This report has identified specific strengths and deficiencies in how the State of Arizona funds and provides care to children and adults with mental illness. In many ways, identifying these attributes of the state's mental health system is the easy work. The more difficult challenge is how to use this information to create change that provides immediate and lasting benefits to people with mental illness, their families, and the citizens of Arizona. Now that Arizona has implemented the structure of a managed public behavioral health system, the content of that system can be further addressed. Many of the immediate steps require no new resources, but they do require a commitment at all levels and among all constituents of the system to reexamine core values and benefits, create a culture for change, and continue to seek excellence. This should be accomplished in a spirit of openness, collaboration, willingness to challenge and be challenged, and willingness to take risks. The strategies for change contained in this section of the report attempt to do just that.

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 would 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 several of these key strategic areas: The Integration of Primary and Behavioral Healthcare; Creating a Defined Benefits Package for People with Mental Illness; Resolving the Arnold v. Sarn Court Case; and Creating a Culture for Change.

Since 1990, Arizona has implemented a behavioral health care carve-out program through its RBHAs on the heels of the state's implementation of a Medicaid waiver program AHCCCS. The development of a behavioral health care carve-out in Arizona, as in several other states, means that there is a fundamental separation of physical healthcare from behavioral healthcare despite growing evidence of co- morbid conditions among people with serious mental illness. In Arizona, some integration efforts have been initiated, but to date they have not been linked to state-level policy and funding practices, and thus have had only limited impact.

While complete integration of physical and behavioral healthcare may not be the answer for Arizona, it is apparent that some effort is needed to provide both structural and functional integration of primary and behavioral healthcare. Recent discussions among ADHS, AHCCCS, RBHAs and the Medical Association have highlighted the complexity of forging integration between primary and behavioral health care. To effectively deal with the complete health status of individuals with mental illness in Arizona, this issue must be examined and strategies developed which bring new direction to this issue.

How should integration between primary care and behavioral health care be achieved?

There are at least three levels of integration:

1. On the individual consumer level - it is important to recognize the mind-body connection, with timely identification of psychosomatic symptoms and treatment, and addressing co-morbidity of health and behavioral health issues. Preventive care and wellness services should be coordinated to reduce the incidence of mental illnesses, along with ongoing collaboration on treating those with chronic and serious mental illnesses to provide the most effective and efficient care.

2. On the discipline level - interaction is fostered between PCPs and psychiatrists, various disciplines within physical medicine, and behavioral health disciplines. There needs to be mutual understanding and appreciation of what both generalists and specialists have to offer, and special protocols for referrals and follow-through.

3. On the systems level - collaboration between physical health and behavioral health is ensured, and among provider networks there are inter- and intra-network coordination and collaboration. Boundary management between plans is also part of the system level integration.

Given these levels of integration, design options for an integrated service could aim at one of two types of integration:

~ Structural integration: In this design option, structurally all primary and behavioral health services are accountable to the same entity; or

~ Functional integration: In this model, structures may be separate, but functional integration is clearly articulated with accountability built in for both primary care and behavioral health care.

To this end, we recommend that:

~ AHCCCS and BHS should jointly develop program specifications for the structural and functional integration of primary and behavioral healthcare. These specifications should detail how integration can be supported at the policy level (state agencies), program level (RBHAs and HMOs), and the client level (primary care physician and therapist/case manager). These program specifications should also provide the criteria by which successful integration can be measured and monitored.

~ With these program specifications in place, both agencies should develop and implement several pilot projects that can test the efficacy of these structural and functional integration healthcare models within Arizona. RHBAs, HMOs and other health care providers and insurers should be encouraged to develop ideas and initiatives through these pilot projects. A prudent approach is to sponsor two pilots, one urban and one rural, for an integrated plan that structurally and functionally integrates primary care and behavioral health care. Allow all interested parties to apply, including both public and private organizations.

~ Allow sufficient time for these models to be tested and for the results to be processed through an independent evaluation process.

~ Use the information from these pilots to suggest further structural and functional integrative strategies that can be formalized throughout the system of care.

Models of integrated primary care with behavioral health care can be found in limited private managed care plans. For example, the Northern California Kaiser-Permanente Plan has attempted to achieve primary care/behavioral health care integration through a combination of structural and functional integration, such as:⁴⁸

~ Case finding integration-early identification of problems that require either medical or psychiatric interventions;

~ Specialized program-place specialists in the primary care setting, such as addiction treatment in OB/GYN clinics for pregnant women;

~ On-site integration-place personnel from primary care and behavioral health care in one physical location;

~ Behavioral health education- provide practice guidelines to PCPs through organized classes, as well as ongoing communication channels; and

~ Data system-share knowledge between providers through a Clinical Information Presentation System.

Another example of integrated primary care and behavioral health care can be found in group practice models such as Allina Health System in Minnesota.⁴⁹ In this not-for-profit regional model, the group practice consists of 550 PCP providers working in Allina-owned clinics in 40 communities, with one million subscribers. Methods of integration include:

~ Site-based integration-add behavioral health professionals to the primary care setting when a "critical mass" is reached;

~ Multi-specialty group practice-restructure the primary care practice into multi-specialty practice, including behavioral health; and

~ Ongoing communication-focus on integration of practices at the delivery level.

The Arizona mental health system is complex. There are various categories of eligibility and different service benefits, depending on eligibility and various funding streams used to support these benefits. In many respects, what one gets from the state's mental health system is a product of what one is financially eligible for rather than what may be needed. This has created in Arizona a confusing system that provides unequal access to care.

In the past, efforts to re-shape Arizona's mental health system have focused on the structural aspects of the system- eligibility, financing, regional authorities, and levels of care. While these are important aspects of the system of care, there has been a little attention on content-what do people get? When do they get it? does it work?

As has been stressed throughout this report, the basic structure and financing to manage public behavioral health care in Arizona is in place. This recommendation focuses on strengthening the content of Arizona's mental health system by examining the methods and modalities through which flexible, individualized, and recovery- and family- oriented services are made available to people with mental illness.

To strengthen the content of the state's mental health system we recommend the following:

Implement a Truly Flexible and Individualized Service Benefit Package through De-Regulation at the State Level and Performance Measurement Based on Consumer Outcomes Rather than Process Assessment.

As noted throughout this report, Arizona's behavioral health system is overly complex, rigid, and un-coordinated at the level of state policy and financing. The state, the RBHAs, service practitioners and providers, and consumers and families would all benefit from de-regulation of the entire system. This means that the state would get out of the business of defining how services are to be delivered, but would focus instead on the outcomes of services delivered. The recent RFP and subsequent contract for the new RBHA in Maricopa County contain examples of steps in the right direction. However, considerable effort remains to change the culture of over- regulation and process orientation in the system, and then to act on that change in culture through massive reductions in regulatory requirements and financial restrictions.

A task force comprised of consumers, families, behavioral health professionals, and state and RBHA managers should be convened to accomplish this task. 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. To be effective, the state must empower this task force to make recommendations for significant changes. The state must also make a commitment to do everything in its power to implement the recommendations of the task force.

In the context of reviewing de-regulation options and approaches, the task force should also review current access standards and outcome measures that either support or detract from the flexible, individualized, equitable and clinically appropriate utilization of services across the state. The task force should make recommendations to the field for the adoption of aggressive care management strategies that can improve equitable access to care and appropriate utilization.

In addition to the above recommendations regarding the content of the behavioral health system, there are several structural changes needed in the Arizona mental health system to reduce the rising pressure that is being placed on the limited amount of funds available to provide behavioral health services to those not eligible for AHCCCS or SMI services. This is an area of great concern that can be partially resolved through the following recommendations:

The current eligibility threshold for AHCCCS coverage for Transitional Assistance for Needy Families (TANF) is 33 percent of the state's poverty rate. This is an extremely low rate-one of the lowest in the country. It creates a gap in eligibility for health coverage under the AHCCCS program. This has been a long-standing issue in Arizona that has generated significant public policy interest. In 1996 this issue was brought to the voters in the form of the Proposition 203 referendum to raise the eligibility rate to 100 percent of the state's federal poverty level. Proposition 203 was approved by the voters but was never implemented.

We recommend that the eligibility rate for TANF 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.

The Child Health Insurance Program (CHIP)-Arizona KidsCare-is being implemented in Arizona through the state's AHCCCS Program. This program provides health insurance to children who are not eligible for coverage under the traditional AHCCCS benefit categories. The KidsCare Program includes good coverage for behavioral health services.

We recommend that the state 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.

The State of Arizona has been under a court order, Arnold v. Sarn, since 1991. This case has stipulated the development of a comprehensive community mental health system in Maricopa County to prevent unnecessary and inappropriate hospitalization of those diagnosed as having serious mental illness, and to meet other requirements as set forth in the court order. Eight years after the signing of the order, there has been much progress, but the state is no closer to satisfying the requirements, even though considerable resources have been expended, and more are to be requested in future years.

The Arnold v. Sarn case has consumed time, energy and leadership, leaving little of each to deal with the many overarching policy, program and fiscal needs of the state's mental health system. It is fair to describe the current sentiment surrounding Arnold v. Sarn as one of mutual frustration on all sides, with insufficient progress to show to date for satisfying the court order. There is also a lack of understanding of whether services delivered are indeed worth the expenditure.

It is time for a concerted course of action by all parties to resolve the outstanding issues in this case. We recommend the following actions:

1. Establish a court order unit in the state agency with sole responsibility for overseeing its implementation, including:

   ~ Identification of issues for resolution; troubleshooting and expediting;

   ~ Developing proactive initiatives to modify standards and procedures, to gain back policy control of the programs and services;

   ~ Monitoring of progress of compliance; and

   ~ Reporting to key stakeholders on the progress.

2. Reexamine aspects of the court order in which modifications are necessary:

   The field has changed since 1991 when the order was issued. Certain clinical and program requirements should be revisited for modification. More immediately required is reexamination of the clinical case management team recommended by the court monitor's office.

3. Implement the core benefit package described above for public behavioral health that applies to all who have been found in need of services:

   This step will address the current inequities in the system and the negative impacts of the court order. There should be a basic core benefits package for all seriously mentally ill adults, whether or not they are Medicaid eligible. Similarly, there should be a core benefit for children with serious emotional disturbances and a sound early intervention strategy for children at risk.

4. Instill a commitment for quality management in the public behavioral health system:

   Ultimately the best assurance for not only fulfilling court order requirements but also avoiding future litigation is to "do the right thing" for all consumers served by the public system. A system that is dedicated to improving quality will be a proactive system, in which judicial interventions will become unnecessary.

What is most problematic in Arizona is a pervasive spirit that only limited success or change is possible within the state's public mental health system. Throughout our review we were struck by how many good people with good intentions felt powerless to change the state's system of care. While many good programs and services are being provided, there are few opportunities to share success or .learn from others. In many ways it is a system where every provider and every RHBA is on its own to succeed or fail, and the failures of past providers and RBHAs remain as vivid reminders of what could happen to those that strive to move the system forward.

In mental health systems such as this, it is often easier for participants to look for someone to blame, rather than for someone to provide leadership. Where leaders do exist they may have a hard time gaining followers, or be viewed as troublemakers by those in positions of power. What often develops in these systems is a culture of blame, rather than a culture of change.

Arizona is in need of a new culture within its mental health system. This new culture must support a learning environment conducive to change. The new culture must seek and foster innovation in programs and create an atmosphere that encourages and promotes recovery for consumers of mental health services. Creating this culture cannot be left to government or local officials. Rather, it is the responsibility of all of those with an investment in Arizona's behavioral health system to create the climate for and the culture for change.

To foster this climate and culture change, we recommend the creation of the Arizona Behavioral Health Institute. The institute cannot change the culture by itself, but it can provide a focal point for discussion, action and leadership that can begin the process of culture change. The mission of this institute would be simple: to improve behavioral health and behavioral health care in Arizona. The institute would pursue this mission by providing programs, services and leadership in a variety of new initiatives targeted at the state, regional and local level.

The institute would be governed by a broad coalition made up of the key constituencies within Arizona's mental health community. It could be housed in a university or similar institution or be freestanding. Its revenues would come in many forms, including program fees, grants and operating support from the state and federal government.

While the Institute could pursue a variety of activities, core activities of the Institute should include the following:

1. Leadership Forum - A regular forum for key behavioral health leaders to meet, discuss and plan for innovative changes in the state's system of care. These meetings would not be forums to discuss current business, but rather opportunities to think collectively about pioneering changes in direction. The Leadership Forum could also be used as a structure for developing new leaders, including consumer leaders from within the mental health system.

2. Training - The Institute would develop and offer training programs to support the human resources development needs of the public mental health system. These training programs would include competency-based training to meet credentialing requirements, as well as training in support of new models of service delivery or concepts of rehabilitation and recovery.

3. Information Dissemination - The Institute would provide a vehicle for disseminating information about promising programs and initiatives within Arizona's mental health system. Information could be targeted to specific audiences (consumers, family members, and clinicians) or be organized around specific topical areas such as housing, clinical advancements, or emerging best practices.

4. Technical Assistance - The Institute would develop the capacity to provide a variety of technical assistance to aid the state, RBHAs and providers with critical issues in the delivery of care. The technical assistance could be in the form of conferences, newsletters, manuals, or on-site problem solving.

5. Evaluation - The Institute would develop the capacity to provide independent evaluations of programs and services. This evaluation capacity could be used to evaluate pilot programs or to undertake special studies on specific aspects of the public mental health system.

6. Quality Management Council

The Institute would form a quality management council to regularly analyze and distribute quality indicator information about Arizona's public mental health system. The Quality Management Council would also use this information to suggest key policy and program changes to seek improvement in the quality of care.

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. These are important and valued contributions, but the Trust can also have an important role in fostering the strategies for change contained in this report."

The Trust should not be viewed as a funder of direct care. This is clearly a government responsibility. However, the Trust can use its limited funds as venture capital for new initiatives, such as to provide planning grants or seed money for pilot projects (primary care integration) and initiatives. Funding should be directed to those areas where new knowledge, models and ideas can be generated and shared with the larger mental health community. Funds can also be used as leverage to obtain other larger funding from government or other foundations interested in participating in these new models. The Trust can also help to sponsor the formation of the Institute referenced above.

It is appropriate for St. Luke's Charitable Health Trust to sponsor an evaluation study of the results of the some of the strategic changes referenced above. These include the primary care integration pilots, as well as changes that may result from the Benefit Task Force or changes in AHCCCS eligibility. At the very least, independent evaluations underwritten by the Trust will help state policy makers in deciding about the next steps.

The independence of the Trust puts it in an enviable position to remain independent of special interests and to provide leadership for resolving many of the issues facing the Arizona mental health system. The Trust should not assume a day-to-day leadership position, but rather view itself as a catalyst for change. It can be the organization that brings together interested parties in a neutral environment with a focus on change. This convener and facilitator role is vitally important to foster a climate of change within Arizona.

As discussed in Section II of this report, in Arizona there is a pervasive lack of knowledge about, understanding of, and sympathy for individuals and families suffering from the effects of mental illness. This lack of understanding and support results in: (a) difficulty generating legislative support for sufficient funding for the system, and (b) hinders the implementation of appropriate services and supports that foster community integration. Thus, a key strategy for the Trust should be to generate positive and accurate public information about persons with mental illness: their strengths, capacities, and needs for on-going community supports. Concurrent with positive public information dissemination, the Trust could sponsor anti-stigma activities, such as letter-writing campaigns when negative stereotypes of mental illness are portrayed in the popular media.

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