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Meeting Minutes
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The President's New Freedom Commission on Mental Health met on December 4-6, 2002 at the Crystal Gateway Marriott, 1700 Jefferson Davis Highway in Arlington, Virginia. In accordance with the provisions of Public Law 92-463, the meeting was open to the public on December 4th from 3:00 p.m. to 5:30 p.m., December 5th from 8:30 a.m. to 10:15 a.m. and 3:15 p.m. - 5:15 p.m., and December 6th from 8:30 to noon, when the meeting adjourned. Commissioners present: Staff members present: Claire Heffernan, Executive Director Consultants who attended portions of the meeting were: December 4, 2002Panel Presentation: Dealing with Fragmentation in the Service Delivery System
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Chair Michael Hogan convened the meeting at 3:05 p.m. and introduced members of the expert panel addressing the issue of service delivery fragmentation. Dr. Steve Sharfstein, President and CEO of Sheppard Pratt Health System in Maryland and a former staffer for the Presidential Commission on Mental Health during the Carter Administration focused on system fragmentation. He maintained that fragmentation of funding leads to fragmented care. Few financial incentives (e.g., reimbursement) exist to promote coordinated care. In addition, providers have been overwhelmed by the administrative paperwork required by reimbursement processes. Dr. Sharfstein suggested that the Commission's final report to the President include a strong statement that, at a time when treatment for mental illness has never been more effective, access to care is fragmented, discontinuous, sporadic, dysfunctional, and often totally unavailable. He encouraged the Commission to emphasize both the recovery model and the medical/scientific service delivery model. He offered several principles for the Commission's consideration, including
Given the importance of the Commission's work, Dr. Sharfstein urged a focus on the next steps once the Commission issues its report to the President. A critical, yet subsequent, outcome of the Carter Commission was the development of the National Plan for the Chronically Mentally Ill, a series of reforms that improved access to rehabilitation and housing. Dr. Kelly, a former Commissioner of the Virginia Department of Mental
Health, also provided his perspective on fragmentation. According
to Dr. Kelly, the problem is that the mental health service system
is stuck on a status quo approach to care that accepts tradition and
mediocrity rather than demanding innovation and excellence. He highlighted
three areas for the Commission to focus upon: Laurie Flynn, former Executive Director of NAMI, and current Director, Carmel Hill Center for Early Diagnosis and Treatment, Division of Child and Adolescent Psychiatry at Columbia University, urged Commissioners to remember that engaged and energetic parents and consumers are the most effective tools for securing needed change. She attributed the current system fragmentation to lack of knowledge by some providers and/or implementing interventions poorly. For example, preventive interventions aimed at adolescents often include phone numbers for contact; yet, adolescents do not reach out by calling phone numbers. Or, she suggested, periodic media campaigns to educate people about depression do not have an impact, as they are too general or not sustained. These types of programs represent good intentions and large investments of money; yet do not have sufficient outcomes. Ms. Flynn described a promising strategy utilized by Columbia University, which provides a diagnostically based screening for youth, which can identify youth who are at risk for serious mental disorders. This computerized diagnostic tool can be self-administered in less than an hour. Yet, Ms. Flynn described the challenges of implementing the screening in communities. Implementation in just one school district often requires piecing together over a dozen funding streams from the education and mental health fields. She cited the need for blended funding to help engage partners in education. She also recommended that children obtain routine mental health check-ups. During the question and answer period between Commissioners and panelists, comments included:
A copy of Dr. Sharfstein's and Dr. Kelly's presentations is available on the Commission's web site, www.MentalHealthCommission.gov. Panel Presentation: Business Executives Share Personal Experiences with Depression
Mr. Gellerstedt, Mr. Fuqua, and Mr. Johnson shared their personal experience of dealing with depression while maintaining high-level executive positions. Panelists agreed that far too many people who suffer from mental illness do so in secret due to stigma. Until the stigma is diminished, too many people will not seek treatment and some will take their own lives. Stigma exists around acknowledging one has a mental disorder, but also when seeking treatment and facing public perceptions. Acknowledging that one has a mental disorder may result in discrimination including financial, (e.g., when seeking health or life insurance), which creates a strong disincentive to seeking treatment. The business leaders pointed out that those employed in the Federal government also experience fear and stigma which prevents them from acknowledging their mental illness. The Federal government could exhibit leadership by reviewing its forms and applications for stigmatizing questions. Currently, employees are fearful of seeking psychiatric care or taking antidepressant medication. It will take both political and corporate leaders to ensure their policies do not discriminate against people with mental disorders. Commissioners were interested in how they might encourage corporate leaders to create environment that encourage people to come forward. Mr. Gellerstedt responded that corporations should provide information about how common mental illnesses are and suggested that companies can gain a competitive advantage and increase productivity by adopting favorable policies. Mr. Johnson agreed that the Commission "cannot legislate" the end of stigma. It will require leadership and education of colleagues in all available forums. He is involved with trying to mobilize other CEO's to engage in a proposed national depression campaign. Other Commissioners suggested that the media and insurance parity would help foster acceptance and minimize stigma. Mr. Johnson urged the Commission to endorse two activities: (1) creation of a national awareness campaign about the treatment of depression aimed at defeating the stigma of depression and (2) creation of a national information center about depression to make information about depression as easy to obtain as information on cancer, perhaps in partnership with Emory University and Stanford University. After thanking the business leaders for their willingness to speak
publicly about their experiences and help penetrate that veil of stigma,
Chair Hogan closed the meeting at 5:30 p.m. December 5, 2002Expert Presentation: A Model to Reduce Fragmentation
Upon opening the day's session at 8:40 p.m., Chair Hogan introduced the presenter, Dr. Diamond, who added his perspective on system fragmentation. Dr. Diamond explained how perceptions of effective treatment of persons with mental illnesses have evolved from (1) simply decreasing the number of hospital patients (2) decreasing the number of rehospitalizations by either decreasing hospital bed availability and/or increasing community supports so that rehospitalization is not required to (3) focusing on persons' rehabilitation to ensure they have more to life than their illnesses to (4) achieving community integration for persons with mental illnesses. In Dr. Diamond's opinion, Dane County was currently in the third stage of treatment development. He also distinguished the difference between a system and a set of programs, maintaining that having a number of good programs does not constitute a system. While a program is responsible for a defined set of clients, a system is responsible for all high priority clients in its locality (e.g., including those in jails and people not yet connected to services). An effective system provides ongoing services to a priority population (e.g., persons with serious and persistent mental illness) and individual program components support one another as part of a larger, integrated system. In contrast, traditional systems have clinical programs that decide what services they want to offer and the person is expected to fit into the available services. If the person needs a service not offered by a program, it the person's problem, not the system's problem. In contrast, an effective mental health system does whatever is required to meet the needs of its high priority clients. Dr. Diamond also emphasized how clinical systems and funding streams are inevitably intertwined: financial incentives and disincentives drive the system. With traditional funding streams, community programs and hospitals are often at odds, competing for dollars from the state budget and debating over responsibility for clients. In Dane County, the local authority controls the pot of money and is able to purchase services from hospitals (including state and private hospitals), as well as a range of community-based programs services (including outpatient clinics, rehabilitation programs, crisis resolution programs and residential programs). Under this arrangement, the locality may allocate resources creatively based on clinical needs (e.g., for a client who needs a brief, supported placement, the system can pay for a person to stay in a hotel accompanied by a crisis aide in lieu of a hospital stay). While flexible funding enables this system to work, leadership and available clinical programs are essential. He laid out several principles for designing a system of care:
Dr. Diamond also offered some "system truisms" based upon his experience in Dane County:
To prevent the system from filling up, administrators may obtain additional resources, choose to extrude people from the system, establish barriers to prevent entry into the system (e.g., cumbersome intake process), increase case load size, or sacrifice one program to protect the rest of the system. As Dane County has experienced system clog, it has determined to "sacrifice" its mobile crisis by expanding its role to provide case management services to individuals who are waiting to get into other services. Dr. Diamond also stressed that it is important to have consumers and families participate in the discussion about how to handle system clogging. During the question and answer period, Commissioners posed questions about how such systems works for people in rural areas, how the community responds to discussions about establishing priority clients, and how to integrate Medicaid financing into this type of system. Dr. Diamond underscored the premise that financial incentives drive clinical programs and the need to look at unintended consequences of funding decisions. In response to questioning, he suggested that the Commission might recommend wrapping Federal and nonfederal monies together and placing it under local control. If localities had access to all resources, as well as all of the responsibility of ensuring care, the system would be more efficient and, in some localities, promote creative experimentation. Such local control also could be combined with accountability mechanisms (e.g., outcomes). Another recommendation was to integrate the budgets of hospitals and community-based programs so that localities are able purchase beds, which may spur the creation of additional service options. Work Session Chair Hogan opened the public work session at 3:25 p.m. and provided
an overview of the Commission's Subcommittees structure and activities,
including preparation of background Issue Papers on a range of topics.
He stated that while the Commission will submit a report to the President,
the final Issue Papers would provide a good foundation for the Commission's
final recommendations and be useful resources for the field. The opening report was offered by Commissioner Lerner-Wren, Chair of the Subcommittee on Criminal Justice, accompanied by Dr. Henry Steadman, consultant to the Subcommittee. Report of the Subcommittee on Criminal Justice Commissioner Lerner-Wren outlined the significant problem of the criminalization of people with mental illnesses. In its discussions, the Subcommittee suggested that three major responses were needed: (1) keep people with serious mental illness who do not need to be there out of the criminal justice system through diversion programs; (2) provide constitutionally adequate services in correctional facilities for people with serious mental illnesses; and (3) link people with serious mental illnesses to community-based services when they are discharged through reentry transition programs. Commissioner Lerner-Wren described several policy options discussed by the Subcommittee, including:
Once Commissioner Lerner-Wren completed her overview of the policy options, a number of Commissioners engaged her and Dr. Steadman in questions. Commissioner Godbole inquired whether the Subcommittee discussed strategies for developing community awareness and acceptance of this population, citing prevalent Not In My Back Yard (NIMBY) attitudes among community members and even mental health professionals. Dr. Steadman responded that while the Issue Paper will address the public's fear of violence among this population, ultimately this population represents the same poor and homeless people who currently cycle through the mental health, substance abuse and criminal justice systems. Through the policy options, the Subcommittee aimed to underscore the importance of good public health and good public safety by ensuring there are appropriate and comprehensive services for individuals with mental illnesses, and often co-occurring substance abuse disorders. Commissioner Postlethwait asked about the application of the policy options to adolescent and school-aged populations. Although there are many overlapping issues between adult and juvenile justice systems, the juvenile justice system also has many unique needs. Thus, the Subcommittee on Criminal Justice did not deal with the juvenile justice system believing the Children's Subcommittee should address the issue. Commissioner Adams and Commissioner Huang agreed that the Subcommittee on Children and Families should focus on the juvenile justice population. Commissioner Mayberg expressed concern about the framing of CRIPA issues and the emphasis on the constitutional right of persons in institutions to treatment. After some discussion about rights and responsibilities, Commissioners agreed that the emphasis should be on the need for Federal leadership to decriminalize this population, promote public health/public safety, and divert individuals into community programs that can assist them. Commissioner Fisher requested that the theme of recovery be woven into the report. He also suggested that treatment in jails should include more than medication. Dr. Steadman indicated that the Issue Paper would distinguish between treatment available in jails (average length of stay is two days) and prison facilities (average length of stay is 18 months). In response to Commissioner Townsend's question about suggested mechanisms for implementing several policy options, Chair Hogan suggested that many of the proposals required clarification from Federal agencies (e.g., clarification from CMS to state Medicaid agencies) rather than changing regulations. Dr. Steadman underscored the need for Federal guidance (e.g., technical assistance or program guidance), as communities have more opportunities to provide services than then they recognize currently. Commissioner Huang requested that the Subcommittee consider providing more specific programmatic or policy options related to persons with mental illnesses who are minorities and involved with the criminal justice system. Once the discussion was complete, Commissioner Godbole moved to accept the Subcommittee on Criminal Justice's report and Commissioner Yates seconded the motion. Commissioners voted unanimously to accept the report. The full outline for the Draft Report of the Subcommittee on Criminal Justice is available on the web site, www.MentalHealthCommission.gov. Report by the Subcommittee on Evidence-based Practices Commissioner Godbole, Chair of the Subcommittee on Evidence-based Practices, accompanied by Dr. Howard Goldman, consultant, gave the following Subcommittee report: During its discussions, Subcommittee members agreed that there is
a need to expand efforts at developing and testing new treatments
and practices, at promoting awareness of and improving training in
evidence-based practices, and in better financing those practices.
Commissioner Godbole stressed the need for national leadership to
overcome fragmentation and diffusion of responsibility around promoting
evidence-based practices. 1. Partnership for National Leadership. The subcommittee recommended a "national consortium" to create a partnership for leadership, initiated and sustained by the Federal government and involving relevant agencies along with other organizations in the public and private sectors. The partnership should include all stakeholders, including consumers and families, to advance knowledge, disseminate findings and implement evidence-based practices. To establish this national leadership, the Subcommittee further suggested:
For each of these policy options, the Subcommittee favors a partnership approach that is initiated by the Federal government and has significant Federal participation and support but is "national" rather than Federal. Federal resources should serve as a "match" to contributions from state and local governments, as well as from private sources, such as foundations and advocacy organizations. 2. Advance knowledge including rigorously evaluated service demonstration
programs. Service demonstrations are intended to provide knowledge
to assist in disseminating and implementing new service models. Under
the direction of the national partnership, CMHS (SAMHSA) and NIMH
(NIMH) should strengthen their collaboration in planning, fielding,
and evaluating mental health service programs in evidence-based practices
in collaboration with other Federal agencies, state and local governments,
as well as private organizations, including foundations, and involve
all stakeholders, including consumers and families.
Upon completion of the Subcommittee report, Commissioner Curie stated his appreciation of the Subcommittee's focus on the sciences to services cycle, a priority area for SAMHSA and NIH. For the suggestions to modify Medicaid and Medicare, he suggested that more appropriate terms might be "clarify" or "address" as the goal is to create an environment where financing mechanisms (including Medicaid and Medicare) begin purchasing evidence-based practices. Commissioner Curie also noted the Subcommittee's mention of research, dissemination, demonstration, and evaluation and the difference in meanings of those respective terms and the implications. Alternate Commissioner Stanton commented that the Subcommittee's report was philosophically consistent with CMS' goal of "getting into the business of paying for what works." He also suggested that the Subcommittee clarify its use of terms, specifically around the difference in coverage and payment issues. For example, rates are set by states, not the Federal government. In addition, there are services that CMS cannot completely support given existing laws (e.g., supported employment). However, technical assistance may be helpful to clarify what supports for employment can be funded and which cannot. Commissioner Fenton was pleased with the Subcommittee's mention of continued research to develop new evidence-based practices in addition to disseminating current knowledge. Commissioner Fisher echoed approval of a focus on new research, indicating
this issue is particularly relevant for consumer research. He requested
that the Subcommittee address research on emerging services so that
the emphasis on evidence-based practices does not preclude the advances
in consumer research and services. He suggested that a statement be
added about consumer involvement with research design and December 6, 2002Work Session Chair Hogan began the work session at 8:40 a.m. and explained the Commission's task to listen to, discuss and accept the reports from the Subcommittees on Suicide Prevention and Co-occurring Disorders. Report of the Subcommittee on Suicide Prevention As Chair of the Subcommittee on Suicide Prevention, Commissioner Prechter provided the report to the full Commission. After describing the pressing public health crisis of suicide, she highlighted the Subcommittee's policy options, including:
Following the report, Commissioner Prechter and Dr. Eric Cain, who served as a consultant to the Subcommittee on Suicide Prevention, fielded questions and comments from the full Commission. Commissioner Lerner-Wren expressed support for incorporating suicide screening into the criminal justice settings, as well as a range of settings, such as the schools. Commissioner Yates questioned if current surveillance systems can indicate whether people who commit suicide were in mental health treatment at the time and, if so, were they in the public or private mental health system. Dr. Cain responded that the data is uneven, but some research has shown that (1) among elderly suicide victims, only 20 percent had a mental health contact during their life times while 70 percent had a primary health care visit within the last month and 40 percent had a visit in the week prior to their suicide, (2) for persons with serious mental illnesses, virtually all were in treatment, but it is difficult to ascertain where they fall between the cracks, (3) during the age span 25-55 when most suicides occur, those who commit suicide often have chronic substance abuse histories, particularly alcohol abuse, and may be seen in chemical dependency settings, the court system, or exhibit at-risk signs in the workplace. Commissioner Insel suggested that the Subcommittee might want to incorporate World Health Organization data on global risk of violent deaths, which indicated 49 percent of deaths were self-inflicted. He suggested that the Subcommittee may not want to compare the number of deaths resulting from AIDS and suicide, as such data may appear to pit one population against another. In response to a question from Dr. Insel, Dr. Cain discussed the quality of systems to track people who are at high risk of suicide, suggesting that it may be more helpful to examine substance abuse, family turmoil, incidence of depression, and work-place problems. The goal should be to seek out and treat populations that demonstrate such risk factors. Commissioner Harbin inquired whether establishing parallel or additional systems outside of the mental health or medical system is desirable. Dr. Cain commented that it would be preferable to better utilize existing systems and cited the cost savings achieved when New York's Monroe County was able to integrate more than a dozen funding streams to provide suicide prevention activities. Commissioner Godbole inquired about how and whether suicide prevention
is incorporated into professional training. Dr. Cain indicated that
the biggest need is to educate professionals outside of the mental
health Commissioner Adams expressed concerns about the need to educate consumers and families about suicide prevention, the need for culturally sensitive and alternative methods for suicide prevention (e.g., Native American models), the need for sufficient attention to the suicide rates among youth in juvenile justice and in foster care, and the issue of tracking/surveillance. Commissioner Huang addressed the challenging of determining effectiveness of suicide prevention efforts and even defining what constitutes a suicide (e.g., accidents or homicides which may really be passive suicides). Alternate Commissioner Hutchings spoke of the tremendous mental health needs of the surviving family members after a suicide and questioned how the Subcommittee's policy options might address that need. Dr. Cain suggested that the trauma field might offer better interventions for this group to address the significant ripple effects of the 30,000 suicides each year. At the conclusion of the discussion, Commissioner Townsend moved to accept the report offered by the Subcommittee on Suicide Prevention and Commissioner Lerner-Wren seconded the motion. Commissioners voted unanimously to accept the Subcommittee's report. The Outline for the Draft Report of the Subcommittee on Suicide Prevention is available on the web site, www.MentalHealthCommission.gov. Approval of November Meeting Minutes Report of the Subcommittee on Co-occurring Disorders As Subcommittee Chair, Commissioner Arredondo acknowledged the contributions
of consultants Dr. Ken Minkoff and Dr. Doug Ziedonis, as well as the
Subcommittee members. He gave an overview of the report, including
integrated treatment focus. Commissioner Arredondo outlined the issue
of appropriately serving people with co-occurring disorders and put
forth several policy options for discussion, including:
Commissioner Curie reported to the Commission about SAMHSA's recently submitted report to Congress on co-occurring disorders and the matrix of SAMHSA's priorities, which includes a focus on co-occurring disorders. Both of these efforts should dovetail well with the Commission's eventual recommendations around treatment of co-occurring disorders. Commissioner Harbin questioned how many states have departments that combine mental health and substance abuse and how many have separate departments. While it is likely that comparable numbers of states operate under both structures, there is still tremendous variation within states, including at the local levels. Commissioner Curie commented that, while some level of structural merging may need to occur to facilitate better integration, a focus on function rather than structure is more helpful. Chair Hogan added that the Commission should focus on the need for integrated treatment rather than how the integration occurs. Commissioner Yates suggested that the Commission include the private sector in its policy options about integrating care. Perhaps dialogues and education efforts could be initiated with the national leadership of organizations like Alcoholics Anonymous and Narcotics Anonymous. Commissioner Fisher expressed interest in an Office of Co-occurring
Disorders, citing the roles of consumers in recovery within both the
mental health and substance abuse fields. It also would be helpful
to have Commissioner Godbole expressed concern that the subcommittee's report may be too proscriptive by recommending a specific model, the integrated treatment model, particularly given the evolving field and the diversity of systems. Commissioner Curie responded that Subcommittee's intention was not to promote one model but to encourage integrated care, particularly as multiple systems are already spending resources upon individuals with co-occurring disorders. Alternate Commissioner Mele-McCarthy suggested expanding the policy options about health training programs to include collaboration with professional organizations, which educate practitioners, as well as families and consumers. Commissioner King-Shaw Ruben encouraged the Subcommittee to include community and faith-based organizations in the policy options and suggest ways to partner with and leverage the capacities of those organizations. Commissioner Huang requested that the Subcommittee address the needs of adolescents with or at-risk of co-occurring disorders, given the important window of opportunity to intervene with these youth. At the end of the discussion, Commissioner Lerner-Wren moved that the Commission accept the report of the Subcommittee on Co-occurring Disorders, which Commissioner Townsend seconded. The Commissioners voted unanimously to accept the subcommittee's report. The Outline for the Draft Report of the Subcommittee on Co-occurring Disorders is available on the web site, www.MentalHealthCommission.gov. Public Comment During its public comment period, the Commission heard from the following
individuals: During the final work session, the following Subcommittees provided brief updates on their activities: Cultural Competence, Children and Families, Housing and Homelessness, Consumer Issues, Medicaid, and General Medicine Interface. Several Subcommittees indicated they might be prepared to report out at the Commission's January Meeting. Chair Hogan highlighted a matrix of Federal government programs prepared by Commission staff for Commissioners. Given the more than thirty Federal programs spanning multiple Departments that impact persons with mental illnesses, he indicated that many of the issues before the Commission must be examined more broadly than the narrow confines of the mental health system, particularly for children. Chair Hogan also mentioned recent correspondence received by the Commission, including a piece submitted by the father of young man who testified before the Commission in September, which encouraged reducing fragmentation by giving consumers and families a more central role in directing their care. In addition, a California mother who lost her son to suicide wrote Mrs. Bush to encourage the replication of programs like The Village. Commissioner Godbole requested that Commissioners receive more qualitative analysis about public comments received by the Commission's web site, in addition to the quantitative report. Chair Hogan mentioned that many Commissioners are reaching out in their respective communities and region to solicit input and engage in dialogue. Commissioner Lerner-Wren sponsored a forum in south Florida, while Commissioner Knight-Richardson hosted a forum for western states in Oregon. Finally, Chair Hogan noted that the Commission's web site, www.MentalHealthCommission.gov, has sections that have been translated into Spanish. Also, in process, and soon to be active are web sections that have been translated into Chinese, Korean, and Vietnamese. Chair Hogan expressed appreciation to members of those communities who were able to contribute to the translation effort. Adjournment and Next Meeting Announcement Chair Hogan adjourned the meeting at 12:05 p.m. The next Commission meeting will occur January 7-9, 2003 in Arlington, Virginia. I hereby certify that, to the best of my knowledge, the foregoing minutes are accurate and complete.
These minutes were considered and approved by the Commission at its January 8, 2003 meeting and any corrections or notations incorporated into the text. Last Modified 1/17/03
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