1. The Center for Policy, Advocacy and Education of the Mental Health Association of New York City NOT JUST HEALTH CARE: THE RESPONSIBILITIES OF HEALTH SYSTEMS A Presentation By Michael B. Friedman, LMSW Adjunct Associate Professor, Columbia University Schools of Social Work and Public Health center@mhaofnyc.org

2. WHAT ARE THE RESPONSIBILITIES OF A HEALTH SYSTEM? To provide treatment and rehabilitiation for physical illnesses and injuries To also provide treatment and rehabilitiation for mental and substance use disorders (“behavioral” health) To provide care for people with serious physical and/or mental disabilities To address the conditions and circumstances –That contribute to illnesses or injuries (  health promotion and prevention of illness and injury) –That interfere with sustained recovery –That must be addressed to overcome or at least limit the disabling consequences of illness and injury –That must be addressed to enable people with disabilities to survive and to live in the “most integrated” setting. 2

3. WHY IS BEHAVIORAL HEALTH CRITICAL? Lifetime prevalence of mental and substance use disorders is about 50%. Mental and substance use disorders are the 2 nd leading cause of years lost to disability. Suicide is a major cause of death for young people Co-occurrence of mental and/or substance use disorders with serious or chronic physical disorders increases: –Risk of disability –Risk of premature death –Medical costs The most expensive cases are those involving co- occurring disorders. 3

4. CONDITIONS AND CIRCUMSTANCES THAT CREATE HEALTH RISKS Exposure to communicable diseases/epidemics Poor nutrition Dangerous/squalid living conditions such as –Homelessness –Lack of heat, running water –Vermin –Housing that is inaccessible to people with disabilities –Lead paint and the like –Hazards in the home, especially for children and older adults Dangerous working conditions Environmental hazards: Pollution, etc. Disasters 4

5. HEALTH RISKS (cont.) Neglect of dependent family members: children, disabled adults and older adults Social isolation/Lack of needed help in the home Family violence –Child, spouse/partner, and elder abuse or maltreatment Violence and crime in the community Unemployment Deep poverty Poor education Demographic changes: esp. aging And many more 5

6. WHICH ARE THE RESPONSIBILITY OF A HEALTH SYSTEM? Debatable, but however answered  Need broad array of services –Physical health –Behavioral health –Social services –Community supports –Social insurance 6

7. BASIC PHYSICAL AND BEHAVIORAL HEALTH SERVICES Crisis services –ER, –urgent care, –mobile crisis Inpatient services –Physical and psychiatric –Acute, intermediate, long-term –For substance abuse: detox and rehabilitation Outpatient services –Hospital based –Community clinics –Private practice 7

8. BASIC PHYSICAL AND BEHAVIORAL HEALTH SERVICES (cont.) Rehabilitation services –Physical therapy –Psych or drug rehab, –Outpatient, day, and residential programs Long-term care services –Home health and personal care services, –Day programs, –Assisted/supportive living, –Skilled nursing facilities 8

9. ADDITIONAL HEALTH AND BEHAVIORAL HEALTH SERVICES Access services: E.g. information and referral Linguistic and cultural competence Care coordination Health and behavioral health education Preventive interventions Tele-health and computer-based services 9

10. SUPPORTS FOR COMMUNITY INTEGRATION Housing In-home care and treatment : –Home health and personal care –Home delivered meals and the like Family caregiver support Social and vocational rehabilitation Socialization/activities Aging services Case management/care coordination 10

11. MENTAL HEALTH SERVICES Population in need is heterogeneous –Serious and persistent mental illness (long-term psychiatric disability) –Transient or recurrent psychotic conditions –Affective, anxiety, behavioral, and personality disorders (Mild, moderate, severe) From institution-based to community-based system –Deinstitutionalization –Commmunity Support Program/Child and Adolescent Services Program (CAASP) Continuum of Care : –Crisis –Inpatient –Outpatient –Residential –Rehabilitation –Case Management 11

12. MENTAL HEALTH SERVICES (cont.) Location of mental health services –MH System, –Physical Health System, –Social Service Systems, –Workplace/Schools –VA/Military Some current themes –Addressing co-occurring disorders –Integration of physical and behavioral health services –Emphasis on “recovery” –Building resilience –MH “exceptionalism” vs. mental health in the mainstream 12

13. SUBSTANCE ABUSE SERVICES Heterogeneous Population –Misuse vs. Diagnosable Disorder (Dependency) –Alcohol, prescription and o.t.c. medications, illegal substances Treatment and rehabilitation –Crisis –Detox: Inpatient or outpatient –Rehabilitation: Inpatient, residential, or outpatient –Methadone maintenance –Self-help/mutual aid Abstinence vs. harm reduction Preventive interventions Issues related to criminalization of drugs –Derivative crime and violence –Invest of resources in interdiction, prosecution, and confinement –Mandatory sentencing 13

14. SOCIAL SERVICES Aging Services –Nutrition Services –Senior Centers –On-site and in-home supports –Caregiver support Child Welfare –Protective services (Identification, investigation, protection) –Preventive services –Foster care (Family and residential) Domestic Violence –Protective services –Re-organizing life Criminal and Juvenile Justice-Related Services Job assistance Housing assistance Case advocacy 14

15. Social Insurance/Public Assistance Income supports –Related to unemployment –Temporary lack of source of income –For dependent children –For people with disabilities –For people who are retired Food –Food stamps –Food banks –Soup kitchens 15

16. Social Insurance/Public Assistance (cont.) Public housing and housing subsidies –Poverty –Aging –Disability Health benefits: Physical and behavioral health –Inpatient –Outpatient –Pharmaceuticals –Rehabilitation –Long-term care 16

17. SOCIAL ISSUES: RESPONSIBILITIES OF THE HEALTH SYSTEM? Poverty Poor education Crime and violence Environmental hazards –Living conditions –Working conditions –Air and water pollution –Etc. 17

18. ROLES OF SOCIAL WORK Casework: assistance for individuals and families Group work: assistance in groups Community organization Social welfare systems Policy and advocacy 18

19. ROLES OF SOCIAL WORK : HOSPITAL Discharge planning: the original role of medical and psychiatric social workers Family work Care coordination Psychological interventions Crisis and grief counseling Administration And more 19

20. ROLES OF SOCIAL WORK: COMMUNITY Social services Clinical services Workplace/school-based services Community organization Policy development and advocacy 20