A. Introduction: What are Best Practices?
As discussed in Chapter I of this report, there are several conceptual domains of best practice that are important to consumers and families in the public behavioral health system. The first domain reflects characteristics of any public sector human services, health care, or behavioral health care system in any jurisdiction. These include:
~ Customer orientation - respect for and responsiveness to the individual needs and choices of consumers and their families at all levels of the system. This also includes consumers and families in governance, planning, program development, quality management and system performance evaluation;
~ Clinical excellence - implementation of evidence-based clinical treatment practices consistently throughout the system, enforced through clinical leadership, training, standard clinical treatment protocols, and constant learning and improving through a strong and systemic quality management process;
~ Continuity - assurance that every individual and family will have a single point within the system with the accountability and responsibility to be there when needed, and to respond to individual and family needs as they change over time;
~ Integration - assurance of seamless and facilitated movement among the components of the public behavioral health system and full and coordinated access to and integration with other important services and supports, including primary health care, housing and vocational services; and
~ Stewardship of public funds - clearly identified single points of public accountability for the quality, effectiveness and efficiency of the public behavioral health system and consistent evaluations of the quality and performance of the system.
The second domain reflects the practical elements of implementing specific program model and clinical treatment best practices within the preferred public behavioral health system. These are elements without which the first set of criteria cannot effectively be met, and include:
~ Vision - clearly articulated and understood mission, values and strategic direction for the public behavioral health system as a whole;
~ Strategy - feasible and proven approaches to structuring, organizing, financing and operating the public behavioral health system:
~ Technology - the actual practice and delivery of services to priority consumers and their families;
~ Human Resources - the supply of trained, competent, and culturally relevant staff necessary to deliver best practice service models; and
~ Culture - the expectations and beliefs by all participants in the system in the value and potential of all consumers and the value of a high quality, customer-oriented, efficient and effective public behavioral health.
The third domain reflects the combination of empirical research, professional judgement, feasibility of implementation and relevance to Arizona. As stated in Chapter I, these include:
~ There have been qualified evaluations of the program model or clinical practice and the positive effects of the approach(es) are described in peer-reviewed literature;
~ The practice or approach has become a nationally accepted best practice and has been widely used as a standard and guideline for program implementation and service delivery for a substantial period of time;
~ The team has knowledge and experience with the practice or approach from successful and beneficial implementation in other jurisdictions;
~ The practice or approach is relevant to Arizona local conditions and definitions. It addresses gaps or needs in the current service system; and/or
~ The implementation of the practice or approach is feasible within the current Arizona public behavioral health system.
The best-practice templates represent a combination of practices that fit one or more of these criteria. They share not only common features that can be found in any preferred system of care, but also the following unique characteristics:
~ They were developed as a result of an open attitude toward change, including the willingness to learn from mistakes and start over again;
~ They started small and were replicated elsewhere-the best practice can become evidence-based through repeated replications and revisions;
~ They represent practices that go beyond behavioral health care-many practices affect other systems of care as well.
B. The Preferred System of Best Practices
for Children and their Families
The federal definition of children with serious emotional disturbance (SED) includes children from birth up to age 18 who currently or at any time during the past year have had a diagnosable mental, behavioral, or emotional disorder of sufficient duration to meet diagnostic criteria specified within DSM. That DSM diagnosis must have resulted in functional impairment that substantially interferes with or limits the child's role or functioning in family, school, or community activities. Using this definition, it is estimated that between nine to 13 percent of children have diagnosable SED.14
For many years efforts have been made at the federal, state, and private level to develop and implement best practice approaches to behavioral health. These have included the Ventura County study in California. In addition, the Robert Wood Johnson Foundation, the Kellogg Foundation, and the Annie B. Casey Foundation have all sponsored major studies and demonstrations of integrated child serving models. Through these and many other studies, the technology of serving children and their families with serious emotional disturbance has improved substantially. For example, clinical interventions with psychotropic medications, including some of the newer atypical antipsychotic medications and selective serontonin re-uptake inhibitors (SSRIs such as Prozac and Paxil) are becoming documented.15 Clinical treatment protocols for many SED conditions, such as oppositional defiant disorder and attention deficit hyperactivity disorder, are also well established.16 Unfortunately, in almost all jurisdictions, even after many years of demonstration funding and effort, the children's' puzzle remains to be solved.
This fact is true for two reasons. First, whether or not children are diagnosed as having SED or general behavioral disorders, the manifest problems and needs of children, families, schools and community life are inevitably intertwined. Children needing treatment and supports often live in environments where substance abuse is rampant, family stability is uncertain, physical and sexual abuse is common17, schools are overcrowded and under funded, poverty and unemployment are widespread, and class, race, and cultural characteristics create unspoken but intransigent barriers to family well-being. For many, the successful treatment of children with SED rests on social and economic interventions far broader than the realm of behavioral health services.
Second, children and their families are impacted by a multitude of often un-coordinated community entities. These include the educational system, the juvenile justice system, the child protective service system and the primary health care system. They are further impacted by the uncoordinated entities from which their families may be seeking services and supports as a way to improve the lives of their children. These multiple entities all have scarce resources, conflicting missions, excessive demands for service, and high risks of failure for youth in their care. It is no surprise that the children's puzzle cannot be put together easily in the face of these organizational differences.
At the federal level, the Child and Adolescent Service System Program (CASSP) philosophy has long been recognized to define best practice and preferred systems of care for children and their families. The CASSP principles clearly state that services for children and families should be child-centered, family-focused, community-based, multi-system, culturally competent, and least restrictive.
At the direct service delivery level, specialized programs have been developed during the last decade to target high-risk children and families. These include the Family Preservation Program, based on the Homebuilder Model pioneered in Tacoma, Washington, to address children at imminent risk of out-of-home placement. Intensive Case Management, tried in several states (New York, Ohio, Oklahoma, Texas), has been used to work with children and families who have not responded to traditional approaches to service delivery. In addition, various assessment tools have been developed to measure the functioning of children and families, from CAFAS (Child and Adolescent Functional Assessment Scale18), to NCFAS (North Carolina Family Assessment Scale19), to Vermont's Child Behavior Checklist.20
To help children gain access to appropriate and effective services, protocols for levels of care for children with behavioral health care needs have also been developed. The American Academy of Child and Adolescent Psychiatry has a working draft for levels of care for children and adolescents and several levels-of-care protocols for children have been developed for Erie, Pennsylvania; Delaware; Iowa; Ohio; Oklahoma; and South Carolina.21 There is recognition that these tools can help determine medical necessity for services and help support child- and family-centered services. Moreover, they are prerequisites to effective utilization management.
Consistent with the above discussion, the elements of a best-practice template for behavioral health services for children and their families include:
~ System-wide commitment to tearing down institutional barriers to allow state and local child-serving agencies to openly and fully coordinate access to and delivery of their discrete services;
~ Methods and supports for empowering children and their families and front-line staff. Children and their families do best when they participate fully in treatment planning and service choice. In many best practice models, families choose service models, select providers, and train and supervise them to work in their own homes and schools. In a similar fashion, front-line staff must feel free to be flexible, creative, and individualized in assisting children and their families to access services. They must also feel supported and free to take risks without fear of retribution;
~ Systematic and coordinated approaches to access, comprehensive assessment, service planning, and outcome measurement for services. Children and their families should have one and only one integrated assessment and treatment plan, and should be able to access all needed and chosen services from wherever they present in the system. This unified access and treatment planning approach should also assure continuity of treatment and supports as well as facilitate access to a variety of services across agency lines;
~ CASSP principles should be implemented consistently on a statewide basis. These include:
- Providing needed services in the child's home community
- Least restrictive, most normalized environment
- Comprehensive array of services that address physical, emotional, social, and educational needs
- Child and family-centered approach to strengths-based service delivery
- Culturally appropriate services
- Interagency collaboration and cooperation
- Early identification and intervention
- Include specific child/family outcomes in the accountability system
- Allocation of resources to prevention and early intervention services
Examples of Best Practice Approaches
in Arizona and in other Jurisdictions
Against this template, some Arizona promising practices, such as the two Interagency Case Management Project (ICMP) demonstrations for children and families with multiple system involvement, and the Model Court as practiced in Pima County have achieved promising results. The Juvenile Drug Court in Maricopa County shows promise as a treatment modality, but its costs and longer term outcomes are still being evaluated. Examples of successful, culturally competent prevention and early intervention programs include the South Side Partnership/Luz Social Services (a substance abuse prevention program for Spanish-speaking youth located in Tucson) and "Storytelling" (a school based primary prevention program of Compass Health Care, Inc. located at the middle school at the Tohono O'odham Indian reservation).
Another promising model is behavioral coaching services for seriously emotionally disturbed youth, currently used in the NARBHA region. In this model, paraprofessional staff are trained to work one-on-one with youth in school and/or at home. The staff assists the assigned youth through important functions of daily living and learning, and teaches skills and coping mechanisms. At the same time, the staff train teachers, parents, and other caregivers on how to work with the particular mental and behavioral difficulties presented by the youth.
In the State of Delaware, under the umbrella agency Department of Children, Youth, and Their Families, an integrated assessment, gatekeeping and authorization unit has been established within the Division of Child Mental Health, as part of the state's Medicaid 1115 waiver project. The centralized assessment, available to referrals from child welfare, juvenile justice, and mental health systems, incorporates EPSDT requirements with a standardized tool that is linked to a protocol for levels of care. Since the unit became operational in 1997, the state has reduced length of stay in residential treatment and psychiatric hospitalization. In 1998, the Division became the first publicly run Managed Services Organization to be accredited by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO).
In Hamilton County, Ohio, a public/ private partnership has resulted in collaboration among three public systems (child welfare, drug and alcohol, and mental health) to jointly purchase information system, care management, and managed care technologies from the Magellan Public Solutions. A uniform assessment, together with a protocol for levels of care, has provided consistency of provider performance in three service systems.
In Iowa, through a statewide Children's Medicaid initiative, five systems (child welfare, juvenile justice, mental health, mental retardation, and substance abuse services) have collaborated to develop Clinical Assessment and Consultation Teams. This is located in social service regions, with the primary responsibilities for assessing children referred by the four systems for appropriate triage into four levels of community-based services (general family-based support, intensive family preservation services, foster care, and group care). The team also provides continued stay review and monitoring of service outcomes. The project was successfully incorporated in the state's Medicaid plan. The project also complemented a Casey Foundation-supported De-categorization Project at chosen pilot sites in which all non-Medicaid funds at the county level were bundled and used by multiple children's systems.
In addition to the specific examples noted above, a number of other jurisdictions throughout the United States have successfully implemented best practice child/family systems of care consistent with CASSP principles, including attainment of relative integration and coordination among all child-serving agencies. These include a consortium of area programs in the Blue Ridge section of western North Carolina, Erie County, PA, and certain multi-county regions of Iowa. All of these jurisdictions have accomplished this through:
~ A planned and thoughtful willingness on the part of all parties to cede control and share resources in meaningful ways;
~ Single-site management of all resources, with the authority to access all applicable service modalities and to commit funds for these services;
~ Integration of and adherence to CASSP principles throughout the system of care;
~ A unified comprehensive, strengths-based assessment and treatment plan governing all aspects of service access and delivery;
~ Leadership committed to managing and delivering services in new, creative, and flexible ways22;
~ A commitment to include families and their children in all levels of service planning, implementation, management, and evaluation as well as in treatment planning and provider choice; and
~ A promise not to let children and their families go - the system will be there for them whenever and wherever they want, with whatever they need and choose.
Issues to be addressed in the Arizona Child and
Family Public Behavioral Health System
As documented in other sections of this report, the child behavioral health system is significantly under-funded in Arizona. It also appears true that state level policies, procedures, eligibility and funding requirements, and service practices and priorities have not been effectively coordinated and integrated for the benefit of children and their families. The combination of scarce resources, funding, and fragmented services administration results in much of the effort of both families and case managers being spent trying to negotiate the various child serving agencies. Effort is also spent trying to piece together a needed array of services from a variety of service delivery and funding sources. Informal efforts such as the multi-agency teams (MAT) in Flagstaff, Apache Junction, and Yuma for example, and the more formal interagency case management projects (ICMP) in Phoenix and Lake Havasu, have found ways to coordinate access and cut through the complexities of these programs. However, these promising approaches rely on personal good will and ingenuity at the point of service level. They are not systematically supported by policy changes or administrative actions at the state level to integrate and coordinate services and to break down bureaucratic barriers to service access.
Another important issue is the very low threshold for eligibility for Aid to Families with Dependent Children (AFDC) (33 percent of the federal poverty level). This has the effect of excluding a large group of indigent, uninsured families and children from Medicaid Arizona Health Care Cost Containment System (AHCCCS) funded services. In concert with slow enrollments in Arizona's KidsCare program, this low threshold creates excessive demand and unmet need for state-funded services for non-Medicaid children and their families.
Finally, funding-related service system capacity limitations remain a consistent issue. There are long wait times to initiate services and to receive a psychiatric evaluation, and there are too few case managers to meet current demand. Child/adolescent residential treatment does not exist in most rural areas, and crisis stabilization resources for youth are particularly limited. Flexible wraparound and family-focused services for youth are also very limited. Several of the recommendations in Section IV of this report offer solutions to these issues.
C. The Preferred System of Best Practices
for Adults with Serious Mental Illness
The technology of behavioral health services for adults has improved significantly in the past 30 years. For general mental health services (i.e., depression, anxiety, post-traumatic stress, etc.) the combination of new medications and brief cognitive-supportive therapies have proven to be almost universally effective. For individuals with serious mental illness (i.e., schizophrenia, bi-polar disease, chronic depression) the new technology includes atypical anti-psychotics and proven community treatment approaches such as assertive community treatment, supported housing and employment, and recovery- oriented psychosocial rehabilitation services.
Some individuals suffering serious mental illness today have benefited greatly from these scientific and service technology advances in public behavioral health care systems. Unfortunately, for a variety of reasons public behavioral health systems throughout the United States have been slow to implement these proven technologies. The result is that the vast majority of low income individuals with serious mental illness, including those in Arizona, continue to receive services and supports more reminiscent of the 1960s than reflective of the 1990s. The consequences, as well documented in the media, are increased incarcerations, increased homelessness, and increased stress on families and communities.
The preferred public behavioral health system is comprised of a number of interlocking and interdependent elements. These start with basic treatment philosophy and values, and extend to specific face-to-face clinical and community support services. As with the preferred child and family public behavioral health system, the integration and continuity of these components are as important to consumers and families as is the presence of each discrete element. The following are the key elements of the preferred public behavioral health system:
Treatment and Support Service Philosophy,
Vision, and Values
Recovery values and principles - Recovery includes building internal strengths, building social support networks, and overcoming stigma through activism and self-advocacy. For the recovery vision to be achieved, all participants in the system must come to believe in the value, individuality, and recovery potential of each individual, and must incorporate recovery principles and values in policy-making, system planning, resource allocation and performance evaluation within the system.23
Consumer self-determination and choice - An essential ingredient of consumer recovery and empowerment is self-determination and choice. This is delivered by the system through: (a) assuring ample opportunities for consumer self-determination and choice; (b) providing whatever supports are necessary to facilitate consumer self-determination and choice; and (c) assuring that there are a range of options from which consumers can make reasonable choices.
Continuity of connection with the system - Most consumers say becoming empowered and exercising choice is the best and most therapeutic way to interact with professionals. Consumers also emphasize that a lasting relationship with trusted caregivers and continued receipt of needed and chosen services are key elements of each person's personal path to recovery.
Arizona is in the beginning stages of developing a recovery vision and principles for adult community mental health services. The community service models being developed under the Arnold v. Sarn Stipulation and Order incorporate recovery values and consumer choice and empowerment strategies, but these are for the most part still in the planning stages. As will be described below, there is at least one consumer-operated program, located in Maricopa County. Outside Phoenix, several of the RBHAs are talking about recovery and rehabilitation, and are exploring service models from other jurisdictions, such as Colorado. But again, much of this service philosophy and approaches has not been translated to the level of consumer services and program models.
States that have fully implemented the federal community support program (CSP) model (see below) tend to be the furthest along in terms of truly integrating recovery and empowerment values and principles into the local public behavioral health delivery systems. These include Rhode Island, Ohio, Vermont, Colorado and Wisconsin.
The Community Support Program (CSP)
Approach - Services and Supports for
Rehabilitation and Recovery
For many years the widely accepted preferred model of community-based services has been the federal community support program (CSP)24 The CSP model emphasizes consumer centered strengths-based services, empowerment, racial and cultural appropriateness, service flexibility, incorporation of natural supports, accountability to consumers, and coordination and continuity. CSP standards for minimum service capacity include: (Note: some of these are discussed in more detail below.)
~ Outreach, including transportation to facilitate access;
~ Assistance in meeting basic needs for food, clothing, shelter, personal safety, and medical and dental services;
~ Mental health treatment, including inpatient and partial hospitalization, medications and medication management, individual and group counseling, and residential evaluation;
~ 24 hour crisis assistance;
~ Psychosocial and vocational services;
~ Rehabilitative and supportive housing;
~ Education about mental illness to the community;
~ Protection of consumer rights; and
~ Case management and community support.
Clearly, CSP principles and service components are consistent with and supportive of the recovery, empowerment, self-determination, and choice visions outlined above. For most state and local jurisdictions, the CSP guidelines have functioned as the preferred system template for adult behavioral health services in the community.
Psychosocial rehabilitation approaches - Recovery is what people with disabilities do… rehabilitation [is] what helpers do to facilitate recovery…."25 Psychosocial rehabilitation, also known as psychiatric rehabilitation, includes a set of services and supports designed to assist individuals regain maximum independent functioning in living environments and communities of their choice. The service modalities, usually defined within psychosocial rehabilitation, include community supports such as peer supports, psychosocial clubhouse services, supported employment and supported housing. The philosophy that binds these services together "involves (a) respect for the consumer and encouragement of his/her active participation in the rehabilitation process; and (b) positive assumptions about each individual's potential for recovery of function and enhancement of quality of life."26
In an important way, psychosocial rehabilitation services are designed to assist consumers to develop skills and strengths in all the aspects of their lives other than clinical treatment. Psychosocial rehabilitation services are concerned with what people do for the 160 hours per week or so in which they are not participating in counseling, medication management, or visits with case managers. Thus, psychosocial rehabilitation addresses skills and strengths related to living, learning, working, loving, socializing and otherwise participating in community life.26
Peer supports/consumer operated services - Consumer operated peer support and self-help activities can take a number of forms. Many consumers form clubhouses or drop-in centers, and/or operate warm lines, peer outreach, and related services. Consumers as peer supports have also been successfully integrated into crisis outreach teams and assertive community treatment teams. Consumers have become engaged in training, satisfaction and quality reviews, ombudsmen services, and a variety of related self-advocacy activities. And, consumers have branched out into entrepreneurial activities, both within and without the behavioral health fields.
From the literature and from self report, two themes are clear: (a) consumers find peer operated self-help type services helpful and satisfying in their path towards recovery; and (b) consumers help themselves substantially by becoming caregivers for others (not necessarily just other behavioral health consumers.) Thus consumer operated peer support and self-help are integral to any community behavioral health system of care, and contribute significantly to the vision of recovery and rehabilitation.
Early intervention - Most individuals exhaust all private insurance and other private and family resources before arriving at the front door of the public system. This is unfortunate, since the public behavioral health system is usually substantially more adept at treating serious mental illness than is the private sector. It is even more unfortunate because proper interventions early in the course of serious mental illness usually have very beneficial results
Early intervention is better for consumers and their families because it reduces the long-term negative effects of the illness and initiates the recovery process at a time when the disabling effects of the illness are minimal and personal and family resources are not yet exhausted. Early intervention also has beneficial consequences for the public behavioral health system, in that it has the potential to reduce the life-cycle costs of services and supports for a substantial number of individuals with serious mental illness.
Arizona has begun making progress towards adopting and implementing recovery and rehabilitation-oriented service values and approaches. For example, consumer operated services such as peer mentoring and warm line services have been implemented in both Tucson and Phoenix. In addition, there are examples of good psychosocial clubhouse models (i.e., CPSA region) and good supported employment programs (i.e., NARBHA region.) These examples can and should be replicated throughout Arizona.
There are many signals that in parts of Arizona the CSP principles and program components are being viewed as defining the direction in which the adult behavioral health system should be progressing. For this to be accomplished will require years of effort directed to system change, service development, effective engagement of consumers and families at all levels, and in-depth training leading to fundamental culture changes in the system. Thus, it should not be expected that the fruits of this transition to CSP principles would be evident at this juncture. What is important is to plan the steps necessary to get there, and then to consistently monitor progress to assure that the system is moving at the right speed in the correct direction.
As noted above, state jurisdictions such as Ohio, Rhode Island and Vermont that have fully implemented the CSP model of services have in place a wide variety of recovery and rehabilitation services that meet the best practice standards discussed above. Specific examples of best practice include Fountain House model psychosocial clubhouses in numerous jurisdictions27, and peer operated services in New York City, Philadelphia, PA, Austin, TX, and Denver, CO.
Acute and On-Going Treatment Interventions
Crisis services - The essential elements of a comprehensive community-based crisis response system include:
~ Twenty-four hour, seven day per week, 365 day per year central telephone response system staffed by qualified mental health professionals and having immediate capacity for face-to-face assessment plus on-call consultation with a psychiatrist;
~ Clinical capacity and legal authority to approve or deny admission, voluntary or involuntary, to any public (operated or paid) psychiatric inpatient facility;
~ Assured and speedy access to appropriate clinical specialties, such as board-certified or board eligible child psychiatrists;
~ Mobile capacity, in which teams of mental health professionals and peer counselors are available to respond within one hour to psychiatric crises wherever they present, including hospital emergency rooms, individual homes, and local jails. The mobile unit must also have the capacity to transport or arrange for transport of individuals in crisis to an appropriate evaluation and stabilization facility;
~ A variety of short term (23 hour to 14 day) adult and child holding and intensive residential treatment resources for crisis stabilization and hospital diversion;
~ Facilitated linkage with other healthcare resources, to arrange for medical clearance, toxic screens, lab work related to rapid medication titration, and medical and non-medical detoxification; and
~ Direct access to cultural and linguistic clinicians and translation services to facilitate assessment and crisis stabilization.
Mobile outreach/ACT/ACM teams - Assertive Community Treatment (ACT) is the model most commonly used to provide intensive mobile services to consumers who are: (a) at very high risk of hospitalization or otherwise losing community housing and supports; and (b) who are unwilling or unable to participate in or benefit from traditional clinic or facility-based services. ACT is defined as "a self contained clinical team that:
~ Assumes responsibility for directly providing needed treatment, rehabilitation, and support services to identified consumers with severe and persistent mental illness;
~ Minimally refers consumers to outside service providers;
~ Provides services on a long-term basis with continuity of services over time;
~ Delivers 75 percent or more of the services outside program offices;
~ Emphasizes outreach, relationship building, and individualization of services."28
ACT teams are typically comprised of a team leader, a psychiatrist (usually part time), licensed mental health professionals (usually including at least one psychiatric nurse), mental health workers, and peer specialists.29
Medical and clinical treatment/ medication management - There are a number of fundamental principles or standards for high quality and effective clinical treatment services in the public behavioral health arena. For example:30
~ Inpatient and partial hospital treatment should be as brief as possible, should focus on acute stabilization and symptom amelioration, and should clinically prepare individuals for smooth and speedy transition into rehabilitation and recovery ser vices. In well-managed systems of care, the average length of stay for acute hospital admissions averages 7 to 10 days.
~ Participation in partial hospital or other intensive day services averages 14 to 21 days.
~ Longer-term, less intensive day services are no longer considered to be appropriate in well managed behavioral health systems, and many systems are now systematically converting traditional day service programs into psychosocial rehabilitation, clubhouse, and supported employment services.
~ Individual or group psychodynamic therapies are being replaced by short-term intensive cognitive ego-supportive treatment modalities. With the exception of medication reviews and medication management groups, it would be unusual for an individual with serious mental illness to be receiving office-based counseling services exceeding 7 to 10 encounters.
~ The new atypical anti-psychotic medications are now almost always the treatment of first choice rather than last choice. This is a major change from clinical practice of only a few years ago.31
~ Discharge policies and practices from intensive clinical treatment services should assure connection with the appropriate array of community support services. Re-admissions within 90 days should not exceed 10 percent of discharges from hospitals.
Meeting these types of clinical practice and utilization guidelines are important advances for a number of reasons. First, they result in better clinical and personal outcomes for most consumers. Second, they facilitate the recovery and rehabilitation process, and minimize the potential for long term dependence on clinical service modalities. Third, appropriate and therefore minimal utilization of expensive inpatient and other intensive clinical services permits the maximum amount of public resources to be focused on more cost-effective community support and recovery-oriented programs.
Another important development in the clinical treatment arena is the development of evidence-based and widely accepted treatment guidelines and clinical pathways for most major mental illnesses. The schizophrenia expert consensus guidelines, cited above, are one example of this type of improvement in the behavioral health system. Preferred clinical interventions, which include combinations of medication, clinical treatment, and on-going community support, are no longer a mystery for most mental illness. Thus, there is no longer a basis for wide and unexplained variation in treatment approaches. Even more important, all components of the behavioral health treatment system can be expected to deliver essentially the same level of consumer outcomes with similar ranges of number of encounters and costs for each episode of care. Finally, these treatment guidelines provide a firm basis for further evidence-based improvements to clinical practice and treatment outcomes for consumers.
Consistent with the new clinical guidelines, a considerable amount of evidence-based work has been done specifying and objectifying the clinical standards and workforce competencies needed to efficiently and effectively operate behavioral health services that meet standards for managed systems of care. For example, the federal Center for Mental Health Services (CMHS) recently assembled panels to define competencies related to adult mental health services, child mental health services, dual diagnosis services, mental health services for elders, and culturally appropriate services for African-Americans, Asian-Americans, Hispanic-Americans, and Native Americans.32 All of the competency guidelines were developed after exhaustive literature reviews and discussions with stakeholders.
The clinical guidelines and competencies support planning for service development, service operations, clinical protocols, and staffing models. They also support development of training and human resource development plans and strategies to assure that the public behavioral health workforce has the correct values, knowledge, and skills to deliver clinically appropriate and effective services.
Arizona has developed some excellent examples of clinical treatment guidelines. These include the service planning guidelines, such as guidelines for treating attention deficit hyperactivity disorder and oppositional defiant disorder for youth, and borderline personality disorders and depressive mood disorders for adults. The recently issued clinical treatment protocols for schizophrenia also reflect up to date evidence-based best practice. Further, the Arizona level of functioning assessment (ALFA) is a good instrument for uniform and consistent level of functioning assessment within Arizona.
Arizona has developed many of these excellent clinical guidelines, protocols, and now needs to concentrate on assuring consistent implementation in the field. Under the bast of circumstances it takes time and effort for evidence-based best practices to the places it is needed most - the point of service between the clinician or other caregiver and the individual consumer. Successful implementation requires continuous and broad-based training, strong and committed local clinical leadership, focused clinical supervision, frequent peer review, and quality management continuous quality improvement of these promising clinical practices. For example, the efficacy of certain clinical interventions for individuals with varying disabilities and diagnoses will be able to be tested reliably in Arizona, now that the ALFA instrument is applied and reported consistently, and clinical diagnoses have been added to the database to which ALFA information is reported.
Arizona has the basis for evidence-based best practice in its clinical treatment operations and approaches. Once recovery and rehabilitation- oriented services and supports in the community are more fully developed, the clinical protocols and guidelines need to address effective linkages among and between these service modalities. It is neither appropriate nor cost effective for these service and support modalities to operate either in parallel or sequentially. They must be fully integrated at all points of the system, and the clinical guidelines, utilization management criteria, and quality management process should all foster and encourage that integration.
In New Hampshire each area mental health center is expected to be competent in and compliant with clinical best practice, but also has performance expectations related to employment and independent living. This model assures a holistic approach tailored to each individual's needs and choices, and also assures improved outcomes for each component of the system of care. In Dane County, Wisconsin, which is the birthplace of assertive community treatment and community rehabilitation services, there is an equal emphasis on best practice clinical treatment interventions as there is on community recovery and rehabilitation.
The guidelines for length of stay and clinical approach to certain acute or intermittent services listed above reflect industry standards in both public and private managed systems of care. Informally, it appears that clinical practices in parts of Arizona meet these basic standards. However, these types of thresholds for treatment activity are not codified clearly in current clinical treatment guidelines, nor are they used as specific measures of performance throughout the system. Many states that have implemented managed systems of care now use these types of measures, not so much as pure indicators of clinical excellence, but rather as indicators of how well all components of the system are working to facilitate access to clinically appropriate services when and as needed. Iowa and Massachusetts are two examples of states with statewide carve-out models for Medicaid managed care that have adopted these types of standards and measures.
Arizona has examples of good crisis response and stabilization services, such as the Octotillo Program, a fifteen-bed crisis residential program in the CPSA region. This could be a model selected for replication as part of comprehensive 24-hour, seven day per week crisis services as they are implemented consistently throughout the state. Examples of best practice crisis services from other jurisdictions include Rescue Crisis in Toledo, Ohio, which has short term stabilization capacity, mobile crisis stabilization teams, and authority to approve or deny psychiatric admissions to both private and public psychiatric facilities.
D. Services for Special Populations
Services for persons with co-occurring mental illness
and substance abuse disorders
30 percent of people with mental illness have co-occurring substance abuse. 37 percent of alcohol abusers have mental illness, and 53 percent of drug abusers have mental illness. 40 to 80 percent of individuals seen in mental health treatment settings have substance abuse problems, and over 50 percent of individuals admitted to state psychiatric hospitals have a history of substance abuse. Among homeless adults, 50 percent are active substance abusers, and 30 percent have co-occurring mental illness and substance abuse. Co-occurring disorders are major contributing factors in loss of housing, treatment non-compliance, emergency room use, and re-hospitalization. From these facts it can be seen that dual diagnosis is the expectation, not the exception.33 Further, when mental illness and substance abuse diagnoses co-occur, they both must be treated as the primary diagnosis, not one or the other.
Thus, the public behavioral health system must be prepared and competent to serve individuals with co-occurring disorders in all components of the system, from inpatient to outpatient to community support and rehabilitation services. Services for individuals with co-occurring disorders are not a separate service component requiring distinct staff and new funding resources. Rather, the systems and competencies must be fully embedded in the entire system of care for individuals with serious mental illness.34
The technology and competencies necessary to serve individuals with co-occurring disorders have been proven for a considerable period of time over many empirical studies. The essential components are:
~ Integrated services coordinating treatment across outpatient, inpatient, and community support/residential service settings;
~ Assurance that all integrated service components are welcoming, accessible, continuous, culturally competent, and linked to all other necessary service systems;
~ Recognition that recovery is not a linear process, but rather one that must flexibly respond to individual consumer needs for engagement, self-acceptance, active treatment, relapse prevention, and maintenance - abstinence is step-wise, not absolute);
~ Use of integrated community support or assertive community treatment teams with dual competencies;
~ Continuous system wide co- and cross training; and
~ Coordinated, system-wide planning, development, and coordination.
Arizona has a federal Substance Abuse and Mental Health Services Administration (SAMHSA) Integrated Treatment Consensus Panel grant to support statewide consensus building and technical assistance related to the implementation of best practice integrated dual diagnosis services. Under this grant, the state has received consultation from some of the foremost experts in the field of co-occurring disorders. The anticipated outcome of this process is the development of state policies, practice guidelines, and training curricula to foster implementation of integrated services and competencies throughout the Arizona public behavioral health system. Arizona also has examples of integrated dual diagnosis service programs, most notably the New Arizona Dually Diagnosed Residential Program and the Life Affirming Dual Diagnosis Education and Recovery (LADDER) Program, both located in Maricopa County.
An example of best practice dual diagnosis service models from other jurisdictions is the Caulfield Center, near Boston, Massachusetts. This Center, started by Dr. Kenneth Minkoff,35 has developed and proven the major tenets of integrated treatment (i.e., definition as lifelong disorders, effective use of rehabilitation models, the need to address stigma, etc.) The program combines substance abuse and mental health treatment on an individualized basis, and is adjusted to both the individual's specific diagnoses and her/his phase of recovery.
In New Hampshire, integrated treatment of individuals presenting with co-occurring disorders is commonplace, and is the expected mode of treatment for the public mental health system for adults.36 Other examples include several of the McKinney homeless housing demonstration grant sites (i.e., Austin, Texas), the Center for Mental Health Services ACCESS sites (eight states), and the Robert Wood Johnson Program on Mental Illness demonstration sites, particularly those in Columbus (Franklin County) and Cincinnati (Hamilton County), Ohio.
Geriatric services - 15 to 25 percent of elders in the United States suffer from significant symptoms of mental illness. Persons over 65 years of age represent approximately 12 percent of the total population of the United States, yet they account for over 20 percent of the suicides nationwide. Despite these statistics, fewer than four percent of individuals treated in mental health centers nationwide are over 65. And, less than 1.5 percent of the direct costs for treating mental illness in this country are spent on behalf of elders living in the community.37
As a proportion of total population, those over 65 are the fastest growing group. This is caused by two factors. First, the substantial burst of population growth in the late 40s and early 50s (the baby boomer generation) results in proportionately higher numbers of individuals who will turn 65 within the next 10 to 15 years. Second, average life expectancies have increased markedly, going from 68.2 years in 1950 to 74.9 years in 1985. By the year 2025, average life expectancies are expected to exceed 85 years, and elders are predicted to comprise over 25 percent of the total population (double their current proportional representation in the general population.)38
These trends are particularly important for Arizona, which already has over 15 percent of the population comprised of individuals over 65. Continuing in-migration patterns of retirees, most of whom are over 55 years of age when they arrive in Arizona, will push Arizona far ahead of the national trends in the aging population. Further, many of these new residents have arrived without natural support systems such as nearby family members and long term neighborhood relationships. Many respondents interviewed for this study identified social isolation, substance abuse, spousal abuse, and co-occurring health and mental health problems among elders as among their greatest concerns with regard to the public behavioral health system in the future.
The characteristics of best practice community-based behavioral health include:
~ Integration and coordination with among resources important to elders, particularly primary health care, mental health and substance abuse treatment, and elder services such as homemakers, meals-on-wheels, and visiting nurse services;
~ Active outreach to and engagement among elders, most successfully conducted by peers;
~ Flexibility as opposed to specialization among service providers. The collaborating components of the system must have an attitude of "these individuals belong to us", not "we don't serve that type of person.";
~ Provision of a full array of clinically competent services designed to reduce institutionalization and to support on-going community living and integration. These include mobile services provided in homes and community centers, in-home services with integrated health and behavioral health competencies, and facilitated access to community social and recreational opportunities;
~ Cross training among a variety of practitioners about depression, substance abuse, co-occurring dementia, and other related conditions affecting elders. Primary care physicians are often the primary caregiver and prescriber of psychotropic medications, usually without specialized training, information, and/or consultation;
~ Engagement of natural community supports and those most likely to come in contact with elders, such as the faith community, shop keepers, transportation providers, postal services, etc.; and
~ Advocacy for the rights of elders in the community.39
One coordinated outreach geriatric service program has been implemented in the PGBHA region. This program, called the "Gate Openers" project, is jointly funded by the RBHA and the regional Area Agency on Aging (AAA). Through the coordinated project, local people likely to come in contact with elders (such as postal workers) are trained to identify signs of social isolation, depression, substance abuse, and/or deteriorating health status. If these warning signs are identified, the individual notifies the AAA and the local mental health center, which in turn arrange for outreach and engagement visits to the home. If applicable, treatment services are then arranged through the mental health center and other local caregivers.
The Bazelon Center has identified a number of programs that meet the above criteria for competent and integrated elder behavioral health programming. These include the Elderly Services Program in Spokane, WA, the Older Adult Services Program in Detroit, MI, The Philadelphia Mental Health Corporation in Philadelphia, PA, and Gulf Coast Jewish Family and Mental Health Services in Florida. Other exemplary integrated elder service programs can be found in the Medicaid On Lok replication waiver demonstration programs, which build on the On Lok Elder Services program in San Francisco.
E. Non-Behavioral Health Best Practices Critical to
the Preferred Public Behavioral Health System
People with serious mental illnesses have difficulty locating and maintaining safe, affordable housing for a number of reasons. In addition to the occasionally debilitating symptoms of the illness itself, they often lack adequate income and social supports, and many have co-occurring disorders, including alcohol or other drug problems and acute or chronic physical health problems. They also face the stigma associated with their illnesses and the fears of potential landlords or neighbors. When the competition for low-income housing increases, individuals with mental illnesses may become homeless.
A recent study by the Consortium for Citizens with Disabilities found that in the Phoenix-Mesa Area, a mental health consumer would need to use 84.4 percent of their $494 monthly SSI check to rent an efficiency apartment leaving them with only $77 a month for all other household expenses including food.40 To rent a one-bedroom apartment in the Phoenix Area, a SSI beneficiary would need to spend 102.2 percent of their monthly income on rent, leaving virtually no funds for other necessary expenses. This scenario is no better in Flagstaff or Tucson, where the percentages are 92.7 percent and 91.9 percent respectively for a one-bedroom apartment.
Many states and counties have addressed this housing issue by developing strategies to build affordable housing capacity or to increase the amount and types of subsidies available to support the housing needs of this population. Local communities have also developed proactive community education programs to combat the stigma of mental illness as a way to deal with the NIMBY - not in my back yard - problem.
There is widespread agreement that when housing is permanent and flexible, and individualized support services are available as needed, people with serious mental illnesses can achieve and maintain residential stability in the community. For persons with mental illness, supported housing offers a safe, viable, more affordable alternative that reaffirms independence and community living. Supported housing is based on the commitment to 1) assert the rights and choices of consumers of mental health services to access affordable, decent, and permanent housing and 2) to develop a flexible and responsive system of community supports that may be accessed by consumers to assist them to maintain independence and quality of life in the community.
A number of factors have contributed to the movement toward supported housing for persons with mental illness:
~ de-institutionalization and the shift toward community-based residential alternatives;
~ shortcomings of residential or other quasi-institutional settings in moving people with psychiatric disabilities toward independence;
~ increasing pressures to manage inpatient utilization and costs;
~ the increase in homelessness among individuals with mental illness; and
~ the growing strength and recognition of the consumer empowerment movement, family advocacy organizations (AMI), and homeless advocates.
These contributing factors provide the rationale for a movement towards supported housing, but there often still exists a gap in the service array for persons with mental illness. In order to fill these gaps in the service array, progressive systems of care should attempt to provide independent living alternatives. This requires a set of core service capacities that sharply contrast with traditional mental health services and service delivery. Thus, a movement to development of supportive housing often involves a significant reorganization of existing services. Some key components of the service array should include home-based services, natural community supports, housing-related activities (e.g., owner outreach and housing search), and developing a flexible and readily available safety net, such as respite and mobile crisis services, assistance with access to financial subsidies for housing costs, daily living expenses and health care. This requires leadership at the local and state level to encourage and support this change, to re-prioritize programs and services and to build consensus around these new priorities. These changes may come at a cost to current services and programs either through re-deployment of staff and program dollars, or, in some cases, complete program elimination.
Examples of best practice in supported housing include the Vera French Housing Development Corporation in Davenport, IA; Baltimore Community Housing Associates in Baltimore, MD; and the Supported Housing Development Initiative sponsored by the Michigan Housing Development Authority.
A 1972 study found that less than 30 percent of individuals with serious and persistent illness ever work.41 More recently, a 1998 study found that less than 12 percent of persons with schizophrenia or bi-polar disorder obtained jobs in the competitive sector, even after finding training in job-finding skills.42 Even using "place-then-train" supported employment approaches, about 50 percent of persons with serious mental illness obtain competitive employment. Only one-half of those who secure competitive employment remain employed in the same jobs six months later.43
The above reports paint a dreary picture of employment prospects for people with serious mental illness. This picture is in stark contrast to the wishes of consumers themselves, who almost always list satisfying employment among their top two to three life goals. It is also in stark contrast to the vision of recovery and rehabilitation that has been presented as best practice in this report.
Despite the strong desire to work on the part of consumers, plus the known benefits of employment to most individual's personal recovery process, there remain many barriers to achieving competitive employment for people with mental illness. First, gainful employment often results in a loss of benefits, particularly Medicaid coverage, which is essential for most individuals to maintain access to medications and needed community supports.44 Second, stigma and lack of understanding often create barriers to people with mental illness attempting to enter the competitive workplace. Third, the current structure and process of publicly funded vocational rehabilitation services often do not match the individual processes and timeframes necessary to successfully move into employment for some people with mental illness. Very often, individuals lose on the job supports after the federal vocational rehabilitation service package has been used up, and the behavioral health system does not provide sufficient follow-along services.
The technology of successful supported employment programs is well documented. It includes:46
~ Assuring consideration of individual's interests, abilities, and goals in selecting jobs;
~ Early intervention efforts designed to assist people to return to work as soon as possible after the onset of a psychiatric disability;
~ Strategies that focus on getting people into the workplace and then training on the job, rather than spending time in pre-employment training;
~ Strategies that match individuals' education and skill levels with employment opportunities. People with mental illness do not have to work only in minimum wage, service sector jobs;
~ Provision of a range of on-going services and supports to assist people to work and interact effectively in the workplace;
~ Flexibility in work expectations during periods of acute exacerbation of the mental illness;
~ Provision of a range of work experiences including short term job tryouts, on the job training, and part time jobs;
~ Provision of a range of other satisfying and productive activities, including education and volunteer activities;
~ Assuring that all components of the public behavioral health system provide sufficient employment opportunities46 for current and former consumers; and
~ Establishment of multi-disciplinary teams to blend vocational supports with other clinical and community supports.
These attributes of successful supported employment programs do not have to be contained in separate and discrete employment service program components. A variety of approaches have been used, including the ACT team model, expanded clubhouse programs, and consumer operated models. In fact, recent experience has shown that all program elements should be focused on supporting individuals in moving towards their choice of productive activity, and then providing sufficient supports to maintain the productive activity.
Arizona and many other states make good use of federal Vocational Rehabilitation Act funds by (1) developing state-level and local agreements with the vocational rehabilitation agency(ies); and (b) by contributing matching funds to draw down the federal dollars. These agreements can be very effective, but in Arizona local implementation has been sporadic. Local success depends on two interlocking strategies. First, it is necessary to engage the local vocational rehabilitation (VR) staff as equal partners in employment service planning and development.47 Second, the local behavioral health system must develop mechanisms and processes to dovetail behavioral health funds with locally administered VR funds. This is particularly important for follow along services after the VR resources have been used to their fullest extent.
Several RBHAs in Arizona reported good rapport with the local VR offices. This also appeared true at the state level. These existing relationships provide a good model for expanding coordinated VR and behavioral health services throughout the state. As the behavioral health system in Arizona moves more towards recovery and rehabilitation services, and emphasizes consumer operated and peer support services, the service and support capacity for effective coordinated employment services will be in place. Once this service and support capacity is in place, the more targeted VR funding can be used to its best advantage.
States such as Wisconsin and New Hampshire have emphasized employment for several years, and have had some positive successes. In New Hampshire, increasing the number of individuals with serious mental illness in competitive employment has been a priority for many years. The state sets performance targets and measures each community mental health center against them. This had the effect of having all local service components working towards the same goal - to see that consumers found and kept competitive employment or other productive activity of their choice. In Wisconsin, state behavioral health dollars have been used to match federal VR funds to create VR capacity in rural areas. The behavioral health system then uses ACT teams to provide all the pre and post employment services and supports that are not provided through VR funding. In several jurisdictions in Michigan, VR staffing and equipment grants have been used to enhance the capacity of psychosocial clubhouses to provide meaningful training and employment experiences that are relevant to the local employment marketplace.
G. Organizational Excellence
This report contains considerable discussion of public behavioral health best practices and preferred systems for adults and children in Arizona. However, best practices cannot be implemented, and certainly cannot thrive, without considerable organizational support. At all levels of the system the organizational and administrative infrastructure must not only support best practices - it must become the source of energy and direction for continuous improvement of best practices.
What are the elements of and criteria for organizational excellence and best practice? The following are some important examples:
~ Customer orientation, including governance by consumers, family members, and other stakeholders;
~ Clear leadership with authority that equals accountability;
~ Consumer-driven mission;
~ Effective advocacy for the mission of the organization and for the larger public behavioral health system;
~ A learning organization - one that remains open to change, willing to learn, anxious to improve, able to take risks;
~ Emphasis on integration, collaboration and coordination
~ Emphasis on outcomes and performance versus process and regulation
~ Creative and flexible use of resources
~ Public accountability; and
~ Efficient and effective use of public resources
- Minimal costs for administration and compliance versus delivery and quality
- Information for management and decision-support
- Consumer-based outcome and performance measurement
- Quality improvement/quality management
- Adequate and competent human resources
- Cultural competence
- Appropriate incentives for performance
All organizational entities within the public behavioral health system, from state agencies to RBHAs to provider agencies to consumer-operated services, should hold themselves accountable for attaining the level of organizational excellence described by these criteria. In addition, there are certain key management capacities and functions that are critical to the change process in Arizona. That is, the functions provide ongoing motivation and sense of direction for the process of continuously improving the quality, efficiency, and effectiveness of public behavioral health services in Arizona. These functions and capacities are:
Meaningful inclusion of consumers and family members at all levels and in all functions within the public behavioral health system - This includes:
~ engagement of consumers and families in the overall governance and policy development functions of public and private behavioral health organizations in the system;
~ involvement of consumers and families in program planning and development, quality improvement, and program evaluation functions;
~ hiring consumers and families to train managers and practitioners throughout the system; and
~ hiring consumers and family members to be employees of the system - to function as real employees in real jobs, and not limited to performing "consumer representative" functions.
Consistent implementation of utilization management criteria and evidence-based clinical protocols and clinical pathways - This means taking many of the good, evidence-based clinical guidelines and practices developed at the state level, and translating them into actual practice in the field. It also means translating those guidelines into uniform utilization management criteria for service access and continuing stay, and then monitoring actual utilization against the criteria. It means expanding the use of clinical protocols and clinical pathways to assure that consumers presenting with certain conditions receive the best and most cost efficient treatment and supports. Finally, it means conducting regular training throughout the system to assure that all service managers and practitioners understand the utilization management criteria and clinical protocols (including ALFA), and apply them consistently.
Assurance of cultural and linguistic competence throughout the system - Given the cultural and linguistic diversity of Arizona, it is not surprising that positive efforts have been made to attain cultural and linguistic competence and relevance in the public behavioral health system. The next essential step is to incorporate culturally competent practices as part of all best practices, with unique features for addressing some of the prominent cultural issues, such as:
~ Role of family, including extended family;
~ Use of reference groups, including civic, religious and cultural institutions outside the mental health community;
~ Proficiency in the language of, and in communication with, consumers; and
~ Respect for different cultural practices of consumers in designing service interventions.
Implementation of consistent and comprehensive continuous quality improvement practices grounded in consumer-based outcomes, satisfaction and performance measures in each major component of the system - The cornerstone of the whole change and improvement process is continuous quality improvement (CQI). CQI becomes the organizational force to:
- assure that evidence-based best practices are implemented as intended;
- assure that the implementation of such best practices has the desired effect in terms of beneficial outcomes for consumers and families in a cost effective manner;
- identify and overcome organizational barriers to quality and effectiveness in working with primary and secondary customers of services; and
- assure constant learning and consequent re-shaping and re-vitalization of best practices within the organization.
CQI assures that, long after the current crop of experts is gone, the organizations and the system continue to learn, grow, change, and find new and better ways to carry out their mission in the public behavioral health sector. The essential components of an effective continuous quality improvement system include:
~ Equal commitment from both top leadership and line staff to constant improvements to the quality and effectiveness of the organization and its services;
~ Assignment of responsibility for CQI to a single point of accountability within the organization with the resources and the authority to make sure the process is implemented and that there is follow-through on CQI activities;
~ Consistent and substantive engagement of consumers and families in all aspects of the CQI process;
~ Basing CQI activities and strategies on empirical data that include information on consumer outcomes and satisfaction; and
~ Completion of an annual evaluation of the CQI process to document: (a) specific improvements implemented; (b) benefits derived by consumers and families from the improvements; and (c) identification of priority CQI activities for the coming year.
Arizona exhibits a number of promising administrative practices, some at the state level, and some at the regional level.
For example, the widely dispersed and rural NARBHA region is now connected through an efficient and effective telecommunications network. Several RBHAs now use performance contracts with performance incentives built in. PGBHA has implemented a good model of utilization management and service access guidelines that is both flexible and individualized and also reflective of both clinical levels of functioning and the costs of various combinations of service packages. The Excel Group successfully experimented with the use of mobile clinical outreach offices to provide convenient services in rural locations, and is now seeking permanent sources of funding to continue their operations. The Excel Group has also developed good models for attaining cultural competence, both through extensive staff recruitment and training, and through the modes of service delivery in certain areas. Finally, the coordinated efforts of many of the RBHAs to attain JCAHO accreditation as managed behavioral healthcare organizations could result in better and more consistent application of clinical standards and quality management practices throughout the state,
At the state level, the Arizona level of functioning assessment (ALFA) and a number of clinical protocols and guidelines have been identified as evidence of promising practices. The state has also been aggressive in seeking federal grants to enhance system development, and is in the process of developing improved dual diagnosis services and substance abuse service outcome measurement under two examples of these grants. The state is also in the process of implementing a new quality assurance process, to be supported by an improved management information system.
As with many state public behavioral health systems, there remain a number of important organizational problems and issues that must be addressed if the 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 needs to 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 earlier in this 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 needs 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 needs 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 needs 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.
14 Friedman, Robert M., et al. Prevalence of Serious Emotional Disturbance in Children and Adolescents. Mental Health, United States, 1996, pp.71-89.
15 For example, see DeVane CL, Sallee, FR. Serotonin Selective Reuptake Inhibitors in Child and Adolescent Psychopharmacology: A Review of the Current Literature. Journal of Clinical Psychiatry 57:55-66. 1996 and Constantino, JN, Liberman M, and Kincaid M. Effects of Serotonin Reuptake Inhibitors on Aggressive Behavior in Psychiatrically Hospitalized Adolescents: Results of an Open Trial. Journal of Child and Adolescent Psychopharmacology 7:31-44, 1997
16 Arizona has published evidence-based clinical guidelines for these and other SED conditions.
17 Across all social and economic strata.
18 Hodges, K. Manual for the Child and Adolescent Functional Assessment Scale. Unpublished manuscript, Department of Psychology, Eastern Michigan University, 2140 Old Earhart Road, Ann Arbor, Michigan 48105,1990.
19 Kirk, R., Reed, K, and Lin, A., North Carolina Family Functional Scale, Center for Human Services Lab, University of North Carolina at Chapel Hill, North Carolina, 1997.
20 Achenbach, T.M. Child Behavior Checklist for Ages 4-18, University of Vermont, 1 S Prospect St., Burlington, VT 05401, 1991.
21 For additional information, contact Dr. Alice Lin of Technical Assistance Collaborative, Inc., One Center Plaza, Suite 310, Boston, MA 02108.
22 For example, one agency in North Carolina put its own child serving mental health clinic out of business because it could purchase better and more flexible services in the marketplace.
23 For example, see Fisher, Daniel M., MD. Empowerment and Rehabilitation: Boston University Center for Psychiatric Rehabilitation; Coping and Recovery: Ralph, Ruth, Ph.D., et. al.; Recovery Issues in a Consumer Developed Evaluation of the Mental Health System Proceedings - Fifth Annual Conference on Mental Health Services Research and Evaluation, Arlington, VA February, 1996
24 For example, see Sproul, B. A., Models of Community Support Services: Approaches to Helping Persons with Long Term Mental Illness NIMH August, 1986
25 Anthony, William A. Recovery from Mental Illness: the guiding Vision of the Mental Health Service System in the 90s Psychosocial Rehabilitation Journal 16(4) April 1993
26 Kuehnel TG, Liberman RP, and Backer TE. Psychiatric Rehabilitation: Competencies for Mental Health Workers Center for Improving Mental Health Systems, Northridge, CA 1997. p. 85
27 The International Center for Clubhouse Development in New York City is the clearinghouse for information on psychosocial clubhouses.
28 Allness, Deborah and Knoedler, William, Recommended [P]ACT Standards for New Teams Revised 3/31/99. p. 1
29 Allness, Ibid. p. 7
30 These standards have been synthesized from managed behavioral health contracts, public sector managed behavioral health care utilization management guidelines and clinical protocols, and discussions with leaders in public managed behavioral health care in Arizona and other jurisdictions.
31 McEvoy, Ibid. p. 12
32 These guidelines can be obtained from the University of Pennsylvania School of Medicine, Center for Mental Health Policy and Services Research 3600 Market Street, Philadelphia, PA 20742.
33 These data were synthesized from the environmental catchment area (ECA) studies, and published articles by Osher, Drake, Test, and Minkoff
34 Minkoff, Kenneth. Presentation to the National Community Behavioral Health Directors, St. Louis, July, 1999
35 Dr. Minkoff is a national expert on dual diagnosis services, and is the primary consultant to Arizona under the SAMHSA Integrated Treatment Consensus Panel Grant.
36 New Hampshire is the home state of Robert Drake, MD, who, along with Dr. Minkoff has been a leading pioneer in dual diagnosis services delivery and research.
37 These facts were extracted from a literature review conducted by the American Psychiatric Association, 1998
38 Bazelon Center. At Home: Strategies for Serving Older People with Mental Disabilities in the Community. Washington, DC, 1995
40 Priced Out: The Housing Crisis for People with Disabilities. Consortium for Citizens with Disabilities Housing Task Force. Technical Assistance Collaborative, Inc. March 1999.
41 Anthony WA, Buell GJ, Sharrett S, et. al. The Efficacy of Psychiatric Rehabilitation Psychological Bulletin 78:447-456, 1972
42 Liberman RP and Mintz J. Psychopathology and the Ability to Work Unpublished, June 1998 (Quoted in Wallace CJ, Tauber R, and Wolde J. Teaching Fundamental Workplace Skills to Persons with Serious Mental Illness Psychiatric Services 50(9):1147-1153)
43 Drake RE and Becker DR. The Individual Place and Support Model of Supported Employment Psychiatric Services 47:473-475 1996
44 Note: if the Work Incentives Act is enacted by Congress, this barrier could be mitigated in the future.
45 The following were extracted from a National Technical Assistance Center for Mental Health Planning publication on supported employment published in 1999.
46 Some public behavioral health systems have made the mistake of employing consumers only as "consumer advocates" or representatives. While these roles are necessary and productive, consumers should also be employed as case managers, administrative staff, and any other functions that meet their skills, education level, and choices.
47 Occasionally these local VR staff need to be reminded by their state administrators of their responsibilities to serve individuals with serious mental illness.
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