discharge from the state hospital - the Springfield Hospital for the Mentally Ill. Patients cannot be discharged unless housing is available. This logjam has both human and monetary costs.
The newly formed Alliance for Housing Action (AHA) composed of representatives from the Mental Health Association, the Coalition for the Homeless, the National Alliance for the Mentally Ill, providers, and others is searching for ways to find personal living quarters for all of the homeless-including the mentally ill. Their first position paper outlined possibilities for a continuum of care with different types of housing to accommodate different levels of need. Their work will bear watching -- and possible support.
THE JUSTICE SYSTEM AND THE MENTALLY ILL
Legal issues
Legal issues surrounding psychiatric treatment and hospitalization are fraught with controversy. There is a growing debate in Maryland as well as across the country about the use of "dangerousness" as the deciding factor in providing treatment to those who don't willingly seek it or recognize their need for it.
Currently, in Maryland for an individual to be involuntarily hospitalized, a "petitioner," i.e. a family member, a neighbor, a physician, etc., must petition the court for an emergency evaluation. The petition may be made only if the petitioner has reason to believe that the individual has a mental disorder and that there is a clear and imminent danger of the individual doing bodily harm to self or another.1
Mental health advocates point out the flaw in this approach that withholds needed treatment until a person becomes dangerous - thereby making the police the front line mental health workers. This approach also ignores the needs of those who refuse treatment because they do not think they are ill, thus leading them to physical and mental deterioration, homelessness, victimization, and unnecessary suffering.
Some advocates press for changes in the law to allow court ordered treatment on an out-patient basis, as well as changes in the "dangerousness" standard as a sole basis for treatment decisions. Others site the potential violation of an individual's civil rights and oppose the changes.
One approach that might work for both groups is the establishment of a special Mental Health Court with judges trained to make decisions about the need and appropriateness of treatment. Montgomery County has considered this option but no decision has been forthcoming.
The Treatment Advocacy Center in Arlington, Virginia has developed a Model Law for Assisted Treatment that is more flexible than our current law, and is designed to provide care to individuals who need it when they are unable to make informed decisions concerning their treatment. In addition to expanding the grounds for court ordered treatment, the Model Law provides safeguards that ensure appropriate treatment and the least restrictive alternative to meet the patient's clinical needs.
The police program: Crisis Intervention Team (CIT)
In December 2000, a unique training program for police officers was initiated in Montgomery County. Modeled after an award-winning program of the Memphis police, the course prepares officers to deal effectively with the mentally ill and reduce the level of deadly force often associated with emergency calls involving mentally ill citizens.
The department plans to train 25 officers each month, eventually training 20% of officers. The program is voluntary but has been well received by members of the department. The Crisis Intervention Team (CIT) has worked closely with staff from the Crisis Center in the development of curriculum and classroom demonstrations. This has also strengthened the relationship between CIT officers and the Mobile Crisis Team who work together in the community. The estimated expenses for this excellent program for 2001 were less than $7,000.
The Detention Center
Over the past 150 years there have been changes in the treatment of the mentally ill. In the eighteenth century, they were relegated to prisons, receiving minimal or no mental health care. By the late 19th century, states established mental hospitals to treat these patients more humanely.
When psychotropic drugs were introduced in the mid-20th century many states started the process of de-institutionalization. The original goal was to provide treatment in the community through the establishment of community mental health centers. This concept, however, failed. Housing for the mentally ill was lacking, funding for treatment was limited and civil liberty laws were passed in the 1970's that made it difficult to commit patients in need of treatment involuntarily.
Arthur Wallenstein, Director of the Montgomery County Department of Corrections and Rehabilitation, says that in the last year approximately 16,000 people were brought to the Central Processing Unit. Of these some 9,000 were booked into the jail. Out of this number 15-20% were mentally ill with conditions ranging from seriously mentally ill to non-violent chronically mentally ill. These numbers, according to Mr. Wallenstein, raise the question, "Is the jail to be used as a substitute for the mental health system?"
The Clinical Assessment and Triage Services (CATS) is a team of mental health professionals at the jail who assess new inmates suspected of having a mental illness at intake and try to divert them out of the criminal justice system and into community mental health treatment. Suicide prevention is one of their goals. There were 3 suicides between 1998-99 but none since. Three psychiatric nurses are part of the team and, among other responsibilities, they may be administering psychotropic drugs to as many as 125 people on a given day, although jail personnel cannot compel an individual to take his medication.
To correct the cycle of release and re-admission, Mr. Wallenstein believes that we must reduce barriers to service-lack of funding for treatment, managed care and housing. "We must build a seamless system." Presently inmates are released from the courtroom without appropriate clothing, medication, or help. If they were released from the jail there could be some discharge planning which might give them a better chance to succeed. At present all bookings and releases are from Rockville. The Clarksburg facility will open in the spring of 2002. There will be 60 days of practice and the county hopes to move prisoners in by June.
PROBLEMS AND THE NEEDS
1. Many believe that there should be parity in insurance that pays for treatment of mental and physical illnesses where now none exists. This is really a national issue that has been debated in Congress, but no legislation to this effect has yet been passed.
2. There must be not only adequate funding but also oversight of private providers under contract to the county. Is the present billing system and administrative setup too complex? Would the Baltimore Capitation Project be a model that Montgomery might follow? Would it be feasible to make the change? What about help for Medicare and also "gray zone" patients? Is it adequate?
3. How can we make more housing available to the mentally ill? What can be done to assist them in finding housing? Could HOC be convinced to modify its rule that it won't find housing for people with criminal records? Many mentally ill persons have jail records, but the may be for non-violent offences.
4. There is a need for more interagency data collection and sharing -- with proper safeguards for privacy. For example it would be helpful when a person is admitted to the jail, if the detention center personnel could refer to medical/psychiatric records.
5. The county apparently needs more information technology. Funding for updated information systems always seems secondary to pressing service needs.
6. Could grant writers for mental health help find monies that could be used to address some of our problems?
7. There is a tremendous need for greater cooperation between state and county personnel working in this field. At the time this Fact Sheet is being written services for the mentally ill in the public sector in Montgomery County, and in fact, around the state, are in crisis. We hope, however, that out of the crisis there may be opportunity. It will require a good deal of work on everyone's part.
CONSENSUS QUESTIONS:
In the Spring of 2000 LWVMC reached consensus on support for a number of public mental health services for children and adolescents. The following list of services combines those services that also apply to adults with mental illness, as well as certain services that are specific to the needs of this adult population:
1. Should the League support provision of the following public mental health services for adults: a. A range of treatment services including in-patient, out-patient, residential, home and community-based crisis intervention, and pharmacy? b. Culturally sensitive, diverse, multi-lingual providers? c. Case management with coordination and continuity among agencies including in-patient institutions, shelters and the correctional system?
2. How should Montgomery County ensure an accountable and reliable system for mental health services? a. Develop a comprehensive mental health plan? b. Define professional standards and best practices for all providers to observe? c. Provide oversight of contracted services? d. Develop an information technology system that will collect data and define standards for inter-agency sharing and collaboration, while safeguarding patient privacy? e. Work collaboratively with the state to ensure appropriate and timely payment of providers and streamlined administrative systems?
3. How should Montgomery County ensure that adequate mental health services are available and accessible to adults in all parts of the county: a. Seek more realistic funding from the state to provide comprehensive care? b. Supplement state funding with county funding when needed? c. Identify and pursue additional funding such as federal or private grants? d. Maintain a safety net of public mental health services? e. Increase availability of housing for the mentally ill homeless through a range of housing possibilities, including group homes, "safe havens," and personal living quarters?
The committee thanks the following people for their generous help with our study: Jean Burgess, Clinical Coordinator, the Crisis Center; Evelyn Burton, NAMI, Montgomery County; Jeff Carswell, Affiliated Sante Group; Marilyn Kresky-Wolff, Mental Health Association; Officer Joan Logan, MC Police Dept; Daryl Plevy, Acting Chief, Mental Health Services, MCDHHS; Rich Schiffauer, Threshold Services; Arthur Wallenstein, Director, MC Department of Correction & Rehabilitation - and Ellen Menis, LWVMC Housing committee.
League of Women Voters of Montgomery County, MD, Inc. Fact Sheet March 2002
The following positions were approved by the board:
MENTAL HEALTH SERVICES FOR ADULTS
ORGANIZATIONS AND INDIVIDUALS ARE INVITED TO DUPLICATE THIS FACT SHEET WITH ATTRIBUTION GIVEN TO LWVMC. BEFORE REPRODUCING, PLEASE CALL THE LEAGUE OFFICE AT 301-984-9585 FOR CORRECTIONS OR UPDATED INFORMATION.