How Far Iowa Has Come - How Far to Go?

Iowa Mental Health Conference: “The Road to Recovery”
Oct 11, 2006, Ames, IA
How Far Iowa Has Come How Far to Go?
Michael Flaum, MD
Director, Iowa Consortium for Mental Health
Department of Psychiatry, University of Iowa Carver College
of Medicine
“Are we there yet?”
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“When are we going to be there?”
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“How much longer?”
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“I’m hungry”
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“I have to go to the bathroom”
Progress over the past year in moving
towards a recovery-oriented MH system?
Notable Progress Over Past Year
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Increased awareness of what we are
talking about when we say “recovery”

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Peer support

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Frequency of the term heard around many
tables and conferences
Training academy
Recreation of a Division of Mental
Health and Disabilities

with some $
"The introduction of recovery into our
national mental health dialogue is
nothing short of revolutionary."
A. Kathryn Power, M.Ed.
Director, Center for Mental Health
Services, SAMHSA
From the Carter Commission to the
New Freedom Commission
“The biggest change in mental
health from 1978 to today is that…
…we now know that recovery is
possible for any individual with a
mental illness.”
Rosalyn Carter
Changing Paradigms and Models
of Mental Illness and Treatment
1950’s
Asylum
1960’s
De-institutionalization
1970’s
Comm. Mental Health
1980’s
Revolving Door
1990’s
Managed Care
2000’s
Recovery?
Psychodynamic
Bio-psychosocial
Neurobiological
Holistic?
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Massively changing attitudes about
mental illness, ideas about where care
is delivered, what that care should be,
how it should be paid for, who should
direct care, …but…

The state hospitals are still here

Legal settlement is still here

County care facilities are still here

Sheltered workshops are still here…

Etc.
Funding sources for mental health programs in Iowa
Source: Torrey, 1996
The President’s New Freedom Commission on
Mental Health
Cover Letter for the Interim Report
October 29, 2002
Mental Health System
Technology
&
Information
(6)
Evidence-Based
Practices
Training / Research
(5)
Mental Health
& Health
(1)
Recovery
&
Resilience
Consumer /
Family Driven
(2)
Eliminate
Disparities
(3)
Early
Intervention
(4)
“Transforming State Mental Health
Systems”
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SAMHSA Regional Meeting

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Chicago June 13-14, 2005
Iowa Delegation:

Mary Nelson - DHS (Team Leader)

Josh Mandelbaum – Office of the Governor

Jim Rixner – MHDD commission

Michael Flaum - ICMH
Charge: Transformation in Your State
Technology
&
Information
(6)
Evidence-Based
Practices
Training / Research
(5)
Mental Health
& Health
(1)
Recovery
&
Resilience
Consumer /
Family Driven
(2)
Eliminate
Disparities
(3)
Early
Intervention
(4)
SAMHSA Consensus: 10 Fundamental
Components of Mental Health Recovery
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Self-Direction
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Strengths-Based
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Individualized and
Person-Centered
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Peer Support
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Respect
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Responsibility
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Hope
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z
z
Empowerment
Holistic
Non-Linear
Vision Statement
Iowa MHDD Redesign 2003
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“We envision a coordinated recoveryoriented mental health system where
all Iowans have access to high quality,
timely services and supports that
facilitate their capacity to live, learn,
work, recreate and otherwise optimally
contribute in their chosen
communities.”
Goal 1 - Americans Understand that
Mental Health Is Essential to Overall
Health
Understanding that mental health is
essential to overall health is fundamental
for establishing a health system that treats
mental illnesses with the same urgency as
it treats physical illnesses.
Recommendations – Goal 1
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1.1 Advance and implement a national
campaign to reduce the stigma of
seeking care and a national strategy for
suicide prevention.
1.2 Address mental health with the
same urgency as physical health.
Goal 1: Iowans understand that MH is
essential to overall health
z
z
Indices of progress

Increasing demand for services

Parity bill passed
Indices of work to do:

Parity doesn’t work

Lots of ongoing evidence of stigma

Limited interaction between behavioral
health and primary care
States with MH Partiy Legislation
(as of the year 2000)
Effect of Federal and State Legislation
Mandating Equal Coverage for MH
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State parity mandates have not measurably
increased access to mental health care or use of
mental health care services.
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Co-payments and deductibles for mental health
benefits offered through employer-sponsored plans
did not change significantly between 1995 and 2000.
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Compared with the general population, individuals
with mental health problems have experienced
deterioration in their health insurance status and
were more likely to have lost their health insurance.
Source: Rand Corporation – Policy
Resources for Congress, 2002
Goal 2: Mental Health Care Is
Consumer and Family Driven
The plan of care will be at the core
of the consumer-centered, recoveryoriented mental health system.
Recommendations – Goal 2
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2.1 Develop an individualized plan of care for every
adult with SMI and child with SED.
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2.2 Involve consumers and families fully in orienting
the mental health system toward recovery.
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2.3 Align relevant Federal programs to improve
access and accountability for mental health services.
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2.4 Create a Comprehensive State Mental Health
Plan.
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2.5 Protect and enhance the rights of people with
mental illnesses.
Goal 2: MH care is consumer and
family driven: Progress in Iowa
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CINA legislation
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Children’s MH Waiver
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“Cash and Counseling” initiative, supported by
RWJ grant and IME
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Olmstead real choices work – Executive Order 27
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“Consumer as provider” training programs (e.g.
Drake)
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Peer Support Training Academy
Iowa Peer Support Training Academy
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RFP from DHS 2005
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Awarded to Outlooks, Inc.

State Public Policy Group
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Renewed 2006
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Georgia Model of Peer Support

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Larry Fricks
4 day Training June 2006
Peer Support as a Funded Medicaid
Service in Iowa
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Magellan has tried this with limited
success thus far (phase I)
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Negotiations underway to revamp with
peer specialists “certified” in the
Georgia model (phase II?)
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Expansion of training opportunities?
Goal 2: MH care is consumer and
family driven
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Indices of work to do in Iowa

Lack of an array of services in most places

Real Choices?

Lack of meaningful consumer and family
input in treatment planning

Lack of infrastructure on recovery-oriented
services or to train workforce in concepts
of consumer-driven care
Goal 3 - Disparities in Mental
Health Services Are Eliminated
In a transformed mental health system,
all Americans will share equally in the
best available services and outcomes,
regardless of race, gender, ethnicity, or
geographic location.
Recommendations – Goal 3
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3.1 Improve access to quality care that
is culturally competent.
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3.2 Improve access to quality care in
rural and geographically remote areas.
Goal 3: Disparities in MH services are
eliminated: Indices of work to do

Language barriers

growing Hispanic population and shortage of
Spanish-speaking MH workers
Access to psychiatric services (esp. child
psychiatric services) are increasingly limited

Rural vs urban disparities are dramatic, e.g.
Southwest Iowa

Pockets of excellence amidst regions of neglect

Transportation is not typically covered
Current (March 2006) Supply and
Demand for Psychiatrists* in Iowa
Type of
Practice
Current
Supply
Psychiatry
217
197
197
63
23
23
29%
12%
12%
Internal
Medicine
405
43
11%
Pediatrics
229
1,239
15
76
7%
6%
OB/GYN
General
Surgery
Family Medicine
Current
Critical
Demand Demand Ratio
Source: Office of Statewide and Clinical Education Programs (OSCEP)
*Full time only
University of Iowa Carver College of Medicine
Factors driving the psychiatric shortage
z
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Increased demand

Stigma-busting

Awareness

Early detection
Decreased supply

Role of psychiatrist as prescriber

Limited interaction with clients

Limited interaction with colleagues
Goal 3: Disparities in MH services are
eliminated: Indices of Progress
z
z
Some use of telepsychiatry

Kids through CHSC – MBC collaboration

Prisons

Elsewhere
$ for MH training for “mid levels”
Goal 3: Disparities in MH services are
eliminated: Indices of Progress
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Efforts to transform legal settlement
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Enhanced coverage for brain injury
services
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Efforts and $ towards standardized
functional assessment and outcomes
Goal 4 - Early Mental Health Screening,
Assessment, and Referral to Services
Are Common Practice
For consumers of all ages, early
detection, assessment, and links with
treatment and supports will help prevent
mental health problems from worsening.
Recommendations – Goal 4
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4.1 Promote the mental health of young
children.
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4.2 Improve and expand school mental health
programs.
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4.3 Screen for co-occurring mental and
substance use disorders and link with
integrated treatment strategies.
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4.4 Screen for mental disorders in primary
health care, across the lifespan, and connect
to treatment and supports.
Goal 4: Early MH screening,
assessment and referral to services are
common practice: Progress
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Early childhood ABCD initiative
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Systems of Care grant in NE Iowa
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SAMSHA “Policy Academy” for Cooccurring Disorders
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Block Grant funding

IDDT

school-based programs

Primary care / MH programs
Goal 4: Indices of work to do
z
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Ongoing barriers to meaningful integration
and cooperation of MH services with:

Substance abuse

Primary Care

Schools

Vocational Services
Barriers include administration, funding,
information sharing, location, training,
culture, etc.
Goal 5 - Excellent Mental Health Care
Is Delivered and Research Is
Accelerated
Research discoveries will become routinely
available at the community level.
Recommendations – Goal 5
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5.1 Accelerate research to promote recovery and
resilience, and ultimately to cure and prevent mental
illnesses.
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5.2 Advance evidence-based practices using
dissemination and demonstration projects and create a
public-private partnership to guide their
implementation.
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5.3 Improve and expand the workforce providing
evidence-based mental health services and supports.
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Develop the knowledge base in four understudied
areas: mental health disparities, long-term effects of
medications, trauma, and acute care
Goal 5: Excellent Mental Health Care is
Delivered and Research is Accelerated:
Indices of Progress
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EPB legislation of 2004

z
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Block grant spending
MBC promoting evidence-based
practices

Expansion of ACT

EBP grants
Emerging infrastructure for technical
assistance for EBP’s
Block Grant Funded Programs
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40 agencies

39 programs for adults with SMI

40 programs for children with SED
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FY 2006
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FY 2007
Themes of Iowa Block Grant funded
Programs 2005-2006
Adult Programs
Child Programs
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Recovery Oriented
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School Based
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Integrated MH and
SA treatment
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Intensive Home and
Community Based
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Other
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Other
Iowa Mental Health Block Grant Funds
(FY 2007)
z
18 of 39 adult programs are “recovery
oriented”
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9 programs: Illness Management and
Recovery program

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a la SAMHSA Resource Kits
Others:

Recovery Centers

Some focusing on WRAP model
Goal 5 – Indices of work to do
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Capacity to assess fidelity remains
very limited
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Supervision and ongoing learning is
undervalued and under-supported
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ACT is still limited and not a required
services in state plan
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Supported employment markedly
underutilized
County Funding for Employment Services Statewide
2005
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$1,600,000
$1,400,000
$1,200,000
$1,000,000
$800,000
$600,000
$400,000
$200,000
$0
MI
CMI
Goal 6 - Technology Is Used to Access
Mental Health Care and Information
The privacy of personal health information
- especially in the case of mental illnesses will be strongly protected and controlled
by consumers and families.
Recommendations – Goal 6
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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.
z
6.2 Develop and implement integrated
electronic health record and personal
health information systems.
Goal 6: Technology is used to access
MH care and information
z
z
Indices of progress

Some small telemedicine initiatives

Administrative rule that allows DHS to get
identifying data from counties and institutions
Indices of work to do

Reimbursement for telehealth

Ongoing stigma about MH information as distinct

Lack of resources for data infrastructure

Collection, analysis and feedback
The Evidence Based Practice Cycle
Quantify
Priority
Outcomes
Regularly
Specify Core
Components
of Practice
Optimize
Priority
Outcomes
Modify
Core
Components of
Practice
Review
Outcomes
Regularly
Building Consensus
“Recovery must be the common,
recognized outcome of the services
we support”
Charles G. Curie, M.A., A.C.S.W.
Director, SAMHSA
National Outcome Measures (NOMs)
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Employment / Education
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Perception of Care
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Housing stability
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Access / Capacity
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Crime / Criminal justice
z
z
Social connectedness
Decreased
hospitalization
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Cost effectiveness
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Use of EBP’s
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Decreased symptoms
“Recovery – Oriented” Outcomes
“…a decent job, a place called home and
a date on Saturday night…”
Charles G. Curie
(former SAMHSA director)
“Knowing is not enough,
we must apply.
Willing is not enough,
we must do.”
- Goethe
What can providers do?
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Meaningfully involve consumers in oversight
and planning
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Hire consumer educators
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Attend to language and covert messages
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Ongoing assessment of recovery-orientation
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Establish attainable goals
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Pursue continuous quality improvement
What can consumers do?
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Self advocacy

Be an informed consumer

Internet literacy

Establish relationships with legislators

Organize

Don’t fight among yourselves

Establish goals

Pursue your own recovery in an evidencebased manner
What can administrative and
community leaders do?
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Pursue meaningful partnerships

School systems

Criminal justice

Vocational rehabilitation

Chambers of commerce

Primary care

Substance abuse service system
What can the University do?
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Support conferences like this
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Start a Division of Community Psychiatry

Training at all levels

Development of meaningful partnerships

Outreach, consultation, telemedicine

Informing mental health policy

Integrating recovery and evidence-based
practice
“Transformation”
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A conversion, revolution, makeover,
alteration or renovation
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An act, process or instance of change
in structure appearance or character.
Webster’s Dictionary
Contact Info / Website
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Michael Flaum, MD
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319-353-4340
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[email protected]
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www.icmentalhealth.org

(Put “Iowa consortium mental
health” in search engine)

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