[NYAPRS Enews] HA: Hogan, Sederer Seek Targeted Reforms in Wake of MH Crises

[Matt Canuteson]

NYAPRS Note: In the following thoughtful and provocative piece, OMH
Commissioner Mike Hogan and Medicaid Director Lloyd Sederer make the
central point that while the primary responsibility for public mental
health care lies at the state level, true progress depends on the
state's ability to "develop and sustain empowered and accountable local
'systems of care' that manage care,  including access to and use of
hospitalization, and that provide capable community care to help avert
deterioration and provide alternatives to costly hospitalization."

They compare policy responses to two prominent mental health crises, the
1999 death of Kendra Webdale at the hands of Andrew Goldstein and the
2008 series of murders of or by NYC residents with psychiatric
disabilities.

In the first instance, they conclude that "public and political leaders'
concern about Webdale's death in 1999 mobilized major investments of
resources but did not address the fragmentation of care. They go on to
point out while "the increased and coordinated services provided under
(the Assisted Outpatient (court ordered) Treatment" program created at
that time) are beneficial, it is unclear whether the
involuntariness/court ordered nature of the care has any impact."

They summarize how the priority to achieve improved coordination and
follow through by services has driven the most recent response,
conducted under their Administration, that has prioritized the
development of a "clinic alerts system," revised clinic standards of
care, new 'tracer methodology" to track the care for at risk individuals
and a proposed new residential alternative-to-prison treatment program
for teens.

Interesting, they suggest that reforms are harder to do in large states
like New York since "solutions might require sacrifice by powerful
interests such as hospitals, municipal and county governments, nonprofit
providers, and state employee unions."

 

Perspective: State Policy

Mental Health Crises And Public Policy: Opportunities For Change?

A crisis can provide the opportunity to make needed changes, but
sustaining the changes and gauging their actual impact remain
challenging.

by Michael F. Hogan and Lloyd I. Sederer  Health Affairs Volume 28, no.
3 (2009): 805-808; 10.1377/hlthaff.28.3.805

Michael Hogan (Cocomfh at omh.state.ny.us) is commissioner of the New York
State Office of Mental Health in Albany. Lloyd Sederer is its medical
director.

 

ABSTRACT: Mental health care is a state responsibility. Periodically,
tragic incidents involving a person with a mental illness (such as the
shootings at Virginia Tech) attract the public's attention. But little
is known about the impact of this attention. Does meaningful change
occur, and how? In this commentary we explore recent efforts to advance
change in the wake of tragedy. 

 

Managing change in state mental health systems is difficult; these
systems are complex and subject to both bureaucratic and political
dynamics. Yet this challenge has received little attention. 

Richard Frank and Sherry Glied link changes in mental health care to
federal policy advances, as do Gerald Grob and Howard Goldman, and David
Mechanic.1 Clearly, federal policy shapes mental health care in the
states. By 2001, Medicaid surpassed the state mental health agencies
(SMHAs) to become the largest payer for mental health treatment.

Still, the role of these state agencies remains substantial.

Periodically, mental health issues come to the public's attention-often
as a result of incidents or crises (for example, the shootings at
Columbine or problems in the care of Iraq War veterans). Crises can
precipitate change, but they also bring the risk of hasty policy
formulation.

Mental health programs are dispersed, subject to many masters, and
contentious, making change difficult. To further complicate matters,
special-interest groups may seek to use crises to advance positions they
favor, such as court-ordered care.

Against this backdrop, we explore efforts to change state mental health
systems following well-publicized crises. Can effective leadership in
times of crisis result in positive change? What are the determinants and
limits of success? In this volume, Richard Bonnie and colleagues
describe struggles to change Virginia's mental health system, before and
after the Virginia Tech shootings in April 2007.2

New York State, where we are the mental health commissioner and medical
director, has faced similar challenges. The state has an enormous mental
health system ($5.5 billion in annual spending, 650,000 people served
annually).

The system is famously complex and fragmented, with strong
cross-currents (for example, upstate versus New York City, powerful
labor unions and a politically potent hospital industry) that militate
against planned change. As in many states, Medicaid is the dominant
payer.

The fragmentation of New York's mental health system has long been
evident. Susan Sheehan's account of the journeys of "Sylvia Frumkin"
through a chaotic system won a Pulitzer prize.3 

 

The 1999 death of Kendra Webdale, pushed under a subway car by a man
with a long history of revolving-door treatment, also revealed a
fragmented system, with no one responsible for his care. The 1999
tragedy led to enactment of "Kendra's Law," creating a program of
Assisted Outpatient Treatment (AOT) ordered by courts. In addition to
the law, New York budgeted $130 million to expand services, including
case management programs and medications.

 

_ Response: review panel. These reforms, however, failed to prevent a
murder, several violent assaults, and police shootings of people
receiving mental health care in New York City in 2007-08. Following
intense media attention, the state's governor and the mayor of New York
City established a Mental Health-Criminal Justice Panel to propose ways
to reduce incidents of violence and improve police encounters. The panel
was led by six state and city officials and comprised multiple city and
state agencies with diverse interests.

To focus the panel's work, we conducted intensive reviews of patterns of
care in several cases and began meetings with presentations by national
experts on mental illness and violence and on mental health/criminal
justice system coordination.

The reviews yielded rich and disturbing insights into patterns of care
that were revealed to be casual and poorly coordinated. Community
services, including clinics, case management, and even Assertive
Community Treatment, were not consistently coordinating care, engaging
and retaining consumers in treatment, communicating with families, or
adequately engaging consumers whose conditions were worsening.
Hospitalization, poorly connected to community care, was the customary
intervention in crises-often after a person's condition had deteriorated
for months.

These patterns, against the backdrop of research suggesting that
continuous care and integrated attention to substance use are key to
mitigating violence, suggested directions for reform. The resulting
report recommended improvements for adult and youth mental health care,
the adult and juvenile justice systems, and the connections between
them.4

Panel recommendations included a new "clinical alerts" system that will
use Medicaid claims to identify the most vulnerable people who may be at
risk for relapse and violence (prompted by breaks in service or
prescription refills as well as sudden escalations in acute services,
such as emergency room and inpatient care). The alert system will be
used by New York City's borough-based monitoring teams run conjointly by
the state and city to contact responsible providers and focus attention
before conditions worsen. To improve routine care, Mental Health Clinic
Standards of Care were issued to clarify expectations for clinical
quality (for example, a primary clinician, collaborative treatment
planning among multiple caregivers, communication with families,
screening and integrated treatment for individuals with co- occurring
mental illnesses and addictive disorders, violence risk assessment, and
outreach and engagement).

Implementation of these standards throughout the state's mental health
clinics will be tracked via a state license survey process conducted by
the Office of Mental Health (OMH), which will now use a version of the
"tracer methodology" developed by the Joint Commission, where the care
of high-risk people will be "traced" through the processes of care they
receive.

In the area of children's services, the panel focused on youth with
mental illnesses in the juvenile justice system. Recommendations
included development of a special residential treatment model as an
alternative to juvenile prisons and stronger efforts to sustain family
involvement with youth.

 

_ Response: AOT program. New York's response to Webdale's death in 1999
was robust, involving sizable investments in services and creation of
the comprehensive (and controversial) AOT program. The effectiveness of
AOT is still being reviewed; an evaluation conducted by an external
research team will be completed in 2009. (Preliminary results show that
the increased and coordinated services provided under AOT orders are
beneficial; it is unclear whether the involuntariness/court ordered
nature of the care has any impact.)

It is also clear that the fragmented nature of care was a factor in the
1999 incident and that the reforms that then followed did not address
this problem, except for those people under AOT order. This underlying
problem, along with quality problems, plays into known risk factors
(namely, disintegrated and discontinuous care for mental and addictive
disorders) associated with poor outcomes and dangerousness for people
with serious mental illnesses. These were prominent problems uncovered
in our reviews of the 2007-08 incidents involving mentally ill New
Yorkers.

New York's 2008 review panel followed a closely scripted path, driven by
a charge from the governor and mayor. Relying on expert testimony to
define the field of concerns and then conducting detailed case reviews
led to findings and recommendations that are more focused, but also less
comprehensive and robust, than the changes following the more highly
charged 1999 incident. The "midrange" recommendations developed by the
review panel do not seek broad-scale change (for example, reorganizing
care systems, dramatic expansions of services) but attend to more
narrowly defined problems, such as improving quality of care in existing
programs and better tracking and continuity of care for high-need cases.

 

Potential Lessons

Contrasting case studies of states' responses to tragic incidents
illustrate the technical and political challenges of state level mental
health reform. Good mental health care for those with serious disorders
requires both adequate investment in the right services and care
management strategies (such as enabling counties or local entities to
manage access to hospital care and its alternatives). These can be a
difficult political "sell," as hospital and state employee unions may
resist threats to their domains, while local governments may resist
taking on additional risks and responsibilities.

Increases in spending or agency staffing are notably difficult to
achieve, especially in times of economic hardship.

The Virginia Tech story illustrates how crisis can focus attention on an
ongoing policy concern and also affect its trajectory. Progress on
rebalancing from hospital to community services, and creating
accountable substate entities to orchestrate care, had been slowed by
lack of urgency and the complexity and cost of reform.

Changes in the law (for example, making community service boards the
"single point of entry") were accomplished more easily than allocation
of the resources needed to carry out the policy. The Virginia Tech
shootings galvanized energies to accelerate reform, but perhaps the
responses fell short where resource investments or structural change was
required.

New York's experience illustrates other challenges of reform. Public and
political leaders' concern about Webdale's death in 1999 mobilized major
investments of resources but did not address the fragmentation of care-a
complex problem whose solutions might require sacrifice by powerful
interests such as hospitals, municipal and county governments, nonprofit
providers, and state employee unions.

Although improvements were made, the reforms did not ameliorate
underlying flaws in the system and were unable to prevent subsequent
disasters. (We must note that there are limits to preventing rare acts
of violence, so it is not clear that any set of reforms would have so
succeeded.) The recent New York review panel experience illustrates that
the judicious use of expertise and the careful review of incidents (a
core element of continuous process improvement) can help produce a more
focused and informed response to crisis. However, the low-cost, midrange
approaches that were recommended (such as better monitoring of care
received by high-need individuals) might not be adequate to achieve
desired changes.

State mental health programs, in a way, are "legacy systems," like dated
computer protocols. They predate and function outside the mainstream
health system. The nation's failure to integrate coverage and care for
those with mental disorders means that these systems have remained in
place. The periodic incidents that stir crises of confidence present
opportunities and threats. The experiences in Virginia and New York make
it clear that it is possible to use crises to advance change. Whether
the changes are adequate and can be seen through to effectiveness
remains unclear.

Excellence in state mental health systems, aside from minimally
necessary resource investments, depends on the ability to develop and
sustain empowered and accountable local "systems of care" that manage
care,  including access to and use of hospitalization, and that provide
capable community care to help avert deterioration and provide
alternatives to costly hospitalization. These systems may be directed by
county government (as in Wisconsin), designated local authorities (as in
Ohio and Michigan), or nonprofit lead agencies (as in Vermont, Rhode
Island, and New Hampshire). In turn, the consolidation of resources and
authority needed to manage money and care requires political will, and
these arrangements are easier to achieve in smaller states and those
without large urban settings.

How can good mental health care within the states be achieved? Although
national-level reforms, such as including mental health care in larger
health reforms, are necessary, they are insufficient. Adept management
of crises offers promise as a motivator of change, but it is not enough.
Greater attention to the policy and management challenges of state-level
improvements might not be as glamorous as federal policy change, but it
is what is needed.

 

NOTES

1. R.G. Frank and S.A. Glied, Better but Not Well: Mental Health Policy
in the United States since 1950 (Baltimore: Johns Hopkins University
Press, 2006);

G.N.Grob and H.H. Goldman, The Dilemma of Federal Mental Health Policy:
Radical Reform or Incremental Change? (New Brunswick, N.J.: Rutgers
University Press, 2006); and D. Mechanic, Mental Health and Social
Policy, 5th ed. (Boston: Pearson/Allyn and Bacon, 2008).

2. R.J. Bonnie et al., "Mental Health System Transformation after the
Virginia Tech Tragedy," Health Affairs 28, no. 3 (2009): 793-804.

3. S. Sheehan, Is There No Place on Earth for Me? (Boston:
Houghton/Mifflin, 1982).

4. New York State Office of Mental Health, New York State/New York City
Mental Health-Criminal Justice Panel Report and Recommendations, 2008,
http://www.omh.state.ny.us/omhweb/justice_panel_report (accessed 10March
2009).

 

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