President’s New Freedom Commission on Mental Health Report Overview Pablo Hernandez, M.D.

Overview n President’s New Freedom Commission on Mental Health n National Mental Health Association “Can’t Make the Grade” n NAMI TRIAD (Treatment/Recovery Information and Advocacy Database) n SAMSHA Priorities: Program & Principles Matrix n Evidence-Based Practices

President’s New Freedom Initiative

The President’s New Freedom Commission on Mental Health n Achieving the Goal n Transforming Mental Health Care in America

The President’s New Freedom Commission on Mental Health “Americans with mental illness… deserve a health system that treats their illness with the same urgency as physical illness.” President George W. Bush - April 29, 2002

The President’s New Freedom Commission on Mental Health n Three obstacles must be overcome: –Stigma –Fragmented mental health service system –Unequal treatment and dollar limits for mental health care in private health insurance. President George W. Bush April 29, 2002

The President’s New Freedom Commission on Mental Health n Interim Report Findings –Fragmentation and Gaps in Care - for Children –Fragmentation and Gaps in Care - for Adults with Serious Mental Illnesses –High Unemployment and Disability for People with Serious Mental Illness –Older Adults with Mental Illness Are Not Receiving Care –Mental Health and Suicide Prevention Not Yet National Priorities

The President’s New Freedom Commission on Mental Health VISION IT’S A FUTURE IN WHICH n Everyone with mental illness will recover n Mental illness can be -- –Prevented or cured –Detected early n Everyone of all ages with a mental illness has access to effective treatment and supports -- essentials for living, learning, and participating in the community

The President’s New Freedom Commission on Mental Health Principles Underlying the Transformation Care focused on: n Promoting consumer’s ability to manage life’s challenges successfully n Facilitating recovery n Building resilience, not just managing symptoms

The President’s New Freedom Commission on Mental Health The Goals for a Transformed System Goal 1. Americans Understand that Mental Health is Essential to Overall Health. Goal 2. Mental Health Care is Consumer and Family Driven Goal 3. Disparities in Mental Health Services are Eliminated Goal 4. Early Mental Health Screening, Assessment, and Referral to Services are Common Practice Goal 5. Excellent Mental Health Care is Delivered and Research is Accelerated Goal 6. Technology is Used to Access Mental Health Care and Information

The President’s New Freedom Commission on Mental Health Goal 1 Americans Understand that Mental Health is Essential to Overall Health

The President’s New Freedom Commission on Mental Health Goal 2 Mental Health Care Is Consumer and Family Driven

The President’s New Freedom Commission on Mental Health Understanding the Goal The failure to provide consumer- and family- driven care may contribute to: n An opaque system of care n A system that places the burden of both finding and coordinating care on the consumer/family.

The President’s New Freedom Commission on Mental Health Achieving the Goal: Recommendation 2.1 Develop an individualized plan of care for every adult with a serious mental illness and child with a serious emotional disturbance.

The President’s New Freedom Commission on Mental Health Achieving the Goal: Recommendation 2.2 Involve consumers and families fully in orienting the mental health system toward recovery.

The President’s New Freedom Commission on Mental Health Achieving the Goal: Recommendation 2.3 Align relevant Federal programs to improve access and accountability for mental health services.

The President’s New Freedom Commission on Mental Health Accomplishing Recommendation 2.3 n Realign programs to better meet consumer and family needs. n Coordinate Federal funding for health care with States’ resources to better address unique local needs. n Make supported employment widely available. n Make housing with supports widely available. n Address mental health problems in the criminal and juvenile justice systems.

The President’s New Freedom Commission on Mental Health Achieving the Goal: Recommendation 2.4 Create a Comprehensive State Mental Health Plan

The President’s New Freedom Commission on Mental Health Achieving the Goal: Recommendation 2.5 Protect and enhance consumer’s rights

The President’s New Freedom Commission on Mental Health Accomplishing Recommendation 2.5 n Fully integrate adults and children into their communities as called for under Olmstead n Eliminate the need to trade custody for care n End discrimination in public and private sectors. Especially in employment n Reduce the use of seclusion and restraint

The President’s New Freedom Commission on Mental Health Goal 3 Disparities in Mental Health Services Are Eliminated

The President’s New Freedom Commission on Mental Health Understanding the Goal The failure to eliminate disparities in mental health care may contribute to: n Less access to care and a higher burden of disability for racial and ethnic minorities n Continuing disparate care in rural/frontier areas

The President’s New Freedom Commission on Mental Health Achieving the Goal: Recommendation 3.1 Improve access to quality care that is culturally competent.

The President’s New Freedom Commission on Mental Health Achieving the Goal: Recommendation 3.2 Improve access to quality care in rural and geographically remote areas.

The President’s New Freedom Commission on Mental Health Goal 4 Early Mental Health Screening, Assessment, and Referral to Services Are Common Practices

The President’s New Freedom Commission on Mental Health Understanding the Goal n Insufficient early mental health screening and treatment across the life span n Poor detection in primary care settings and schools n Pain and suffering for children and adults who have or are at risk for co-occurring mental and addictive disorders

The President’s New Freedom Commission on Mental Health Achieving the Goal: Recommendation 4.1 Promote the mental health of young children

The President’s New Freedom Commission on Mental Health Achieving the Goal: Recommendation 4.2 Schools should have the ability to play a larger role in mental health care for children

The President’s New Freedom Commission on Mental Health Accomplishing Recommendation 4.2 n Urge Federal, State, and local child-serving agencies to recognize and address the mental health needs of youth in the education system n Collaborate with families to develop, evaluate, and disseminate effective mental health services and supports to youth in schools

The President’s New Freedom Commission on Mental Health Achieving the Goal: Recommendation 4.3 Screen for co-occurring mental and substance abuse disorders and link with integrated treatment and strategies

The President’s New Freedom Commission on Mental Health Achieving the Goal: Recommendation 4.4 Screen for mental disorders in primary health care across the life span, and connect to treatment and support

The President’s New Freedom Commission on Mental Health Goal 5 Excellent Mental Health Care is Delivered and Research is Accelerated

The President’s New Freedom Commission on Mental Health Understanding the Goal n Gaps between science and services have contributed to the failure to use known evidence-based practices n Research must better advise and advance services

The President’s New Freedom Commission on Mental Health Achieving the Goal: Recommendation 5.1 Accelerate research to promote recovery and resilience, and ultimately to cure and prevent mental illnesses

The President’s New Freedom Commission on Mental Health Achieving the Goal: Recommendation 5.2 Advance evidence-based practice (EBPs) using dissemination and demonstration projects and create a public-private partnership to guide their implementation

The President’s New Freedom Commission on Mental Health Achieving the Goal: Recommendation 5.3 Improve and expand the workforce providing evidence-based mental health services and supports

The President’s New Freedom Commission on Mental Health Achieving the Goal: Recommendation 5.4 Develop the knowledge base in four understudied areas

The President’s New Freedom Commission on Mental Health Accomplishing Recommendation 5.4 n Develop comprehensive minority mental health research program n Study effects of long-term medication use n Examine impact of trauma on mental health, particularly for women, children and victims of violent crime n Address acute care issues for persons in crisis who need a safe and intensive treatment setting

The President’s New Freedom Commission on Mental Health Goal 6 Technology is Used to Access Mental Health Care and Information

The President’s New Freedom Commission on Mental Health Understanding the Goal Mental health care needs to capitalize on new, but underutilized, new health care technologies: n Electronic personal health records n Use of Internet for communications and self-help n Telemedicine and other treatment-related technologies

The President’s New Freedom Commission on Mental Health Achieving the Goal: Recommendation 6.1 Use health technology and telehealth to improve access and coordination of mental health care, especially for Americans in remote areas or in underserved populations

The President’s New Freedom Commission on Mental Health Achieving the Goal: Recommendation 6.2 Develop and implement integrated electronic health record and personal health information systems

National Mental Health Association “Can’t Make the Grade” n Tricky Business: Medicaid and Mental Health –Cutting payment rates to providers. –Instituting preferred drug lists for medications. –Reducing benefits and services. –Reducing eligibility levels for Medicaid.

NAMI TRIAD Treatment/Recovery Information and Advocacy Database n Step1: Consumer and Family Centered Care n Step 2: Applying the Evidence n Step 3: Funding n Step 4: Ending the Barriers to Recovery n Step 5: Public Accountability and Information Technology n Step 6: A Role for All of Us

NAMI TRIAD Treatment/Recovery Information and Advocacy Database n Step 1: Consumer and family-centered. Long standing evidence-based knowledge that the involvement of consumers and families is crucial for healthcare. Institute of Medicine reports have spoken about this in many publications. n Consumer and family-centered care values the desired outcomes of the individual and families dealing with a mental illness.

NAMI TRIAD Treatment/Recovery Information and Advocacy Database (Step 1 continued) n Action plans and recommendations: To expand peer provided services to all individuals with serious mental disorders and their families (to SAMHSA). n To the National Institute of Mental Health to study the impact of peer provided services, its efficacy, effectiveness, cost effectiveness, outcomes and best methods for implementation.

NAMI TRIAD Treatment/Recovery Information and Advocacy Database n Step 2: Applying evidence-based. IOM report observed the need of healthcare system revolution requiring systemic changes and utilizing evidence- based interventions and practices. n Actions: The mental health authority needs to develop a plan to expand evidence-based practices, including: n Medication management, assertive community treatment, supportive employment, dual/co-occurring disorders (mental illness/substance abuse), supportive housing, and jail diversion programs.

NAMI TRIAD Treatment/Recovery Information and Advocacy Database (Step 2 continued) n NAMI calls to NIMH the report “Bridging Science and Service.” n Dissemination of interventions shown to produce positive outcomes, translating research into practice, translating activities in the real world, and modifying the research agenda to include families and consumers. n NAMI calls for the Institute of Medicine study on effectiveness and quality of mental healthcare providers, including a review of training, licensing and other credentialing mechanisms, workforce capacity, and the use of effective, evidence-based interventions.

NAMI TRIAD Treatment/Recovery Information and Advocacy Database n Step 3: Funding. n The IOM Report noted that financing of healthcare must be aligned with quality improvement to understand where the taxpayers’ dollars are going and how appropriately they are being spent. n NAMI calls for major payers of mental health services, including Medicaid, Medicare, state governments and employers to develop and implement payment strategies that support implementation of evidence-based, recovery-oriented services for individuals with severe mental illness and their families (SAMHSA should monitor these efforts).

NAMI TRIAD Treatment/Recovery Information and Advocacy Database (Step 3 continued) n NAMI calls NIMH to commission a study that proves the cost of mental illness to society and the current funding of the public mental health system. n NAMI calls for states not to target budget reductions that are essential for interventions to the safety and health of individuals with serious mental illness, such as formulary restrictions and reduction of essentially needed programs.

NAMI TRIAD Treatment/Recovery Information and Advocacy Database n Step 4: Ending the barriers to recovery. There are many barriers to appropriate care and recovery, especially employment and housing. Again, the IOM report noted the barriers are very large and do exist (Crossing the Quality Chasm). n Stigma, discrimination, poverty, and lack of culturally appropriate services. n NAMI urges Congress to hold a series of hearings on persistent barriers to employment and to eliminate barriers such as SSI/SSDI, Medicaid, Medicare and other programs. NAMI urges the passage of federal legislation to address health insurance parity.

NAMI TRIAD Treatment/Recovery Information and Advocacy Database (Step 4 continued) n NAMI calls on the U.S. Department of Justice and other appropriate federal and state agencies to force the law and punish those that illegally discriminate against people with mental illness in housing, employment and access to community services.

NAMI TRIAD Treatment/Recovery Information and Advocacy Database n Step 5: Public accountability and information technology. Outcomes for individuals that have meaningful value to their recovery, not just symptom management should include employment, housing. This needs to be further validated through investment in infrastructure and technology that is required for reforms in the mental health system. Usage of information technology in frontier and rural areas will enhance access to care.

NAMI TRIAD Treatment/Recovery Information and Advocacy Database n Step 6: A role for all of us. n “Crossing the Quality Chasm” notes that to see significant improvement, all of the stakeholders in the healthcare system must be engaged in the enormous task of reform, which requires strong coalition of advocates, providers and policy makers at all levels, from planning to the implementation; from policies to standards.

NAMI TRIAD Treatment/Recovery Information and Advocacy Database (Step 6 continued) n Education to the public about mental illness. Dispelling ignorance and prejudice, and providing information about effective and appropriate treatment. Example: Consumer and family-provided education and support, peer to peer program, NAMI CARE and In Our Own Voice. NAMI’s Campaign for the Mind of America, multi- year effort to promote investment in recovery and prevent abandonment of yet another generation of Americans with mental illness. n The TRIAD which is a treatment/recovery information and advocacy database. n Grassroots advocacy (

National Mental Health Association “Can’t Make the Grade” n The Cost of Under-Investment in Mental Health –Hospital and Primary Care Costs –Corrections –Homelessness –Lost Productivity –Suicide

National Mental Health Association “Can’t Make the Grade” n Mental Health Parity: Ending Insurance Discrimination

National Mental Health Association “Can’t Make the Grade” n Access to Psychotropic Medication –Limiting Access to Medications is Pennywise and Pound Foolish –Grading Criteria

National Mental Health Association “Can’t Make the Grade” n Beyond Grades: Mental Health Policy Trends –Increasing Consumer Involvement –Promoting Diversity Among Mental Health Providers –Enhancing Availability of Medicaid Community-Based Services. –Reducing Disincentives to Work. –Decreasing the Number of People with Mental Illnesses in the Justice System –Supporting Community-Based Services.

National Mental Health Association “Can’t Make the Grade” n State Offices of Consumer Affairs: Increasing Consumer Involvement –Requiring consumer and family involvement on all health and mental health advisory boards. –Employing mental health consumers and family members within state mental health agencies as well as other agencies that provide mental health services. –Establishing an Office of Consumer Affairs.

National Mental Health Association “Can’t Make the Grade” n Promoting Diversity Among Mental Health Providers –84% of psychologists were non-Hispanic white (compared to 74% of the total population). –10% of psychologists were black/African American (compared to 12% of the total population). –4% of psychologists were Hispanic/Latino (compared to 11% of the total population). –3% of psychologists were Asian American & Pacific Islander (compared to 4% of the total population). –1% of psychologists were American Indian/Alaskan Native (compared to 1% of the total population).

National Mental Health Association “Can’t Make the Grade” n Promoting Diversity Among Mental Health Providers (cont.) –For full-time doctoral departments of psychology, 82% of students are white, 6.4% black, 5.0% Hispanic, 5.7% Asian American, and.8% Native American. –For part-time doctoral departments of psychology, 79% of students are white, 11.2% are black, 5.9% are Hispanic, 2.8% are Asian, and.8% are Native American.

Evidence-Based Practices n Illness Management and Recovery n Medication Management Approaches in Psychiatry (MedMAP) n Assertive Community Treatment

Evidence-Based Practices continued n Family Psychoeducation n Supported Employment n Co-Occurring Disorders: Integrated Dual Disorders Treatment

More Stuff n The Positive Aging Act of 2003 (S. 1456) & (H.R. 2241) are designed to integrate mental health screening and services in primary care and promote geriatric mental health outreach to seniors. n Los Angeles County Mental Health has created a progressive, evidence-based model of continuum of care for adolescents and adults with co-occurring disorders. n More than half of adults with serious mental illness go untreated according to the 2001 National Household Survey on Drug Abuse. According to Charles Curie, “Fewer than half of the 15 million adults with serious mental illness in the United States are receiving treatment” The data show racial disparities and educational differences as well.”