President's New Freedom
Commission on Mental Health

Meeting Minutes
November 12-14, 2002

Le Meridien Hotel
Los Angeles, California

The President's New Freedom Commission on Mental Health held its monthly meeting on November 12-14, 2002 at Le Meridien Hotel, 465 South La Cienega Boulevard in Los Angeles, California. In accordance with the provisions of Public Law 92-463, the meeting was open to the public on November 13th from 9:30 p.m. to 5:30 p.m. and November 14th from 9:30 a.m. to 11:30 a.m., when the meeting adjourned.

On Tuesday, November 12, 2002 the California Department of Mental Health arranged for individual Commissioners to visit and learn about mental health programs in the Los Angeles area. Commissioners visited the Mental Health Association's The Village, U.S. VETS' Villages at Cabrillo and the Sheriff's Twin Towers Correctional Facility. In addition, the California Department of Mental Health hosted a stakeholder forum on Tuesday afternoon, which several Commissioners attended. A brief summary of the forum discussion is included in these Meeting Minutes.

Commissioners present:
Michael F. Hogan, Chair
Rodolfo Arredondo, Jr.
Patricia Carlile
Charles G. Curie
Daniel B. Fisher
Anil G. Godbole
Henry T. Harbin
Larke N. Huang
Norwood W. Knight-Richardson
Ginger Lerner-Wren
Stephen W. Mayberg
Joan Mele-McCarthy
Frances M. Murphy
Richard Nakamura
Robert N. Postlethwait
Waltraud E. Prechter
Nancy C. Speck
Glenn Stanton
Randolph J. Townsend

Staff members present:
Claire Heffernan, Executive Director
H. Stanley Eichenauer, Deputy Executive Director
James Finley, Senior Policy Analyst
Dawn Foti Levinson, Health Policy Analyst
Elaine Viccora, Senior Policy Advisor
Patty DiToto, Administrative Assistant

Presenters who attended portions of the meeting were:
Tanya Tull, President/CEO, Beyond Shelter, Inc., Los Angeles, California
Carol Wilkins, Director of Intergovernmental Policy, Corporation for Supportive Housing, Oakland, California
Tim Cantwell, Managing Member, U.S. VETS, Los Angeles California

November 12, 2002

The California Department of Mental Health invited stakeholders from throughout the California mental health system to join individual Commissioners for a facilitated discussion. Commissioners who participated in the forum were Michael Hogan, Dan Fisher, Henry Harbin, Larke Huang, Stephen Mayberg, and Nancy Speck.

After giving a brief overview of the Commission's charge, structure, and activities, Dr. Hogan opened up the floor for comments and input. Participants voiced concerns and recommendations about a number of topics, including:

• Workforce. The lack of trained mental health clinicians, particularly people of color and individuals with specialized training to work with children and older adults, was of great concern. Participants suggested a number of systemic changes to address this growing problem. Ideas mentioned included creating career ladders for non-degree staff to pursue clinical training, mentoring, establishing long-distance learning opportunities, offering financial aid, increasing salaries, using pipe line strategies like aiming efforts at secondary education levels, training clients and family members to deliver services, creating certificate programs, expanding use of visa programs, enlisting retirees, and instituting loan forgiveness programs. One participant highlighted the hiring practices of Sacramento's mental health system, where consumers comprise more than 20 percent of the work force. Sacramento provides a12-week training program for consumers and, after hiring them, provides ongoing support.

• Barriers to employment. A tremendous barrier for people with serious mental illness who want to work is their fear of losing benefits. Participants advocated for changes to the Social Security and Medicaid systems that would allow people to reach the poverty level and not be penalized for working. For example, a pilot project in San Mateo utilizes a waiver program that allows a person returning to work to create an Independence Account and save up to $8,000 without penalty and to forgo continuing disability reviews. In addition, one person commented that the Medicaid Rehabilitation Option should reimburse for job coaching as a tool for assisting people with serious mental illness obtain employment.
  
  

• Family support. Family members seek family-to-family education, respite care, a role in setting policy and, in some cases, delivering care. In California, there is an explicit expectation at the state level that consumers, family members and providers will all sit at the policy-setting table; this expectation translates to a similar practice at the local levels.

• Realignment. In 1990, a budget crunch in California served as the impetus for realignment and forced integration of funding within the mental health system. Once California counties had to purchase institutional beds, they quickly developed the rest of the service array to provide more (and less expensive) service options. California's realignment initiative, AB 34, brought funding streams together at one level, giving that entity not only the funding, but the responsibility and accountability to serve individuals and families.

• Medicare and Medicaid. Several participants pointed to systemic discrimination in these federal programs as evidenced by lower co-pays and reimbursement levels for mental health care, as well as the Institute for Mental Diseases (IMD) exclusion.

• Shortage of acute care. California participants reported that psychiatric emergency rooms in large general hospitals licensed for eight beds were ending up with more than thirty individuals because of the lack of inpatient beds.

• Criminal justices. Representatives from the Sheriff's office, who have been active partners with the California mental health system, addressed the inadequate resources and supports for people with serious mental illness once they leave jail facilities. Mental health and law enforcement in jurisdictions across the country must be educated about the value of working together. In addition, more focus is needed on mental health needs of youth in the juvenile justice system.

• Children and adolescents. The discussion about children and adolescents covered broad ground, from suggestions to incorporate mental health/mental illness into the health curriculum of middle schools to the importance of culturally competent services for youth and families of color. By integrating social/emotional opportunities into federal programs for children aged 0-6 and infusing mental health into the "No Child Left Behind" campaign, programs can reach children and adolescents sooner. Participants underscored the importance of federal leadership in building bridges between the child-serving systems (education, mental health, child welfare, and juvenile justice) in order to address the considerable fragmentation within those systems.

• Women's programs. Some participants lamented the lack of focus on women's concerns, including the needs of women with mental illness raising their children. Such families require integrated and comprehensive services for the whole family.

• Role of private sector. Participants encouraged the Commission to create incentives for further partnership with the business, faith-based, and philanthropy communities.

Commissioners encouraged stakeholders to remain interested and involved in the Commission's deliberations and eventual recommendations. The stakeholders of the mental health system will be the "foot soldiers of change" who can help implement many of the recommendations generated by the Commission.

Discussion participants from California included:

November 13, 2002

Panel Presentation: Housing Opportunities for Persons with Mental Illness
Tanya Tull, President/CEO, Beyond Shelter, Inc., Los Angeles, California
Carol Wilkins, Director of Intergovernmental Policy, Corporation for Supportive Housing, Oakland, California
Tim Cantwell, Managing Member, U.S. VETS, Los Angeles California

Chair Michael Hogan convened the meeting at 9:40 a.m. and introduced the expert panelists. Tanya Tull opened the panel presentation by providing an historical overview of homelessness, including the development of a separate system of programs for homeless people. She commented that America has come to view the existence of homeless people - including those with serious mental illness - as inevitable and acceptable. She emphasized the importance of permanent housing, noting that without the existence of permanent housing, emergency shelters and transitional housing perpetuate and prolong the homelessness state. Ms. Tull described several models for addressing the needs of people who are homeless: "Housing First," services-enriched housing, and neighborhood-based services coordination.

The Housing First philosophy is premised on the beliefs that (1) permanent housing should be the central goal of those working with people experiencing homelessness; and (2) by providing permanent housing assistance immediately and up-front, providers can significantly reduce or eliminate the time people spend in homelessness. Housing First includes:

· crisis intervention and stabilization (emergency shelter)

· intake and assessment (which identify both needs and strengths)

· targeted assistance moving into permanent housing (including accessing subsidies, negotiating leases, helping overcome barriers of bad credit and eviction histories)

· home-based care management (time-limited and intensive during first few months, longer-term for those with special needs).

Services-enriched housing is a model where services coordination is available to low-income individuals living in an affordable rental property. Typically, a care manager facilitates access to services and resources for residents, including people with serious mental illness. As Ms. Tull explained, this model is simple, adaptable, non-duplicative of existing services and cost effective. Services-enriched housing can work with a variety of housing types and tenant populations.

Finally, neighborhood-based services coordination consists of a central point of contact for services coordination which is available to all residents in a neighborhood. This model connects residents to existing services that meet the full range of needs within the neighborhood population (e.g., families, elderly residents, residents with disabilities).

The next panelist, Carol Wilkins, also called attention to the shortage of available affordable housing for persons with mental illness, referring to one study that found people on Supplemental Security Income (SSI) - on a national average - needed to pay 98 percent of their SSI benefits to rent a one-bedroom apartment in 2000. To combat this issue, Ms. Wilkins recommended implementing some combination of the following strategies:

· improve access to housing created or subsidized through mainstream housing programs. Otherwise, mainstream programs will continue to abdicate their responsibilities to specialized, parallel systems.

· target resources to create permanent housing for people with disabilities

· enforce Fair Housing protections against discrimination

· build community acceptance for housing for people with special needs and addressing the prevalent NIMBY attitude

· strengthen partnerships between agencies that finance and deliver housing and services so that these relations are sustained over the long term

· create 150,000 units of supportive housing to end long-term homelessness within 10 years, a goal that has been embraced by several federal agencies, Congress and the President.

Ms. Wilkins also described the model of supportive housing. Supportive housing is housing that is permanent (not time-limited), affordable (tenants pay around 30 percent of their income) and independent with private living space. Through supportive housing, a broad range of flexible services and supports are available to help tenants reach their own goals and meet the obligations of tenancy (e.g., pay rent). However, services are voluntary for tenants and not a condition of participation in supportive housing.

Ms. Wilkins cited promising outcomes from several studies of supportive housing, including: (1) Eighty percent of tenants (including those coming directly from streets and shelters) were able to achieve housing stability for at least a year, (2) emergency room and hospital visits dropped by more than 50 percent, (3) use of primary care and services to address substance abuse problems increased, and (4) there was increased participation in work and employment services. The largest study - nearly 5,000 individuals in a supportive housing project sponsored by the City and State of New York - revealed that the cost of homelessness for persons with serious mental illness in New York was more than $40,000 per year. Approximately 86 percent of those costs were incurred by the health care and mental health systems, not the shelter system. The study also demonstrated that the cost associated with creating and operating supportive housing was offset by savings in other public systems (e.g., shelter, psychiatric hospital, Medicaid outpatient and inpatient services, prison, jail, veteran hospital).

Ms. Wilkins commented that, while effective solutions are available to solve the problem of homelessness, creative and successful projects are often financed through a patchwork of funding and typically use money for purposes that were not officially intended. The lack of a flexible and streamlined funding makes it difficult to replicate effective strategies. Calling for strengthened partnerships at the federal, state, and local levels, Ms. Wilkins offered several policy recommendations to the Commission:

· ensure sustainable funding for rent subsidies and operating costs of housing targeted to people who are homeless and disabled. Currently, many funding streams are not predictably renewable

· encourage strong and effective interagency partnerships involving HHS, HUD, and other federal agencies

· streamline funding for approaches that integrate housing and services to support recovery in community settings

· remedy the annual funding crisis around renewal funding for HUD's Homeless Assistance and 811 programs, which provide critical funding for permanent housing

· increase federal investment to produce rental housing for people with disabilities and with incomes below 30 percent of Area Median Income. Most of the housing developed in the last 20 years has not been truly affordable for people with SSI income.

· implement, expand and learn from the President's Interagency Council on Homelessness initiative on chronic homelessness and Policy Academies

· authorize more flexible Medicaid benefits consistent with recovery principles and encourage use of Medicaid to pay for services in supportive housing. Few of the services and models that SAMHSA considers to be effective can be paid for by Medicaid.

· provide Medicaid eligibility for chronically homeless adults with co-occurring disorders who are not receiving SSI benefits due to their substance addiction. These individuals incur frequent and huge costs in emergency health care.

Tim Cantwell shared information about U.S. VETS, the largest private organization in the country dedicated to helping homeless veterans. The organization and its extensive housing operations are a result of partnership between a nonprofit corporation and a for-profit limited liability company in California. The Department of Veterans Affairs (VA) is also a critical partner in the arrangement, serving as a funder, service provider and/or tenant that stages its own facility operation.

U.S. VETS operates facilities around the country and currently houses nearly 1,300 veterans nightly. After projects under development are complete, this capacity will grow to 3,000 veterans. The partnership has locations in Inglewood, Long Beach, Ventura, and Riverside, California, Honolulu, Hawaii, Houston, Texas, Phoenix, Arizona, Las Vegas, Nevada, and Washington, D.C. Mr. Cantwell provided mental health prevalence data from its Inglewood location. Approximately 34 percent of the residents of the Westside Residence Hall have mental illnesses, including bipolar disorder, PTSD, depression, and schizophrenia. Of those residents with mental illness, 80 percent were also being treated for substance abuse.

Mr. Cantwell described the philosophy of U.S. VETS public/private partnership. The partnership is based on the belief that it is necessary to: (1) engage the private sector around development, management, and financing of housing, (2) involve the business community to make jobs available, (3) partner with nonprofits to provide the services that would promote reasonable tenants and employees, and (5) work with the VA to provide clinical interventions. Thus, the for-profit real estate company secured, financed, built, and delivered the properties used by U.S. VETS. The non-profit was established and financed from a line item of the housing corporation's budget. Without this type of flexible financing, the nonprofit and U.S. VETS success could not have happened.

Mr. Cantwell urged the Commission to:

· encourage mainstream capital markets to fund these types of housing products at competitive costs (versus more expensive bridge financing). No program exists at HUD, Freddie Mac, or Fannie Mae that offers such instruments. While VA is rolling out a promising demonstration instrument, the available funding will finance only a few projects.

· allow housing funded with tax credits to grant a presumption of eligibility for people who have been homeless so that those who graduate job programs are not deemed ineligible to enter such housing.

During the brief question and answer period, Commissioners inquired about ideas for structuring partnerships between real estate companies and service providers, strategies to enhance capacity and reduce fragmentation among the thousands of homeless service provider organizations, incentives for mainstream public housing systems to connect with the mental health and social service systems, and lessons that can be learned from the VA, which has combined resources to secure more than 7,000 transitional and permanent living situations for veterans in the last reporting period.

A copy of each panelist's presentation is available on the Commission's web site, www.MentalHealthCommission.gov.

Public Comment

The public comment period was held from 11:15 a.m. - 12:15 p.m. Chair Hogan welcomed members of the public who were scheduled to present comments and encouraged others to provide information and recommendations to the Commission via the web site. Individuals who spoke and submitted written testimony were:

Steve Beschoff, California Coalition for Mental Health
Richard Louis III, College Hospitals
Rod Shiner, Los Angeles County Department of Mental Health
Melissa Lackman, Child and Adolescent bipolar Foundation
Toby Ewing, Little Hoover Commission
Bruce Wiseman, Citizens Commission on Human Rights
Betty Dahlquist, California Association of Social Rehabilitation Agencies
Jeff Lustman, Supporco Coalition
Dan Stradford, Safe Harbor
Mike Rupp, Consumer
Stella March, Coordinator, NAMI StigmaBusters and president, NAMI Los Angeles
Gary, Brown, Consumer
Roy Crew, President, California Network of Mental Health Clients
Rusty Selix, California Council of Community Mental Health Agencies
Karenlee Robinson, Chief Operating Officer, Sharp Mesa Vista Hospital
Judy Tiktinsky, Phoenix Programs, Inc.
Robert Ross, President and CEO California Endowment

November 14, 2002

Public Comment

Dr. Hogan opened the period for public comment at 9:35 a.m. The Commission heard from the following individuals:

David Wanser, Texas Commission on Alcohol and Drug Abuse in Austin
Beverly Abbott, Chair, California Women's Mental Health Policy Council
Lynnett Peraza, Project Return: The Next Step
Catherine Bond, Project Return: The Next Step
Gail Green, Project Return: The Next Step
Susan Mandel, Pacific Clinics
Andrea Stephenson, Consumer and family member
Sam Bloom, SPAM - CA
Tom Petit, Desert Healthcare Foundation
Ruth Hollman, SHARE
Jesse McGuinn, Department of Alcohol and Drug Program

Work Session

Chair Hogan requested that Commissioners approve the draft minutes from the October 2-4, 2002 meeting. Commissioner Townsend moved to accept the minutes and Commissioner Lerner-Wren seconded the motion. The minutes were accepted unanimously with two edits requested by Chair Hogan.

During the work session, the following Subcommittees provided brief updates on their activities: Children and Families, Criminal Justice, Evidence-based Practices, Consumers, Housing, Older Adults, Interface with General Medicine, Employment, Medicaid, and Rights and Engagement. Several subcommittees will report their findings to the full Commission at the December meeting: Criminal Justice, Evidence-based Practices, Suicide Prevention, and Co-Occurring Disorders.

Adjournment and Next Meeting Announcement

Dr. Hogan thanked all presenters and adjourned the meeting at 11:35 a.m. The next Commission meeting will occur December 4-6, 2002 in Arlington, Virginia.

I hereby certify that, to the best of my knowledge, the foregoing minutes are accurate and complete.

Claire Heffernan
Executive Director
President's New Freedom Commission on Mental Health

Michael Hogan, Ph.D.
Chair
President's New Freedom Commission on Mental Health

These minutes were considered and approved by the Commission at its December 6, 2002 meeting and any corrections or notations incorporated into the text.

Last Modified 12/06/02

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