Dear Readers, While there is some disagreement in the community regarding the diagnosis of Postpartum Mood Disorders as a mental illness, I believe that each and every PPMD sufferer comes out of her experience with a new appreciation for mental wellness and a desire for all those who suffer from psychological problems to achieve emotional health. I find myself a more educated and passionate advocate from having been through the hell and pain that my postpartum reaction caused for me physically and mentally. Sarah, Executive Director of MHA of GA, and her colleagues in the GA Mental Health community are seeking endorsements for the following initiative. If you are interested in personally or professionally endorsing this effort, please contact her or leave a comment here.
Revival of Georgia's Mental Health and Addictive Disease Services System
THE TIME IS NOW
The care for and support of Georgia's citizens with mental illnesses and addictive diseases has historically been a state responsibility - the safety net is a public good as central as highways, public health, prisons, and financial support of education. This essential characteristic has been true for over 170 years and manifestly was not taken over or relieved by the federal government. OCGA § 37-1-2(a)(4) reads: “Public programs are the foundation of the service planning and delivery system and they should be valued and nurtured; at the same time, while assuring comparable standards of quality, private sector involvement should be increased to allow for expanded consumer choice and improved cost effectiveness.”
• Our public system is in crisis, lacking quality of care and resources. It has been underfunded throughout the modern era. Moreover, there has been a systematic dwindling of state resources, through budget cuts and Medicaid maximization in the 1990s and the establishment of the care management organizations in the first decade of this century.
• The public system is fragmented and in disarray, both in the community programs and the state facilities. It has been conceptualized to focus on community-based services, but the "underfunding and fragmentation has led to unnecessary and costly disability, homelessness, school failure and incarceration," as President Bush's New Freedom Commission on Mental Health characterized the national crisis.
• These issues have come forth front and center from the reporting by The Atlanta Journal-Constitution on suspicious and unexplained deaths and other issues in the state hospitals, as well as the ensuing investigation by the United States Department of Justice.
• This result is ironic given Georgia's key role in developing peer support programs, research, public policy design and advocacy at The Carter Center, and community programming innovations for adults and children.
• Renewed political support and leadership is essential to reconnect the shards of our shattered system. That leadership must emerge with a unified vision of services and the ability to attain adequate funding for services.
• Response to the DOJ investigation has begun, with some additional psychiatric resources and salary support made available to increase personnel at state hospitals. In addition there has been a proposed reorganization and rebuilding of the state hospitals by private for-profit operators. The response still lingers unfinished, however, and a new federal administration is likely to affect the negotiation.
• The reorganization of DHR can and should bring greater attention and resources to mental health and addictive disease initiatives and the opportunity to present budget priorities directly to the Governor. Until deinstitutionalization of inpatients with developmental disabilities and mental illnesses pursuant to Olmstead is completed, however, it may not be possible to assess appropriate state fund allocations for mental health and addictive diseases.
• Reorganization alone is not sufficient to address the quality of care issues in the state facilities because they are overcrowded and have insufficient professional and basic care staff. Providing enough community services for adults and children who suffer from mental illnesses and addictive diseases needs to continue as the dominant public goal.
• Services should be focused on the recovery model, supporting citizens with chronic illnesses through case management, peer supports and certified peer specialists, transportation, housing, and supportive employment
• Community service boards are public providers who form part of any community safety net and should be used in any re-created delivery system.
• The 2008 report by the Governor's Commission appropriately acknowledges the need for a community-based, not hospital-based, system, with the ancillary services of case management, transportation, supportive housing, supportive employment, and peer support that are essential to success and are necessary supplements to excellent medical management, crisis stabilization, and counseling.
• The Department of Human Resources' Behavioral Health Game Plan recognizes the need for these other services; however, it focuses on one regressive tactic to finance improvements in community services and to rebuild/replace the hospitals. As a partial response to the DOJ, it has an unbalanced focus on the hospitals, risking continuing our hospital-centric system. The pending RFP to relocate all forensic beds in one place seems to prejudge a similar solution for the adult units in Georgia's state facilities.
• Forensic beds are most effective when their evaluation and treatment resources are close to the jails and diversion courts, as well as to the families of the patients.
• The use of private resources, typically in non-profit entities that can bring charitable donations to and expand state funded services, has had successes in Georgia, particularly for children and adolescent core day and residential services, as well as for housing and day programs for adults. Its benefits are not, however, uniformly distributed or fully leveraged. Georgia has yet to utilize its existing community inpatient facilities for children and adults, most of which can bill Medicaid and expand state resources.
o Only four states have taken the step to lease their inpatient facilities to private for-profit providers and the longer-term experience with costs in Florida, North Carolina, and Pennsylvania indicate that there are no real savings. Moreover, no other state has fully privatized all its public inpatient beds.
o This type of complete inpatient privatization forfeits access to a safety net of state-controlled beds. It also forfeits budget flexibility for alternative use of state inpatient funds in the future and creates a private stakeholder, with contractual rights to insist on its model, as a long-term counterweight to shifts in public policy or improvements in community services.
o Focusing on hospital replacement first also inherently continues to accent the centrality of inpatient care, rather than on community-based supports following crisis stabilization and good medical management.
• Until community services for persons suffering from mental illnesses and addictive diseases are improved, fully accessible geographically, and adequately funded, consideration of privatization of the state hospitals by for-profit companies seems premature. It also is extremely expensive since Georgia’s taxpayers will be repaying those private providers for the next twenty years.
• The value that core benefits be standardized across funding streams is important so that no child, adolescent, or adult is disparately treated because of his or her funding stream; however, Medicaid billing should be used to the fullest extent possible. Such expansion will stretch existing state dollars, as has begun in child and adolescent services.
• Mobile crisis intervention, at homes and in jails and hospital emergency rooms, peer support, central access, and crisis intervention and assertive community treatment teams should be expanded statewide. Crisis stabilization for adults should be located in community facilities and programs, not on isolated campuses of existing state hospitals. Georgia has several excellent models for crisis intervention that can be readily expanded.
• Discharge planning should begin at the time of admission in the hospitals and crisis units, and then intensive and basic case management should follow a consumer after admission. Such case management is equally important to citizens suffering from mental illnesses or addictive diseases in the jails and prisons, and diversion of them to treatment resources is critical. Georgia's successful diversion courts should be available statewide.
• Children and adolescent beds in state facilities can be closed and replaced in the short term using existing or expanded psychiatric treatment facilities that can bill Medicaid, as well as the excellent child and adolescent inpatient hospital facilities and child caring institutions throughout the state.
Until the community-based services described above are implemented and the ongoing deinstitutionalization is completed, it is not possible or financially prudent to right size the state hospitals and focus on their replacement. When hospitals are replaced, smaller regional facilities and units are the standard of care in the United States, not large centralized ones.
Without adequate funding, service providers in a revitalized delivery system cannot address the diverse needs of individuals seeking care, treatment, rehabilitation, and habilitation. While Medicaid and other rates are no longer cost-based, any new system must provide a mechanism for providers to negotiate reasonable rates for their services.