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July 17-19, 2002
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Commission Members Present: Michael F. Hogan, Chair Ex Officio Representatives Present: Charlie Curie, Substance Abuse and Mental Health Services Administration Staff Members Present: Claire Heffernan, Executive Director Presenters present for a portion of the meeting were: Janet Corrigan, Director, Board on Health Care Services, Institute
of Medicine July 17, 2002 Introduction and Agenda OverviewDr. Hogan convened the meeting at 5:00 p.m. and welcomed the Commission members and observers. He acknowledged a new ex-officio member of the Commission, Frances Murphy, MD, Deputy Undersecretary for Health with the Veteran's Administration. He described the purposes of the hearing to be obtain expert presentations on issues in the field and to hear testimony from a number of the major mental health advocacy groups. Presentation of IOM Report: "Crossing the Quality Chasm"
Dr. Hogan introduced Dr. Janet Corrigan, Director of the Board on Health Care Services with the Institute of Medicine (IOM), which has been active in recent years in examining the quality and accessibility of the nation's health care system. Dr. Corrigan described the work of the IOM Committee on the Quality of Healthcare in America, which produced two groundbreaking reports. The first report focused on patient safety and drew tremendous press and public attention when released. It concluded that somewhere between 44,000 and 98,000 people die each year because of medical errors. The Committee's focus on medical errors influenced their next examination of systemic issues involving quality problems. The Committee found about 70 studies documenting serious quality shortcomings and concluded that the system is not designed to deliver high quality care in a safe fashion. The second report, Crossing the Quality Chasm, mapped out a vision of what the health care system should be, calling for fundamental change in the health care system. The second report also identified serious quality problems across all health care settings, in all geographic areas and among all age groups. Quality problems included overuse and under use of services as well as medical errors. The Committee concluded that because of the rapid expansion of the knowledge base in health care, the field needs a different method of clinical practice and decision-making. The IOM Committee developed a five part agenda for improving the system, including an expanded definition of high quality care and ten rules for redesigning care. Dr. Corrigan cited several broad environmental forces that have restrained the health care system from restructuring itself, including information technology, the payment system and the clinical knowledge base. The full text of Dr. Corrigan's presentation is available on the Commission's website: www.mentalhealthcommission.gov. The session concluded with Commission members posing questions, many of which focused on how to transfer IOM's recommendations for the general health care system to the mental health care system. Dr. Hogan recessed the Commission at 6:50 p.m. until 8:30 a.m. July
18.
July 18, 2002 Dr. Hogan reconvened the Commission at 8:45 a.m. and welcomed the first panel of expert presenters, whom he stated have provided leadership in the consumer movement. At Dr. Hogan's request, Dr. Fisher gave a brief introduction of each presenter. Presentation by Consumer Leaders
Jackie McKinney described her background and experience with the mental health system as a consumer and family member. She stated that four generations of her family have experienced a legacy of mental health issues, co-occurring disorders, trauma, violence and contact with the criminal justice system. Her grandchildren, for whom she is responsible, are currently receiving mental health wrap around services in Philadelphia. She described three of the most important guiding principles for promoting consumer involvement: inclusion, choice and voice. She concluded by asking the Commission to talk through the issues of stigma, culture, race and ethnicity and to remember the children. Joe Rogers of the National Mental Health Consumers Self-Help Clearinghouse
addressed the Commission on the role of consumers in the development
of mental health services and the value of consumer-operated services.
Mr. Rogers urged the Commission to support the role of technical assistance
programs for consumer-operated services and recommended examining
a program called ACCESS, a national research project in Philadelphia.
He stated further that consumer-operated services are important because
they break down organizational barriers and are cost-effective in
reaching underserved populations like those who often become incarcerated.
Following the presenters prepared remarks, the Commission members engaged in questions and answers with the panelists on a wide range of consumer issues. Witness Panel
Jim McNulty, a consumer and President of the National Alliance for the Mentally Ill, stated that the U. S. system is really not a system, but multiple systems and that NAMI believes that models similar to those presented by Sally Zinman and Joe Rogers need to be applied throughout the country. Mike Faenza of the National Mental Health Association urged the Commission to address the problem of low Medicaid reimbursement rates and the impact of those rates on the ability of mental health programs to provide service. Mr. Faenza also mentioned the lack of political support to address the mental health needs of the broader population. He urged the Commission to expand the public mental health system's narrow mandate of serving only persons with serious mental illness and encompass the needs of millions of people currently excluded from services. Robert Bernstein of the Bazelon Center for Mental Health Law stated that system coordination and collaboration are rare, while cost-shifting between systems is rampant. He recommended that funding streams follow individuals rather than be tied to beds or slots. Consumers must have a greater role in defining services and supports, more choice of services, and greater control over how resources are spent on their behalf. Finally, Mr. Bernstein recommended adoption of a law creating an entitlement to voluntary, recovery-oriented mental health services and supports. David Osher, Federation of Families for Children's Mental Health, highlighted promising treatments and technologies available for children with mental disorders. The Federation urged the Commission to recommend policies that allow families to direct service planning for their children and select providers. The Federation also recommended that the Commission support funding for a network of family-run centers that offer information, training and support to family members. Chris Zeigler-Dendy, Children and Adults with Attention Deficit Disorders, expressed the tremendous frustration experienced by CHADD members as they struggle to negotiate the system for their children with ADHD. She maintained that ADHD is the most commonly diagnosed behavioral disorder among children, occurring in 3-5 percent of school-aged children. Unfortunately, treating professionals frequently do not follow evidence-based practices. She made the following recommendations to the Commission: 1) educate professionals on evidence-based practice; 2) devote more attention to accurate diagnosis and treatment of all co-occurring disorders; 3) conduct more research on effective school-based and mental health programs; and 4) work to coordinate the delivery of mental health services in the schools. A question and answer period followed the witness statements. Presentation on Evidence-Based PracticesDr. Hogan introduced Tony Lehman, Chairman Department of Psychiatry, University of Maryland. Dr. Lehman's presentation provided details on the evidence-based practices for the treatment of schizophrenia. While the scientific evidence is quite good, most people do not receive treatment that is consistent with these evidence-based practices. The full text of Dr. Lehman's presentation is available on the Commission's website at www.mentalhealthcommission.gov. A question and answer period followed Dr. Lehman's presentation. Witness Panel
Speaking on behalf of the National Association of State Mental Health Program Directors, Robert Glover described key challenges facing the public mental health system. He stated that State mental health agencies struggle to ensure that consumers have access to innovative and effective services. Most lack the necessary resources to adequately serve even those people with the most severe needs. State budget shortfalls, erosion of State general revenues for mental health, and a growing reliance on Medicaid and other Federal programs to fund services all undermine States' ability to provide needed mental health services. NASMHPD advocated for more flexible Federal and State policies that allow systems to work together to meet the complex needs of persons with mental illness. Flo Stein represented the views of the National Association of State Alcohol and Drug Abuse Directors. She summarized North Carolina's model framework for integrating care for persons with multiple disabilities (MH/SA/DD). The model is based upon the premise that consumers' varying levels of illness require different levels of interagency collaboration, coordination and integration. Each of the State's three agencies has equal responsibility for providing resources and services for these consumers with co-morbid conditions. The Association urged the Commission to examine North Carolina's framework to see how it could be used to develop guidance for other States. James Stewart, National Association of County Behavioral Health Directors, urged expansion of Federal funding and technical assistance for States and localities to develop comprehensive service systems for children and youth. For adults, NACBHD recommended merging the Federal substance abuse and mental health block grants into a single funding stream. Other recommendations included: 1) expansion of drug and mental health courts, including providing assessment and treatment in every jail in the country; 2) expansion of HUD Section 8 vouchers for special populations; and 3) elimination of the Medicaid IMD exclusion for facilities larger than 16 beds Pope Simmons spoke on behalf of the National Council for Community Behavioral Healthcare. He highlighted several recent developments that will further strain the community mental health service system, including implementation of HIPAA and the resulting administrative costs. In addition, the Association is very concerned that workforce and training problems are reaching crisis levels. Paul Seifert, International Association for Psychosocial Rehabilitation Services, urged the Commission to focus on three areas: 1) the incarceration of people with mental illness; 2) the need to develop effective services for those described as treatment resistant; and 3) development of effective alternatives to acute inpatient hospitalization. Finally the Association recommended using residential crisis care facilities with fewer than 16 beds to avoid Medicaid restrictions on IMD payment. Commissioners engaged in a question and answer period with all of the panelists on a wide range of issues, including funding trends in the public sector and shifts in the locus of patient care. Dr. Hogan recessed the Commission at 3:52 p.m. until 8:30 a.m. July 19
Dr. Hogan reconvened the Commission at 8:30 a.m. and introduced the first two speakers, emphasizing the Commission's focus on children and family issues. Presentation on Children's Mental Health Issues
Bob Friedman, Chair of Child and Family Studies at the University of South Florida, provided an overview of current problems confronting the child and adolescent mental health service system. He described serious emotional disturbance (SED), its prevalence, characteristics of youth with SED, and cost of the disorder. He summarized recent literature on effective systems of care for children including the system's vision, values and outcomes. A system of care approach, such as Wrap Around Milwaukee, utilizes multiple service sectors to address the complex needs of youth with SED. Velva Spriggs, Director, Child and Youth Services, District of Columbia Department of Mental Health and leader in the child mental health family movement stated that the need for mental health services is high, but utilization is actually low because many children with severe disorders are not receiving needed services. Children and families continue to be plagued by a lack of access to services. Families experience unreasonable burdens as they try to negotiate multiple and confusing systems to meet their children's complex developmental needs. She recommended that service interventions be family-focused and based upon children's strengths and resiliency rather than deficits. Service systems must also recognize that culture affects how children and families view mental health, cope with adversity, and seek help. If outreach to minority populations is not culturally appropriate, it will not attract many consumers. The presentations concluded with a question and answer period for Commission members, covering a wide range of topics addressed by both presenters. Witness Panel
Speaking on behalf of the National Association of Psychiatric Health Systems, Edward Irby urged that the system provide the most appropriate intervention instead of first offering the least expensive intervention. He recommended funding changes, including elimination of Medicaid's IMD exclusion and better integration of funding streams. David Kaplan with the American Counseling Association called for enactment of mental health parity legislation for the private sector and expansion of Medicare coverage for mental health services. He urged that the Commission recognize the role of school counselors and include them in the design of a comprehensive children's mental health system. Elizabeth Clark, National Association of Social Workers, focused on three obstacles within the public system: 1) lack of coordination between various systems of care; 2) regional shortages of qualified credentialed providers; and 3) restricted access to health care for too many Americans. NASW recommended full mental health parity and Medicare reform to address the perception that mental health conditions do not warrant the same level of treatment as medical and surgical conditions. Darrel Regier spoke about the status of the mental health system for the American Psychiatric Association. He presented national data on the incidence and prevalence of mental disorders and described the expansion of mental health services over the past 50 years. However, he maintained, services for persons who are homeless or in jails have not been sufficiently developed. Diane T. Marsh, American Psychological Association, offered several
overarching recommendations: 1) encourage the use of effective treatments
by increasing funding for basic and applied research; 2) enhance the
opportunities for professional training by increasing Federal funding
of training programs; 3) improve coordination among the various systems
by implementing flexible funding; and 4) expand outreach and early
intervention programs to better integrate adults and children with
mental disorders into communities. Questions and answers from the
Commissioners followed the prepared witness statements. Public CommentDr. Hogan welcomed speakers, who gave three-minute comments. Members of the public who spoke included Mark Davis, Richard Yanes, Laura Van Tosh, Joan Levy-Zlotnik, Norma Melendez, Libby Nealis, David Sanders, Nuala Moore, and John Bird. Work SessionDr. Hogan requested approval of the June minutes. Commissioner Harbin moved acceptance of the minutes, which was seconded by Commissioner Speck. The draft minutes were approved after adding the names of those people who made public comments at the hearing. Dr. Hogan asked each Subcommittee to provide a brief status report
on their work. Brief reports were heard from the Subcommittees on
Evidence Based Practice, Medicaid, Criminal Justice, Children and
Youth, Rights and Engagement, Cultural Competence and Housing and
Homelessness. Commissioners engaged in a brief discussion about each
Subcommittee and suggested topics for future Subcommittee attention.
Subcommittee reports are available on the Commission website: www.mentalhealthcommission.gov. Adjournment and Next Meeting AnnouncementAfter thanking all of the presenters and witnesses, Dr. Hogan announced the next Commission meeting will be held in Washington, D.C on August 7-8, 2002. The meeting adjourned at 3:05 p.m. I hereby certify that, to the best of my knowledge, the foregoing minutes are accurate and complete. Claire Heffernan Michael Hogan, Ph.D. These minutes were considered and approved by the Commission at its
September 11, 2002 meeting and any corrections or notations incorporated
into the text. Last Modified 09/16/02
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