Changes and Constants in Behavioral Health Ron Manderscheid, Ph.D. Executive Director, National Association of Counties Behavioral Health and Development Disability Directors and National Association for Rural Mental Health Adjunct Professor, BSPH, JHU © NACBHDD The views, opinions, and content of this presentation are those of the presenter and do not necessarily reflect the views, opinions, or policies of SAMHSA or the U.S. Department of Health and Human Services.

Time for a Thrilling Ride! Image: Person zip-lining at an amusement park.

Introductory Comments on Behavioral Health Workforce Issues The Behavioral Health Workforce is in crisis: Baby boomers are retiring. Baby busters are not there. Opioid crisis has vastly expanded demand. We are not training clinicians in sufficient numbers. We are training people with yesterday’s knowledge. Clearly, we need a new strategy going forward. The University of Michigan Center on Behavioral Health Workforce Research is a breath of fresh air!

Very Recent Developments—1 21st-Century Cures Act (an authorization bill) Includes the Mental Health Reform Act of 2016 Increased grant funding for services integration. Some funding for human resources, particularly in the National Health Service Corps. Includes the Mental Health and Corrections Collaboration Act DOJ will be permitted to spend reentry funds on appropriate services. Grants will be available to build reentry infrastructure between corrections and mental health.

Very Recent Developments—2 21st-Century Cures Act (cont’d) $1 billion authorization for the Comprehensive Addiction and Recovery Act (CARA) $500 million has been appropriated in the current Continuing Resolution. We now are working to get the other $500 million appropriated as part of the next Continuing Resolution or 2018 Funding Bill.

Very Recent Developments—3 Medicaid Managed Care Regulation (Spring 2016) Permits the use of federal Medicaid IMD funds for restricted inpatient and residential treatment care (up to 15 days in a month) CMS Letter to the State Medicaid Directors (Spring 2016) Federal Medicaid funds can be used for persons in the correction system if the person is not actually in a cell

Very Recent Developments—4 New 1115 Medicaid Waivers CA Systems of Care for Substance Use Clients: The length of residential services range from 1 to 90 days with a 90-day maximum for adults and a 30-day maximum for adolescents, unless medical necessity authorizes a one-time extension of up to 30 days annually. Governors are now discovering the power of these waivers.

The Factors Have Become More Complex Image: Roller coaster.

Key Game Changers POLICY: Healthcare reform is in question. RESEARCH: Early intervention with first- episode psychosis. PRACTICE: Trauma as a causative factor in most mental illness.

Key Underlying Trends From “deficit” to “strength-based” approaches (e.g., NAM panel). From “separate” to “integrated” services. From “clinical only” to “clinical and community” together.

Key Responses MOVING UPSTREAM: APHA has a major 5-year initiative on altering the negative social determinants of health. Goal: Health for all society! MOVING DOWNSTREAM: The United Nations has set personal and community “well-being” as a worldwide 15-year objective for 2030. REBUILDING THE STREAM: Major U.S. corporations are beginning to embrace a “culture of well-being” in the workplace (e.g., Carter Center Summit).

Let’s Begin Our Adventure Image: Road sign reading “Thrills.”

Our Model Is Changing-1 Old Model: Focus: Disease is a personal characteristic. Role is to treat disease. Goal is to restore functioning. Focus: Clinical intervention. Care system management. Care policy.

Our Model Is Changing-2 New Model Focus: Disease is a principally a community characteristic. Role is to change communities. Goal is to improve community functioning. Focus: Community intervention. Community management. Community policy.

Our Model Is Changing-3 Our current task is to blend the old and new models to achieve the Triple Aim: Better population health Better quality care Reduced care costs

How? Population Health Management. Integrated Care Systems that bring together mental health, substance use, and primary care services AND incorporate disease prevention and health promotion strategies.

Our Dilemma

Health and Well-Being—1981 VERY HEALTHY NO DISEASE SEVERE DISEASE VERY UNHEALTHY

Viewed as Population Health VERY HEALTHY NO DISEASE SEVERE DISEASE VERY UNHEALTHY Pop 1 Pop 2 Pop 3 Pop 4

Tomorrow’s Well-Being Model

Pervasive National Concerns in Behavioral Health Move to Integrated Care Services Developing better linkages with social services Incarceration of persons with mental and substance use conditions Linkage with public health

Integrated Care Services

Importance of Social Services

The Incarceration Crisis

Tonight: City and County Jails About 730,000 persons in these jails: 182,500 (25 percent) persons with a mental illness 365,000 (50 percent) persons with a substance use disorder Major co-morbidity between the two groups The two groups (547,500) actually approximate the total number in state mental hospitals in 1955 just before deinstitutionalization started (559,000).

Linkage With Public Health: 1,943 County Public Health Departments

Change Is in the Air Image: Four-way street sign, with each sign reading “CHANGES.”

Block-Granting of Medicaid Concerns: Financial implications for the states and coverage for those insured by Medicaid. Understand: Fixed amount per state? Per person in population? Per person covered? With what baseline: Now? 2013? Other? Avoid: Discussions about the federal and state roles.

Privatization of Medicare Concerns: Health insurance coverage (good benefits) and access to care (good care for all). Understand: Benefit variability from plan to plan? Fixed payment plans? Health savings accounts for premiums? Coverage of other age groups? Avoid: Change nothing versus change everything.

Commentaries My commentaries on all of these issues are available at www.behavioral.net.

So, Which Will It Be? Image: Two-way street sign reading “BORING” and “Interesting.”

Contact Information Ron Manderscheid, Ph.D. Executive Director NACBHDD—the National Assn. of County Behavioral Health and Developmental Disability Directors NARMH—The National Assn. for Rural Mental Health 660 North Capitol Street NW, Suite 400 Washington, DC 20001 (V) 202.942.4296 (M) 202.553.1827 The Only Voice of County and Local Authorities in the Nation’s Capital!