There are few public policies and government programs that are less understood by the general public than state behavioral health care. In many jurisdictions it is the only part of the health care delivery system where state or local government is both the primary funder of care and a direct provider of care. Millions of dollars are spent on the treatment, support, and supervision of a narrow segment of our population. Very often this is a segment that has been shunned or ignored by traditional health care delivery systems, and where government has become the provider of last resort.

Most would agree that people with serious mental illness are among the most vulnerable in our society. Yet, attempts to adequately fund or provide services to these individuals are often viewed as low government priorities. In Arizona, like so many other states, the question of what to do for people with serious mental illness is debated not in state legislatures or county councils, but in courtrooms where lawsuits have resulted from years of inaction or restrictive care.

A state's policy toward the care and treatment of people with mental illness should not be treated as a low public health priority. Rather, as some states and local jurisdictions have found, the care and treatment of people with mental illness can include progressive policies and actions that foster effective rehabilitation and recovery, and the efficient use of tax dollars. But how do you get these systems and public attitudes to change?

In attempt to find the answer, St. Luke's Charitable Health Trust began a strengths-based analysis of Arizona's public behavioral health system. This analysis identified the elements of "best practice" found in public mental health care delivery systems across the United States and applied these best practice models to Arizona's public mental health care delivery system. The results of this analysis form the basis of this report.

The findings and recommendations included in this report ultimately focus on issues and gaps that should be addressed if Arizona is to move toward the best practices goal for adults and children with behavioral health issues. Nonetheless, conducting a strengths-based assessment has been the appropriate focus, as many strengths and positive service delivery models have been identified. The intent was to find and document a foundation on which the improvements in the system could be built. That intent has been satisfied.

The 10 most promising aspects of the Arizona public
behavioral health system identified in this study are:

1. Structure for Managed Care - Arizona has developed a managed care structure, based on the carve-out model. Although the carve-out model engenders issues with regard to primary health care integration, it is currently preferable in jurisdictions in which Medicaid is a primary funder of the public behavioral health system. The current structure supports the use of managed care principles and technologies, including utilization management, information management, outcome measurement and quality assurance.

2. Risk-Based Financing - Risk-based financing is used in Arizona to create incentives and push the system toward appropriate utilization and cost control. Risk based financing, with appropriate risk sharing arrangements such as those in use in Arizona, provide the most positive incentives to manage care effectively and efficiently. It also provides flexibility to local managers on the design and implementation of public mental health services.

3. Local Systems of Care - The behavioral health carve-out has been implemented in a manner that emphasizes local systems of care, and in which financial, clinical, and administrative authority is consolidated in the agencies managing the local systems of care. The five RBHAs in Arizona have different organizational and service delivery models, and have flexibility to arrange service delivery tailored to local needs.

4. Strong Clinical Leadership - There is evidence of strong and forward-thinking clinical leadership at the top of Arizona's public mental health system. Many of the clinical protocols and guidelines emanating from the Arizona Division of Behavioral Health Services are examples of evidence-based best practice, and provide a good foundation for implementing such best practices in the field.

5. Examples of Innovation and Best Practice - Pockets of cutting-edge best practices have been identified in Arizona, and these could be replicated more widely throughout the state as part of the strategy to improve the system.

6. Strong Data Collection - There is relatively good and consistent data collected throughout Arizona's public mental health system, and the management information systems are on a path to becoming even better. Consistent, timely, and accurate data that can be used for accountability, planning, quality improvement, and system management is essential to a high quality managed system of care.

7. A Focus on Those with Serious and Persistent Mental Illness - The system of care for adults in Arizona is appropriately focused on individuals with serious mental illness. This is partly a result of the state's efforts to comply with the Arnold vs. Sarn stipulation and order. It also reflects a firm and long-standing commitment on the part of state and local behavioral health system leadership to individuals with serious mental Illness.

8. Strong Cultural Competency - Arizona is a culturally and linguistically diverse state. Its successes in tailoring service components and delivery approaches to culturally and linguistically diverse individuals, when implemented more consistently statewide, will be a model for the rest of the country.

9. Models of Rural Service Delivery - There is a strong commitment to providing good public behavioral health services in rural areas of Arizona. Rural strategies such as telemedicine and paraprofessional behavioral coaching are good models for serving diverse populations in large rural areas.

10. A Record of Research and Demonstration - Arizona has a history of conducting demonstration projects aimed at improving behavioral health services. Several demonstration grants, such as the consensus panel activity related to co-occurring mental illness and substance abuse, show promise in terms of developing and replicating best practices in Arizona.

As with many state public behavioral health systems, there remain a number of important organizational problems and issues that must be addressed if the Arizona system is to continue to move towards best practices. These include:

~ The Arizona system needs to be more consumer and family driven. There are few formal efforts to organize and empower families and consumers or include them in governance, planning, policy development, quality management, or performance evaluation.

~ There needs to be a clear and cohesive vision of what Arizona's mental health system should be at all levels of the system. There is no multi-year budget or strategic business plan that brings all the elements of the system together. There does not appear to be a commonly understood definition of the horizon towards which all components of the service system should be moving.

~ Access to public mental health services should be improved. There are dual systems of care for both adults and children, one for Medicaid enrollees and adults with serious mental illness, and another less generous system for all others, including non-Medicaid but indigent children in need of services. Also, as noted in the main report, there are substantial inconsistencies in per capita resources and penetration rates throughout the state. These inconsistencies are indicators of unequal access to consistently delivered services for all citizens of Arizona.

~ There ought to be formal mechanisms to connect policy and knowledge to local practice/service delivery. Good clinical practices and guidelines are not yet consistently implemented at the service delivery level because there is no over-all training plan and strategy and few performance incentives for adopting best practices.

~ There ought to be effective linkages between primary care and behavioral health care. RBHAs and stakeholders reported difficulty referring clients and adequately sharing information among health care professionals. There are no structures or processes required by the state in contracts with either HMOs or RBHAs that foster and enforce meaningful or effective integration and collaboration between the primary health care and behavioral health systems.

~ There ought to be better linkage and integration between the behavioral health system and other important sources of resources and services for priority consumers. Despite numerous intergovernmental agreements at the state level, coordination of resources and access to services with school systems, adult and juvenile justice systems and affordable housing and vocational service systems remain inconsistent. Partially as a result of poor linkages, the supply of integrated services, particularly affordable housing and modern supported employment services, is relatively low.

The following is a summary of common elements in those states that have moved most successfully towards best practice:

• There is a strong and consistent leadership that articulates a vision and forges consensus and momentum for implementing that vision.

• The vision articulated by leadership incorporates the concepts of recovery, consumer self-determination and choice, self-sufficiency, community and family-based services, and empowerment of consumers, families, and staff to be creative, flexible and accountable for local service delivery.

• Information about mental illness and emotional disability is made widely available to the general community; stigma and prejudice are publicly confronted when they become evident, and the vision and mission of the public behavioral health system are espoused constantly in all available forums.

• Consumers and families are engaged and involved in all aspects of the public behavioral health system, from governance and policy development through planning and program development to quality management and system evaluation. Consumers and families in those states have become the most effective advocates for the vision and mission of the public behavioral health system. They have also provided the motivation and momentum for the change process.

• Local systems of care have been developed, and these local systems have the requisite clinical and financial authority and accountability to carry out the statewide vision and mission in ways that are reflective of local conditions and needs. These local systems can be non-profit, for profit, quasi-governmental, county-based or multi-county programs.

• Information gleaned from a variety of data sources is used to drive system planning, budgeting, quality management and performance evaluation. In "best practices" states decisions are made at all levels based on consistent analysis and interpretations of accurate and timely data. Included in the information analyzed is literature describing evidence-based best practices from other jurisdictions as well as information generated from within the state's own systems.

• An organizational culture that fosters and supports constant learning, change, challenging of sacred principles, and trying out new ideas has been created throughout the public behavioral health system.

In the above list of characteristics there is no mention of service types, financing levels or approaches, clinical technologies, or requirements for organizational models. Rather, the list incorporates attributes that move these systems toward excellence and responsiveness as a context for the details of service provision. Specific best practices related to service models and treatment models will continue to evolve and change. Public behavioral health systems that embody the above characteristics will be in the best position to implement specific changes. In fact, it is systems that meet the above characteristics that most often will generate new and improved ways of meeting consumer and family needs and choices in the most cost effective and accountable manner.

It is virtually impossible, and a poor use of the state's limited financial and human resources, to attempt to "fix everything" or create "wholesale" change in Arizona's mental health system. Rather than take a wholesale approach to change, we encourage the state to be more strategic in how to use the valuable and scarce resources it has to leverage change where it will dramatically improve care and provide leadership for ongoing policy and program advancements. Our analysis of the Arizona system has identified the following key strategic initiatives:

The Integration of Primary and Behavioral Healthcare. AHCCCS and BHS should jointly develop program specifications for the structural and functional integration of primary and behavioral healthcare. RHBAs, HMOs and other health care providers and insurers should be encouraged to develop creative approaches to integration through pilot projects.

Changes in the Regulation and Delivery of Benefits for People with Mental Illness or Emotional Disorders. Arizona should implement a flexible and individualized service benefit package through de-regulation at the state level and performance measurement based on consumer outcomes rather than process assessment. To accomplish this, the state should form a task force comprised of consumers, families, behavioral health professionals, and state and RBHA managers. The task force should be charged with the responsibility to review all regulations and funding requirements, assess the purposes of such regulations and requirements in terms of specific benefits to consumers, and then recommend outcome and performance measures that would assure the same positive benefits are being attained in the absence of regulations.

Raise TANF Eligibility. The eligibility rate for TANF should be raised to 100 percent of the state's federal poverty level to provide health coverage to this population now under served by the state's behavioral health care system.

Increase Enrollment under CHIP (KidsCare) Program. The state should continue to improve the current outreach and engagement strategy to enroll families in this important program. In doing so, the state will close another gap in coverage for behavioral health services. This will reduce the number of people who are to be served with the limited amount of funds set aside for those not under the AHCCCS or SMI program. Further, recent budget action notwithstanding, reductions to state appropriations for indigent care for children and families should not be reduced based on assumed savings from the KidsCare program.

Resolve Arnold v. Sarn. It is time for a concerted course of action by all parties to resolve the outstanding issues in this case. To accomplish this, we recommend that the state establish a court order unit in the state agency with sole responsibility for overseeing its implementation, including: (a) reexamining aspects of the court order to which modifications may be necessary; (b) implementing the core benefit package described above for public behavioral health that applies to all who have been found in need of services; and (c) instilling a commitment for quality management in the public behavioral health system.

Create a Culture for Change - Arizona needs a new culture within its mental health system. This new culture must support a learning environment conducive to change. To foster this climate and culture change, we recommend the creation of the Arizona Behavioral Health Institute. The institute cannot change the culture overnight alone, but it can provide a focal point for discussion, action and leadership that can begin the process of culture change.

St. Luke's Charitable Health Trust has begun to provide leadership in efforts to improve mental health services in Arizona. These efforts include underwriting this study as well as the formation and operation of the Mental Health Dissemination Network of Arizona (MHDNA). The Trust and MHDNA should continue to have an important role in fostering the strategies for change contained in this report. These strategies might include:

a. Funding of certain demonstration projects.

b. Sponsoring independent evaluations leading to improved evidence-based practices.

c. Providing leadership as a catalyst for change.

d. Sponsoring public education and information dissemination activities.

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