Positions on Mental Health Policy Issues - 2008

Many children and adolescents with emotional disturbances do not get mental health services. In addition, many of those who do get services—especially those who are most seriously emotionally disturbed—do not get appropriate services. The Lyons Study, commissioned by OMH several years ago, showed that institutional and inpatient services are overused because of a lack of alternative outpatient and community support services.

Recent improvements, such as the expansion of the home and community-based waiver program and the establishment of Clinics Plus, which will increase capacity for screening, assessment, and treatment, are making a significant difference. But the MHAs believe that more needs to be done to fully address the mental health needs of children, adolescents and their families. The MHAs support:

• A comprehensive community-based system of care for children and adolescents
• A full continuum of services including crisis, outpatient, community support, residential treatment, and inpatient services
• Expanding outpatient and community services
• Reshaping outpatient and community services so that they are more intensive, more mobile, and more flexible
• Providing adequate alternatives to inpatient and residential treatment services
• Increasing research designed to improve treatment and other mental health services
• Expanding training in state-of-the art practice
• Increasing family support
• Improving interagency collaboration among mental health, child welfare, juvenile justice, education, and health care
• Confronting issues of underserved and inappropriately served children and adolescents in these systems
• Health coverage that provides parity for mental health for kids who are without coverage.

The MHAs also support improvements of mental health services in schools, in the child welfare system, and in the juvenile justice system.

Use of Psychiatric Medications for Children and Adolescents

Over the past few years there has been growing concern about the possible inappropriate use of psychiatric medications for children and adolescents by practitioners—especially primary care physicians—who are not adequately knowledgeable about when and how to prescribe them.

NYS has made a commitment to involve consumers and families, and their participation is unquestionably more extensive than it was a decade ago. But, both families and consumers continue to report that their participation is limited by a variety of logistical problems and that their impact is extremely limited because of persistent disdain for them. The MHAs believe that consumer and family participation is critical and should be enhanced at all levels including:

• Treatment planning
• Program development
• Systems planning
• Evaluation and oversight

Co-Occurring Mental and Addictive Disorders

Mental And Addictive Disorders

Many people with serious mental disorders also suffer from addictive disorders, and it is widely known that integrated treatment approaches work best for this population. Unfortunately, integrated treatment continues to be the exception rather than the rule. This failure reflects schisms of ideology and treatment philosophy, impermeable bureaucratic boundaries between public systems, and disdainful distance between mental health and substance abuse professionals. Over the past 25 years, several efforts have been made to improve collaboration between OMH and OASAS so as to facilitate integrated treatment. There have been modest improvements as a result. The new administration has established another task force, which is supposed to report recommendations during the Fall of 2007. We hope that this task force will recommend thoroughgoing change and that the state will act to bring about extensive change.

The Mental Health Associations do not believe, however, that a merger or the two departments would be useful. In fact, we believe that expectations of collaboration—which has failed historically—should be kept to a minimum and that the state should focus on integrated treatment in practice rather than on extensive collaboration between the bureaucracies. For example, we support the development of a comprehensive, integrated services license in each state agency, thus permitting service organizations to provide integrated treatment without dual licensure—which is an administrative nightmare.

Health and Behavioral Health

In recent years it has become clear that integration of health and behavioral health services is critical for several reasons.

1. People with serious mental illness have a life expectancy 10-25 years less than the general population because of poor health and poor health care.
2. People with co-occurring health and mental health conditions are among the most expensive Medicaid cases because they do not get timely, effective treatment.
3. Depression complicates physical illnesses such as heart disease resulting in increased risk of disability, lowered life expectancy, and much higher medical costs.
4. Many people putatively in nursing homes because of physical disabilities are actually there because of mental and behavioral problems or because of the emotional and physical toll on family caregivers.

The Mental Health Associations support efforts to address all of these issues.

Co-occurring Developmental Disability And Mental Illness

Over 40% of people served in NYS’s mental retardation/developmental disability system also have psychiatric diagnoses. Yet, there is very limited coordination with the mental health system. The Mental Health Associations support an initiative to determine how best to meet the needs of these people.

Special Programs

People who are mentally ill and developmentally disabled frequently need specially designed services, which are in short supply in NYS. The MHAs advocate for continued development of specialized housing and community services for this population.

Improve Transfers to OMR-DD Programs

Under the current system providers’ responsibility for their clients is limited to providing particular services. There is limited collaboration among providers, a lack of clarity about who is responsible for clients outside of their service programs, and limited flexibility to provide critical supportive services in community settings. It is essential to address issues related to enhanced coordination among providers and to developing clarity about responsibility for people with mental illnesses. The MHAs advocate for systems changes which enhance:

• Responsibility for people served
• Service integration within the mental health system
• Service integration between the mental health system and other systems serving people with Mental illnesses
• Flexibility to respond to individual needs and preferences.

Cost of Living Adjustments (COLA)

Over the past decade and more funding for community mental health providers in NYS has not come close to keeping pace with the rate of inflation. For example, while the wages for workers outside of the field of mental health have risen about 30%, the wages of mental health workers have risen only about 10%. In many cases, one can earn more in a fast food restaurant than as a paraprofessional in a mental health agency.

While failing to provide funding to keep pace with inflation, the state has also made more and more administrative demands on community mental health organizations, creating increased administrative costs. For example, state-of-the-art computer systems are essential to handle billing and reporting requirements, but no additional funding is available to cover the costs of managing such systems.

In 2006-7, NYS’s budget included a 2.5% COLA and a promise of 2.5% in each of the next two years. It appears that this promise will be kept. But cost of living adjustments are essential every year. Therefore, MHA will press NYS to respond to the ongoing threat to the infrastructure of the mental health system by advocating for:

• An automatic annual increase in Medicaid and other funding streams to keep pace with inflation
• Ad hoc adjustments as necessary.

Criminal Justice and Mental Illness

A recent study documented an alarmingly high number of people with mental illnesses in prisons in the United States. This has fueled suspicions that a significant number of people who presumably have been “deinstitutionalized” from the mental health system have, in fact, been “transinstitutionalized” to the criminal justice system.

To improve response to people with serious mental illnesses who are caught up in the criminal justice system, the MHAs advocate for:

• Research to clarify the extent of inappropriate incarceration of both adults with serious mental illnesses and adolescents with serious emotional disturbances
• Improved police interventions including

  Enhanced police training
  
  Establishment of specialized police crisis intervention teams to intervene with people who are mentally ill

• Establishment of jail diversion and treatment alternatives programs
• Expansion of mental health courts
• Access to good mental health services outside of jails or prisons for people who are seriously mentally ill and commit relatively minor crimes
• Improved mental health services in jails and prisons
• Elimination of the use of solitary confinement for prisoners with serious mental illnesses
• Coordinated discharge planning at release from jails and prisons with tight linkages to mental health services
• Coverage for the costs of mental health treatment and medications for people released from jails and prisons.

Cultural Competence

With the growth of minority populations, providing culturally competent services is increasingly important. The MHAs advocate for an aggressive cultural competence program which is designed to:

• Increase the availability of bi-lingual mental health professionals and good translators
• Improve access of cultural minorities to high quality service providers in the private as well as the public sector
• Improve engagement of cultural minorities in mental health programs
• Improve clinical services to culturally diverse people
• Provide training for current and future providers
• Create incentives to encourage minorities to become mental health professionals
• Recruit and hire professional and other staff from cultural minorities
• Assure fair promotional opportunities
• Deal with race relations issues in mental health facilities

Since the advent of deinstitutionalization 30 years ago, government responsibility for people with serious and persistent mental illnesses has been transferred to families to a significant extent. In the early years, approximately 2/3 of the people who left state hospitals went to live with their families. Even now, approximately 30-40% of adults with serious mental illnesses live with their aging parents; others live with siblings. Families not only provide a place to live, they also provide a broad range of supports including crisis intervention, the equivalent of intensive case management, help in negotiating the service system, financial support, and companionship.

Despite the magnitude of service provided by families, government has done little to support families with family members with serious mental illnesses living at home. The MHAs will advocate for major family support initiatives for:

• Families with seriously emotionally disturbed children and adolescents
• Families of adults with psychiatric disabilities
• Families caring for disabled older adults.

This initiative should include:

• Expanded psycho-education
• Improved crisis services
• Increased respite services
• Professional education focused on families as partners using both families and professionals as trainers
• Paid family advocates
• Family resource centers for mutual aid and family education with emphasis on outreach to underserved and culturally diverse communities
• Family support using the Mittelman model
• Future care planning
• Changes in tax and income maintenance policies including:
• Federal protections of supplemental needs trusts
• Tax exemptions for families with a disabled adult living at home
• Tax exempt savings to build supplemental needs trusts
• No SSI deduction for living with family.

Funding for Multi-Year Service Expansion

The MHAs advocate for a multi-year commitment to provide annual funding increases to support the progressive development of a comprehensive, community-based mental health system with the capacity to serve all in need.

State Funding

Mental health advocates in NYS have tended to focus exclusively on the OMH budget and Medicaid as sources of funding for mental health programs. In fact, however, there are other sources, and potential sources, of funds such as:

• Child Health+
• Family Health+
• Pooled funding with child welfare and juvenile justice
• VESID
• Special Education
• Tobacco settlement funds.

The MHAs advocate for the funding of mental health services from all possible funding sources.

In addition the MHAs advocate for efforts to expand the enrollment of eligible children in Child Health Plus, many of whose families are unaware of their eligibility or are troubled by the stigma of getting “Medicaid.”

Federal Funding

The Federal government provides funding for mental health services through Medicaid, Medicare, and the Block Grant. It also provides funding for housing, vocational rehabilitation and work supports, research, for training and education, etc. The MHAs advocate for improvements in Medicaid and Medicare and for increases in the Block grant. We also advocate for increases in funding for housing, rehabilitation, research, and for training and other forms of technology transfer so as to assure that people get access to state of the art treatment.

Currently there are insufficient and inadequate mental health services for older adults and the aging of the baby boom generation will bring a large growth in the number of elderly people in need of mental health services. The MHAs believe that government at all levels must focus far more attention on both the mental health needs of those who are now elderly and the needs of future generations.

With the passage of the Geriatric Mental Health Act, NYS has made a good beginning. It has established a services demonstrations grants program to promote innovation. It has also established the Interagency Geriatric Mental Health Planning Council to develop an appropriate long-term plan. We believe that plan should:

• Develop a vision of how to provide services to help aging people live where they choose in the community
• Clarify the roles and responsibilities of the various levels of government and of governmental departments
• Address the need to integrate health and behavioral health services
• Address the need to integrate mental health and geriatric social services
• Address the needs of people with substance use and other addictive disorders
• Address the needs of people with co-occurring mental retardation and mental illness
• Address the need to help people avoid institutionalization
• Address the need to improve mental health services in institutions
• Address the need for increased funding for services
• Plan for the development of a high quality workforce
• Enhance research related to geriatric mental health.

In addition, the MHAs will call for funding to expand basic geriatric mental health services, to increase demonstration projects, and to establish a geriatric mental health training center.

At the local level, the MHAs are calling on aging and mental health departments to develop plans and to coordinate their activities, and—in NYC—to increase base funding for geriatric mental health.

State Housing Issues

Stabilization of Existing Services

Residential programs are at the core of NYS’s community mental health system. Unfortunately, funding for existing programs has fallen well behind inflation over the past decade. This has resulted in rapid staff turnover, high staff vacancy rates, and potentially hazardous conditions. In addition, funding allowances for rent have fallen far below market costs in downstate New York, resulting in problems retaining current housing.

Funding increases over the past three years have been extremely helpful, but it is critical to provide an automatic annual COLA for housing programs and to continue to provide increased funding to stabilize existing programs.

Development of New Housing

In addition, there are substantial unmet housing needs, and the MHAs have called on the State to declare a decade of housing reform and commit to meet housing need by 2015. This would entail developing 35-40,000 units more than the state has currently planned and would require the pace of housing development to increase from approximately 1,000 units per year to nearly 4,000. This is substantial expansion, but homelessness is a continuing problem in New York State. Governor Pataki’s adult homes workgroup called for the development of 6000 units of community-based housing to replace inappropriate living arrangements in adult homes. People leaving state and local hospitals need adequate housing in the community. In addition, the children’s mental health system has an inadequate supply of residential alternatives to institutional care. Both capital and operating funds are needed to expand residential opportunities in New York City and in the rest of the state.

Positions on Disputes

Although there is widespread agreement among mental health advocates that there is a need for considerably more housing for adults with serious and persistent mental illnesses in NYS, there are a number of subsidiary issues in dispute. These include whether there is a need for more supervised housing, whether all supervised housing should be transitional, how much need there is outside of NYC, how future housing development should be funded, etc. The following is an outline of the MHAs’ positions on these and other issues related to housing.

• OMH Responsibilities: OMH occasionally questions its responsibility to provide housing for people with serious mental illnesses. The current administration has recently released a statement of principles that emphasizes developing access to generic low-cost housing rather than developing specialized housing for people with serious mental illnesses (with a few exceptions.) Although the MHAs fully support developing access to mainstream housing, history has made it clear that OMH must develop housing because otherwise people with serious mental illnesses tend to live in squalid and dangerous circumstances or they become homeless. The MHAs advocate for continued expansion of the OMH housing program in addition to developing access to mainstream housing.

• Needs Assessment: The only available information about housing need is out of date; therefore, OMH should provide a new needs assessment covering:

  People who are homeless or living in shelters
  
  People who cannot be discharged from hospitals because of lack of housing
  
  People living with aging parents or who are living with their families inappropriately
  
  The conditions of housing available to people with serious mental illnesses in the open market
  
  The need for specialized housing for special populations, especially people with co- occurring disabilities
  
  The need for transition from adult homes

  At the very least OMH should develop a waiting list of people with mental illness who need housing like the waiting list used by OMR.

• Types of housing needs: Despite the lack of an up-to-date needs assessment, it is clear that there is need for:

  Increased supervised as well as supported housing
  
  Some long-term, even permanent, supervised housing
  
  OMH funded housing upstate as well as downstate
  
  Peer-run as well as professionally run housing.

Federal Housing Issues

• It is critical to preserve the Federal Section 8 subsidy program.
• Funds for Safe Havens, and other federally funded housing programs must grow so as to develop additional housing.

Shared Responsibility for Funding Housing

The provision of high quality mental health services depends on the availability of staff who are both humane and knowledgeable about state-of-the-art technology. The MHAs believe that the development of high caliber mental health staff is of central importance to the mental health system and therefore will advocate for:

A Living Wage for All Mental Health Workers

Many mental health workers are vastly underpaid making it difficult to recruit and retain high quality staff. In addition, there are significant differences in wage scales among State facilities, general hospitals, and community agencies. The MHAs support equal pay for equal work and the provision of a living wage for all mental health workers.

Spread of State-of-the-Art Practices

Substantial investments should be made to assure that providers are prepared to:

• Use state-of-the-art treatment and rehabilitation technology
• Treat consumers and families as partners in treatment
• Use restraint and seclusion only when unavoidable
• Provide culturally competent services.

Recruitment of Culturally Competent Staff, Especially Those from Minority Cultures

The growth of minority populations creates a challenge to the mental health system to recruit and train culturally competent staff, especially those from minority cultures. Since it is unlikely that there will be enough minority staff even with aggressive efforts to educate and recruit them, it is also important to train staff from majority cultures to be culturally competent.

Recipients and Family Members as Paid Staff

Managed behavioral healthcare has become a major element of America’s mental health system, and the Mental Health Associations do not oppose its continued utilization in both the private and the public sectors. However, managed care raises a number of concerns which have not yet been adequately addressed.

Patients’ Rights

Because managed care inherently limits freedom of choice for patients seeking treatment and is designed to reduce overall utilization of healthcare services, major issues have emerged under the rubric of “patients’ rights”. The MHAs advocate for meaningful patients’ rights provisions at both the Federal and State levels including:

• Access to the highest quality services based on the most up-to-date research
• Access to information about a full range of treatment alternatives
• Access to the best medications regardless of cost or payer
• Right to appeal processes that are rapid enough to provide needed treatment before it is too late
• The right to choose among competing managed care plans (when feasible)
• The right to sue managed care organizations, including behavioral health organizations, for malpractice

Private Sector Cost Transfers

In addition to concerns about patients’ rights, the major concern about managed care in the private sector is that it tends to transfer financial and clinical responsibility for protracted mental health treatment to the public sector via overly restrictive interpretations of the standard of medical necessity and by imposing arbitrary limits on the amount of covered care. For example, coverage for children with serious emotional disturbance is frequently curtailed in a way that forces families onto Medicaid or to give custody of their children to the State. The MHAs advocate for the private sector to take continuing responsibility for the people it covers.

Public Sector Issues in New York State

The Mainstream Medicaid Managed Care Plan is designed for people, including people with mental illnesses, whose needs are fairly basic.

• Non-traditional community-based services: The mental health benefits in the Mainstream Plan are designed on a traditional model using only inpatient and outpatient services. Non-traditional support services including outreach, intensive case management, home based services, etc. should be part of the benefits package.

• Survival of community service organizations and hospitals: NYS’s Medicaid managed care program acknowledges the importance of community agencies and hospitals which have historically taken responsibility for serving the Medicaid population. The program is designed to encourage continued utilization of these providers. The MHAs support this general approach.

Federal Cuts

The FY 2008 federal budget plan may result in significant cuts in Medicaid, especially reductions of Medicaid coverage for case management and rehabilitation services that are vital to people with serious and persistent mental illness who live in the community. MHAs will fight this and other efforts to cut Medicaid coverage for services that are essential to allow people with serious mental illness to remain in the community.

In addition there may be additional cuts to eligibility for Medicaid that could affect older adults in need of long-term care. The MHAs will oppose changes that will result in the impoverishment of spouses or loss of access to services to prevent institutionalization.

Substitution of Medicaid for State Aid to Localities

Over the past decade NYS has repeatedly introduced funding mechanisms to substitute Medicaid for state aid to localities so as to reduce the state share of mental health funding and to increase the federal share. In general, the MHAs have been supportive of using Medicaid in this way because, and only because, it has averted cuts in funding for community mental health services. However, the MHAs are concerned that, as the state substitutes Medicaid for state aid in programs, which do not use a medical model, funding will drive program design to the detriment of sound service models. In addition, the MHAs are concerned that small agencies that do not operate medical model programs will incur great costs to develop and manage Medicaid billing and reporting systems. Therefore, the MHAs will review each new proposal to substitute Medicaid for state aid with an eye to preserving program integrity.

In general, we will advocate for a return to a policy of using Medicaid to increase services rather than to reduce state and local costs.

Elimination of the Medicaid Neutrality Cap

Currently NYS will not permit the development of new mental health services if they will increase the state's spending on Medicaid above annual appropriations. This restriction impedes the development or expansion of programs which serve people who are eligible for Medicaid, and it has slowed the state's response to unmet need for over a decade. In addition, since this restriction does not exist for general health programs, the Medicaid neutrality requirement for mental health programs is discriminatory. For these reasons the MHAs will advocate for the elimination of the Medicaid neutrality cap.

Access for Medicaid Recipients

Unimpeded access to appropriate and high quality psychiatric treatment, rehabilitation, and medication is critical to Medicaid recipients. The Mental Health Associations oppose any and all barriers to access to psychiatric services—whether financial or procedural. Specifically:

The MHAs oppose any effort to limit access to the most appropriate psychiatric medications as determined by a person's physician. Thus, it is unacceptable to:

Establish drug formularies that restrict appropriate access to psychiatric medications

Impose procedural requirements that delay access to clinically appropriate medications prescribed by physicians

The prescription drug program (PDP) in NYS currently carves out anti-depressants and atypical anti-psychotic medications. It also provides for physician over-ride after appeals are exhausted. The MHAs accept these approach as a tolerable compromise.

The MHAs do not oppose a requirement to use clinically equivalent generic drugs instead of brand name drugs.

The MHAs also oppose requirements that people on Medicaid pay a portion of the charge for treatment, rehabilitation, or medication ("co-pays"). Co-pays for very poor people reduce the likelihood that they will voluntarily seek the treatment they need and add to the financial problems experienced by hospitals and other mental health providers, who often provide treatment without the co-pay.

Medicaid Coverage for Children and Adolescents with Disabilities

Prescription Drug Coverage

In order to avoid loss of coverage of critical medications for people on Medicaid and Medicare (“dual eligibles”) during the transition from Medicaid to Medicare drug coverage, NYS established a program through which Medicaid covers what Medicare will not for certain medications including psychiatric medications . The MHAs support the continuation of this Medicaid “wrap-around” coverage.

Lack of Parity and Other Barriers

Medicare presents significant barriers to the provision of high quality mental health services for older adults. Failure to provide parity creates high costs. Other issues include: limited coverage of home and community-based services and geriatric psychiatrists opting out of Medicare.

The MHAs are calling for extensive reform of Medicare to deal with these and other issues.

Medicare Optimization

Many people with serious and persistent mental illnesses reject traditional treatment services. Some of them are able to lead stable lives which they find satisfying. Others experience frequent crises, which often result in hospitalization. Some are in and out of homelessness. A growing number are in jails or prisons, generally for minor crimes. A very few commit acts of violence.

Most people with mental illnesses who have high needs and are hard to reach can be served effectively if appropriate services are available and accessible. Particularly important are aggressive outreach efforts and the provision of services in places and in ways people who tend to reject traditional services will find acceptable.

New York State should continue to expand special services for this population. In addition to supported housing and case management, this should include continued expansion of initiatives to provide “aggressive” outreach and community treatment services using a variety of models including:

• Program of Assertive Community Treatment (PACT)
• Intensive case management
• Peer support services

Parity and Improved Mental Health in the Workplace

Both private and public insurance coverage for mental illnesses is more limited than coverage for physical illnesses in a variety of ways, which result in a significant loss of access to needed mental health services. A variety of changes are needed to create parity between mental health and physical health benefits. The MHAs support mandated parity in both private and public health plans.

NYS enacted Timothy’s Law in 2007, which provides partial parity in commercial but not in public health plans such as Child Health Plus. The MHAs will advocate for improvements in Timothy’s Law and for parity in NYS’s public health plans.

At the federal level, a parity bill has been passed by the Senate and a somewhat different parity bill will soon be passed by the House. The MHAs worked hard to be sure that the federal bill did not eviscerate Timothy’s Law. We will support the Act that provides the most extensive coverage—currently the House Bill.

Managed care

The MHAs believe that NYS should engage in a population-based mental health planning process as required by Pt. 5.07 of the mental hygiene law. Over the past few years OMH has provided such a plan—albeit later than required by law. In addition, the OMH plans have not provided adequate data about needs or quantified commitments regarding program expansion, except for those already included in the Governor’s budget request. Although the MHAs are very appreciative that OMH has restored the planning process, we believe that it can be improved by:

• Releasing the plan on October 1, as required by law
• Including up-to-date, quantified needs assessments
• Including of multi-year, quantified projections of service changes.

Prevention and Early Intervention

From its inception, the Mental Health Association movement has been committed to prevention. Unfortunately over the years, the term "prevention" has acquired a variety of imprecise meanings, which make support of prevention sometimes vacuous and sometimes questionable. For example, it is commonplace to talk positively about "mental health prevention" when what is meant is prevention of the development of mental illness or early intervention or prevention of disabling consequences of mental illness or prevention of a poor quality of life. The Mental Health Associations of NYC and Westchester, therefore, have adopted a stance with regard to prevention and early intervention that is based on recognition of the need for reasonably precise language when speaking about prevention. Our position is:

Prevention of mental illness is a fundamental hope, and the effort to discover ways to prevent mental illness is of utmost importance. Research regarding the development of preventive interventions should be well supported.

It is important not to confuse hope for prevention with an effective preventive intervention technique.

• Preventive intervention techniques which are supported by research should be widely implemented.

• Preventive interventions which are not supported by research should be implemented only on a limited scale as part of carefully evaluated demonstration projects. Demonstrations should be established only for projects which specify clearly what will be prevented, how it will be prevented, and what reason there is to believe that the intervention may work.

• Prevention of hospitalization by providing alternative services in the community should be a core goal of community mental health.

• Early intervention often makes it possible to prevent problems of mental health from becoming severe and/or disabling. For this reason early identification and early intervention are important components of a sound community mental health system.

• The most severe mental illnesses tend to recur. Therefore, relapse prevention should be a major goal of the treatment of people with recurrent psychiatric disorders.

• Relapse prevention and limiting the disabling consequences of mental illness require both psychiatric treatment and rehabilitation. Effective integration of treatment and rehabilitation is therefore an important preventive component of a community mental health system.

Primary Care Physicians

At the very heart of the current state of community mental health is the effort to reduce utilization of inpatient facilities by expanding outpatient services and community support services. Outpatient expansion is a cumbersome process in NYS—even after the recent change from “Certification of Need” to “Prior Approval.” In addition, Medicaid neutrality can be an impediment.

Government Oversight

The MHAs believe that it is critical that New York State provide careful oversight of mental health programs and other settings, particularly adult homes, which house large numbers of people with serious mental illnesses. State oversight should continue to include licensing and critical incident review.

The MHAs also believe that local mental health authorities have responsibility for oversight of mental health programs in their communities, whether they are in contract with local government or not.

Streamline the Licensing Process

NYS’s providers are buried with excessive paperwork which serves little purpose but to create the illusion that programs are carefully overseen by the State and by accrediting bodies. The MHAs will support efforts to streamline licensing and accrediting processes and to reduce unnecessary paperwork.

Focus on Outcomes

There is widespread agreement that program evaluation for certification and accreditation is too focused on processes rather than outcomes. The MHAs supports efforts to develop sound, technically feasible outcome measures.

Link Findings of Quality Assurance Reviews to Planning of Local Systems

Many people with serious and persistent mental illnesses make regular use of community treatment and support services and are able to lead lives which are relatively stable. However, a significant number of these people are still dissatisfied with their lives. Work is of particular importance to many of them, but fewer than 20 % of people with serious mental illnesses have jobs in mainstream workplaces. In addition, many of them have found it difficult to establish social and recreational lives in the mainstream. And many of those who have married, or developed significant love relationships, especially those who have children, have encountered problems of community acceptance.

Work in the Community

In order to increase the numbers of people who have jobs in the mainstream, it is essential to:

• Expand rehabilitation services using a variety of models
• Advocate for active enforcement of The Americans with Disabilities Act

Improving Family and Social Life in the Community

Improving family and social life in the community requires expanding community supports including:

• Access to mainstream social and recreational opportunities
• Supports for parents with mental illnesses

Reinvestment

The MHAs believe that operating savings due to reductions of beds in state hospitals or to state hospital closures should be fully reinvested in the expansion of community services.

However, we oppose the decision made when Middletown, PC was closed to reinvest all funds saved in state operated services. At least 50% of savings should go to local services providers.

In order to make more funds available, the MHAs support:

• Closing more state hospitals subject to an appropriate public planning process
• The use of proceeds from the sale of State hospital lands for housing development for people with serious mental illnesses
• Review of the OMH capital plan for more potential savings to reinvest

Research advances have been the primary source of improved treatment for people with mental illnesses, and research breakthroughs hold the greatest promise for more effective treatment of serious mental illnesses and for enabling people with psychiatric disabilities to live fully satisfying lives in the community.

A Broad Range of Research Initiatives

The MHAs advocate for a broad range of research initiatives including:

• Biomedical research
• Clinical research regarding effectiveness as well as efficacy
• Services research
• Program and system evaluation
• Epidemiology
• Needs assessment
• The development of disease management models
• The development of relapse prevention techniques
• The development of preventive interventions

Review Research Agendas

The MHAs also advocate for OMH to review the research agendas of its institutes with an eye to making them more relevant to the key practice needs and policy priorities of NYS.

Technology Transfer

Even now research is far ahead of the technical mastery of most practitioners. It is critical that the research community do a better job of transferring technology to providers both within and outside academic circles. The MHAs will strongly advocate for greater efforts to transfer available knowledge to the provider community.

Funding for Research and Technology Transfer

The MHAs support:

• Continued NYS funding for mental health research and technology transfer
• Expanded Federal funding for research and technology transfer through both NIMH and SAMHSA

Respect for Consumers and Families

Maintain a Balance of State and Local Planning Authority

In New York State there is an ever-shifting relationship between state and local governments. At some times in history, the State is the dominant planning authority; at other times, local government is dominant. It is not yet clear whether the new administration will continue to emphasize the autonomy of local government to determine key elements of mental health planning, spending, and service delivery. The MHAs will monitor the balance between state and local planning authority and advocate for change as needed.

Enhance Integration Between State Facilities and Local Service Systems

There is frequently tension between State facilities and local service systems. State facilities need to be more responsive to local needs, especially for long-term care. Local departments and community organizations need to be more responsive to the State’s effort to move patients from state hospitals into the community. The MHAs advocate for improved integration between State facilities and local providers.

Funding

The MHAs are opposed to using psychiatric institutions for preventive detention or for political purposes. They should be used only for people with diagnosed psychiatric conditions who cannot live safely in the community even with extensive supports. Thus, the MHAs oppose the use of State psychiatric facilities to house sexually violent predators who have completed their prison terms. The solution to this problem should be found in changing sentencing provisions in criminal justice law.

Continue Hospital Closures with a Public Planning Process

The MHAs have long been advocates for caring for people in the community rather than in institutions. We believe that, with the development of additional and specialized community services, the census of state hospitals can be responsibly reduced further. Until such services are developed, The MHAs will oppose further reductions of the census of state hospitals.

However, it is possible to close state facilities without reducing the census of state hospitals overall. The MHAs believe more State facilities should be closed and that savings in operating costs and the proceeds of the sale of state land should be used to expand community mental health services and housing—using both state and local service programs.

We also support the use of a thoroughgoing public planning process prior to making decisions to close specific state psychiatric centers. These processes should attend to issues regarding alternative care, impact on the workforce, impact on training and research, impact on the economy of the local community, use of saved funds and of the land, etc.

Protect High Quality State Programs and the Expertise of State Workers

Deinstitutionalization was to a large extent fueled by a perception that state facilities provided very poor services. However, as the state system has gotten smaller, it has gotten better. Now there are some very high quality state programs that are specialized in serving populations who are generally not served outside of the state system. These programs have well-trained staff who have a high degree of dedication to serving these populations. The MHAs support preserving high quality state programs and their highly committed staff.

Improve Access to State Facilities

NYS’s mental health policy calls for sharing responsibility for the treatment of people with severe and persistent mental illnesses. Local facilities are to provide short and intermediate term treatment consistent with the standards of utilization review organizations, and State facilities are to provide long-term treatment in state psychiatric centers. Unfortunately it is frequently difficult to get timely admission of appropriate patients to state psychiatric centers. The MHAs support timely access to state facilities.

State Hospital Patients Capable of Living in the Community

OMH’s level of care survey has documented that a substantial portion of the people in state hospitals could live in the community if appropriate community support and treatment services were available. These findings are supported by the experience of the “Second Chance” Program, which has transferred state patients to hospitals in the community, 2/3 of whom have then moved successfully to community settings. Peer advocacy programs have also found that they can identify people ready for the community and help them successfully make the transition.

Clearly, OMH should enhance its efforts to help people capable of living in the community to do so. In addition, NYS must comply with the Olmstead decision of the Supreme Court, which affirms the right of people with serious mental illness to live in the community rather than in a state hospital if they would be capable of living safely in the community with supports. This decision also requires states to develop plans for relocating people from state hospitals to the community.

The MHAs will advocate for:

• Expansion of the 2nd Chance Program or similar efforts
• Expansion of peer outreach programs in state hospitals
• An annual report on compliance with Olmstead.

Stigma and Discrimination

Historically, overcoming stigma and discrimination has been a core function of The Mental Health Associations. In addition to their own community education efforts, The MHAs believe that all levels of government should undertake aggressive efforts to combat stigma and discrimination regarding people with mental illnesses. These efforts should include:

• High profile public education campaigns
• Aggressive anti-discrimination efforts
• Aggressive efforts to develop access to housing in the community
• Aggressive efforts to develop access to work
• Aggressive efforts to develop access to mainstream education, recreation, and religious opportunities

Services

Mental health services should be readily available for people who have experienced emotional disturbance or developed a diagnosable mental disorder in response to terrorism or other disaster.

Funding

Costs not covered by insurance or by philanthropic contributions should be the responsibility of the federal government.

Readiness

Roughly 3 million New Yorkers, including immigrants and undocumented aliens, have no health benefits at all. In order to provide access to mental health services for them, NYS must:

• Continue deficit financing
• Continue to expand Child Health+
• Continue to expand Family Health+

Universal Health Coverage

The Iraq War

Many people who have served in Iraq have developed significant emotional problems and diagnosable mental disorders. The MHAs believe that the VA should provide a broad array of services to meet their mental health needs. But we believe that state and local programs should pitch in. We are particularly concerned about the high rate of suicide among returning veterans and are committed to using our hotline and information and referral services to provide a crisis response.

Coordination of VA and Local MH Services

Workplace policies have a major impact on the mental health of workers and their families. Roughly 60% of Americans have health (and mental health) coverage through work. Virtually all of these mental health insurance plans are managed. Employers often also provide employee assistance programs, and some provide disability management programs as well. Increasingly large employers and insurance companies are instituting disease management programs focused on those illnesses that have the greatest long-term costs. Many organizations have included depression as one of the four or five diseases they typically choose to manage. In addition as more and more large employers have come to recognize the link between productivity and mental health, they have instituted various efforts to promote mental health through improved working conditions, to identify mental health problems early, and to assure rapid access to high quality treatment. Their perception of the importance of access has led to changing expectations of managed care organizations—stressing quality treatment in the service of improved productivity rather than mere cost containment.

The Mental Health Associations will advocate for workplace mental health policies that contribute to improved mental health. This includes good mental health coverage, behavioral managed care emphasizing access to high quality treatment, comprehensive employee assistance programs, disability management to assist people to return to work, efforts to link health and mental health interventions, the inclusion of depression among the illnesses which are the focus of disease management, and organizational arrangements which reduce stress.