2004-2008 Statewide Comprehensive Plan for Mental Health Services
New York City Region
New York City Field Office (Part 1)
May 18, 2004 Testimony
- Jack S. Goldstein
Board of Directors NAMI-New York State, Consumer Representative
Board of Directors NAMI-Rochester, NY
NAMI National Consumer Council Representative for NY NAMI-New York State Consumer Committee Chairperson
- J. David Seay, J.D., Executive Director
National Alliance for the Mentally Ill of New York State (NAMI-NYS)
- Evelyn Roberts, Ph.D., Executive Director
National Alliance for the Mentally Ill of New York City, Inc. (NAMI-NYC Metro)
- David Kaplan
Associate Director of Greenwich Village Youth Council
- Anita Altman
Deputy Managing Director of the Department of Government & External Relations at UJA Federation of New York
- Phillip A. Saperia, Executive Director
Coalition of Voluntary Mental Health Agencies, Inc.
- Raymond Schwartz
- Janet Guzman
Family Support Parent Advocate of the JOY Center
- Lloyd Sederer
Executive Deputy Commissioner for Mental Hygiene Services
New York City Department of Health and Mental Hygiene
- Joyce Wale
Senior Assistant Vice President
NYC Health and Hospitals Corporation
- Loretta M. Cerbelli
- Kathleen Sweeney
Chief Operating Officer for Administration
Institute for Community Living, Inc.
- Amy Chalfy
Mental Health Services
Jewish Association for Services for the Aged
- Raquel Romanick
Council of Senior Center & Services of New York City, Inc.
- Dr. Robert Giugliano
Director of Mental Health, Covenant House New York
- Giselle Stopler
Executive Director of the Mental Health Association of New York City
Jack S. Goldstein
Board of Directors NAMI-New York State, Consumer Representative
Board of Directors NAMI-Rochester, NY
NAMI National Consumer Council Representative for NY NAMI-New York State Consumer Committee Chairperson
The Office of Mental Health's 5.07 Plan is a plan to sail off to a beautiful destination. Unfortunately, the way things are the plan is useless without "a map, an inventory of supplies on hand and a shopping list for what is needed."
For the OMH to form a committee to study hospital closures without knowing exactly what the housing needs are for people with mental illness in New York is like having the desire to meet the needs of New Yorkers and to go on a voyage without a map, compass or stars to be guided by. In deed, it's like planning a long voyage without knowing how much food is needed and throwing away part of the food provisions to save money.
The Office of Mental Health is avoiding an assessment of what housing needs are in New York State to avoid facing up to the responsibility of the State to provide a safe, clean place to live for people with mental illness. Without housing, recovery from mental illness is not possible. With housing, recovery is possible, work is possible and therefore taxes are paid. With proper services and supports, the revolving door between hospital emergency rooms, homeless shelters and jails is ended - saving taxpayers a huge expense.
So, speaking as a Board Member of NAMT NYS and representing 60 affiliates, 5000 members and over 20,000 family members, we demand that OMH make a needs assessment of all types of housing including but not limited to community residences, SRO's, supported housing, supervised apartments and psychiatric hospital beds. For a small number of the SPMI, Hospitals are the closest things to a home. Anything less is simply illogical and irresponsible.
J. David Seay, J.D., Executive Director
National Alliance for the Mentally Ill of New York State (NAMI-NYS)
Good morning. My name is J. David Seay, and I am Executive Director of the National Alliance for the Mentally Ill of New York State (NAMI-NYS), New York's voice on mental illness. NAMI-NYS represents 58 affiliate organizations and 5,000 members across New York State. NAMI has nearly a quarter million members nationwide. Our mission is to improve the lives of all who are affected by serious mental illness. With me is Kelsey Batchelder, a member of the NAMI-NYS Board of Directors. Thank you for the opportunity for us to speak today.
Last year the hearing on the 5.07 plan was held by the Mental Health Services Council, and to NAMI New York State, simply holding that one hearing before the plan came out was a very good sign. We hailed it as a first step on what we hoped would be a journey toward the kind of mental health system we all would like to see in the future.
Or a least a step toward creating the map for such a journey.
This year, we are greatly encouraged by a number of steps that could take us further toward this goal. The Office of Mental Health's effort to obtain more input into the plan --which includes this and other hearings -- and this year's plan itself indicate a renewed commitment that is essential to progress.
The journey remains to be taken, however, and the map that is required, a comprehensive, over-arching, needs-based, multi-agency plan, has yet to be created.
We recommend that anyone who is a member of a county community services board, or anyone who wants to know what OMH is, what it does, and who is doing what should read this year's 5.07 Plan. In this way, it is the most comprehensive we have seen.
It still is much more of a report than a plan, however. It describes a plethora of initiatives and projects: a list of actionable items, but not a real plan.
We are all for the ABC’s Accountability, Best Practices and Coordination -- for example. They are absolutely essential. But we don't quite get using them as a framework for strategic planning. It's as if I were to ask you what you plan to be doing five years from now, and you say I'm going to do my very best. That really doesn't answer the question. In this way, this document is like the 5.07 plans of the recent past.
But this time there are also some new features that could represent a break for the past, particularly this plan's renewed commitment to planning itself. For example, on page 12 it states that OMH will "collaboratively develop a new, broadly inclusive planning platform," a project we welcome whole-heartedly and want to participate in.
Moreover, Chapter Two, "Building a Stronger Planning Process," addresses the critical issue of needs assessment, which is the foundation of good planning. On page 15, for example, it states that "OMH is committed to population-based planning, forecasting and management that utilizes relevant data gleaned from agency performance measurement activities to enable data-driven decision-making."
We sense a sincere effort to apply methods developed in the public health sector to determine how many people need what kind of services. We applaud this effort and believe such methods could play a significant role in the future.
We remain concerned, however, that those who need services, but, for whatever reason, are not getting them might not be accounted for. We are told the population-based approach does take prevalence data into account, but such data is dubious because it has such wide margins of error. We are also told that a number of people with mental illness may be receiving services outside the system or might not even need services. Conspicuously absent from this chapter is any mention of waiting last data, which would be the most concrete indicator of unmet need.
We believe OMH has access to such data through the SPOA process and other means, but either it as not being systematically collected, or if at as being systematically collected, it is not being made public. In regard to this, we could not agree more with what the plan also states on page 12: "The hallmark of a quality mental health system is the degree of transparency it maintains for its planning and decision-making processes."
Transparency is not only needed in planning but also in data gathering. We need to know enough about it to trust it. And not only in terms of accuracy. Advances in record-keeping such as the Baseline Assessment Form and the Child and Adult and Child Integrated Reporting System must not come at the expense of informed consent and the right to review records and correct erroneous information. At this moment, few consumers and families understand that personal information as no longer being kept solely in the office of their care provider. They must be assured that not only will this information be safeguarded, it well be reviewable and correctable.
Our final data concern is prompted by the proposed moving of the 5.07 Plan's release date from not later than October 1st to the same day that the Executive Budget is released. We understand the reality that the plan is essentially a part of the budget, and releasing it after the budget allows for greater detail, but we fear it could be further "politicized."
Whether it was intended that way or not, for example, the first graph presented in Chapter 4 "Utilization of Inpatient Beds, page 36 -showing a comparison of inpatient days in state and general hospitals to those an other states – seems to be irrelevant, except in the political context, which was the proposed closing of Middletown Psychiatric Center. There are such significant differences among the mental health care systems throughout the country and the populations they serve, at provokes this year's apples and oranges comparison.
As for those states that have all but eliminated long-term and intermediate care, from them we hear reports of great misery and suffering - nothing to be emulated.
We would like to acknowledge, however, that Chapter 4 does also provide new information on state hospitals that is helpful, and we hope in the future more such information will be provided as a basis for meaningful discussion.
We, meaning all stakeholders, must have a meaningful discussion of the fate of the state psychiatric centers, for what happens to long term- and intermediate care will determine what happens in every part of our mental health care system. The system inevitably fails when those it would serve simply aren't ready to benefit. This has been the experience of some ACT teams.
We also need to act according to the results of such a discussion, and, unfortunately, this is where the proposed Commission on the Closure of State Psychiatric Centers fell too short. The legislation called for a list of centers to be closed, not for a plan to close them as part of an overall plan. Such a plan would ensure intermediate- and long-term care and proper support services, including housing, for the communities involved according to an accurate assessment of needs.
Meanwhile, reports from NAMI families tell us that we are already at the minimum number of state hospital beds that are needed, staff shortages are affecting quality and some patients are being released prematurely.
Another discussion that is obligatory pertains to the fate of reinvestment. For the second year in a row, community services will not receive any additional reinvestment funding. This time, because the money is being diverted to fund 600 supported housing units. While we support the development of such housing, the use of reinvestment money to fund it denies the counties their use of this money, prevents them from having any say in how it is spent and circumvents the local planning process.
Again, this leads us back to the need for an overall plan, a needs based, over-arching plan.
Speaking of community services, the Personalized Recovery Oriented Services initiative, or PROS, which has the potential to dramatically alter the form and delivery of community based mental health services for more than 20,000 New Yorkers with severe and persistent mental illness, garners a mere six paragraphs in this plan. Any initiative that impacts nearly every aspect of community care, from clinics and clubhouses to affirmative businesses and IPRTs, and which involves the conversion of tens of millions of dollars from Community Support Services and reinvestment funding to Medicaid, deserves further elaboration.
We applaud OMH's stated objectives to utilize PROS as a platform from which to implement evidence based practices, as a mechanism by which to improve the coordination of care, and as program to promote wellness and recovery. We hope, however, that next year's plan will also discuss issues related to implementation, from the fate of affirmative businesses, which will not be eligible for Medicaid funding, to consumer choice and the fiscal viability of niche service providers. Much more needs to be said about this initiative regarding how it will work, both with individual community services and the overall system.
Another program that deserves a fuller report is the ACT program. The Office of Mental Health has made a heroic effort to increase the number of ACT teams from only a handful of unlicensed teams two years ago to 44 that are now licensed and an additional 26 that are in the licensing process. A separate report on the progress of these teams and the issues they face would be appropriate.
Housing continues to be our top priority as it is basic to recovery.
"Is there no place on earth for me" was the cry of a young woman with schizophrenia who was repeatedly shuttled back and forth between hospitals and her parents' home in Queens. A book written by journalist Susan Sheehan twenty years ago about the plight of people with mental illness describes her ordeal.
Twenty years have passed. Her outcry has been multiplied a thousandfold across the state. The answer is still a resounding "no" to the majority of voices.
This year's Executive Budget continues Governor Pataki's efforts begun three years ago to address the long-standing crisis in housing. Total housing units will increase from 26,700 to 31,000 making it possible for 13.7% of the population designated by an earlier OMH epidemiological study as having serious and persistent mental illness to access state-assisted housing.
Unfortunately, the 5.07 Plan does not project any further housing expansion even though the need is overwhelming.
Over the years, the stream of appropriations for housing development has been inconsistent. Some years there has been none. Our best information indicates a need for as many as70,000 additional housing slots. We must have a plan to reach this goal within the next ten years. Meanwhile, housing must be developed at a minimum of 4,000 slots each year.
The Plan briefly describes the variety of options and supportive service levels provided by the state and not-for-profit providers to offer consumer choices. We question the concept of transitional housing as we believe that housing should be what we all want: permanent homes. As policy, the State Mental Health Program Directors have stated that housing should be stable while services can change as needed.
To provide more options, NAMI has attempted for the last three years to secure funding for establishing more community residences for those needing more support. Also we advocated for an intensive supported housing program on Long Island for those not ready to move directly to supported housing. We have found that some individuals need a more gradual transition in order not to return to hospitals.
We are pleased that OMH is committed to maximizing housing access to essentially the same groups that we advocate for: Those leaving psychiatric hospitals and prisons, the homeless, those in unsafe adult homes or homes that go out of business, those with dual diagnoses of mental illness and substance abuse, and those receiving treatment under AOT court orders.
We are deeply concerned, however, about the omission of adults with serious mental illness who live with their families because there is no other housing available to them. In our 1988 Housing Survey it was found that 80% would prefer living elsewhere in order to attain the benefits of independence. Family members who bear the burden of their care would also benefit, especially aging families unable to cope and deeply worried about where their loved ones will be once their care-giving family members are gone. The 1992 Office of Mental Health study requested by the State Senate projected that because of parental death or disability, up to 1,300 individuals will experience housing disruptions each year. Families as well as their ill family members have been essentially abandoned without the support they deserve for the care they provide. One national study has estimated that family members provide more than $200 billion a year worth of home care to family members with disabilities.
At the very least, our NAMI-NYS families would be helped to know before it is too late that their family members living at home are a priority for housing when they die, are included on waiting lists for housing, and are recognized by the Single Point of Access (SPOA) as a priority population.
Doing the right thing–expanding housing–has been proven to be cost effective. For example, the creation of 5,000 units of supportive housing under an agreement between New York City and the State led to a corresponding reduction in the size of New York City and the State led to a corresponding reduction in the size of New York City’s emergency shelter system. Many people with psychiatric disabilities were enabled to live in efficiency units with wrap-around services at one-third the cost of bouncing them among emergency shelters, the streets and jails.
We’re also pleased to note that the Plan provides for working with non-profit housing providers to adequately fund and preserve existing housing.
We fervently hope that OMH will amend its plan and provide safe, affordable, permanent housing opportunities each year for people with serious mental illness to promote their recovery and integration into the community.
Research remains another top priority. Appropriately, the plan devotes an entire chapter to the subject. Chapter 9 begins with the statement that research in mental health is accelerating and is continuing to identify the potential for recovery where none had been expected or anticipated. This is absolutely true. Significant breakthroughs are achievable now more then ever. The question is whether New York's first-class research institutes, the Psychiatric Institute and Nathan Kline Institute, will have the wherewithal to finally achieve those breakthroughs. Last year the institutes suffered 27 cut research lines; this year the elimination of 30 more lines has been proposed. Slowly - but surely - these vital research institutes are being wiped out through attrition.
Chapter 9 describes the tremendous benefits New York has already derived from its research program. The benefits to come, and cost savings that will result from them, are far greater. Our families do not understand why the state is uncoupling the train, just when there is light at the end of the tunnel. It simply makes no practical, moral or financial sense to destroy this vital investment. Research is our hope for the future.
Criminal Justice-Related Services
Turning to the plight of those with mental illness who are caught up in our criminal justice system, we would like to begin with the fact that in more than 80 percent of the criminal justice cases that come to our attention, the person also suffers from a co-occurring substance abuse problem. While the issue of integrated treatment has received some consideration, primarily in the form of the Quadrant Four Task Force report, and it is generally accepted that Integrated Treatment is an evidence-based practice, the fact is that the treatment world does not reflect the state of the science. OMH needs to intensify its leadership role to measurably increase the availability of both residential treatment slots and community treatment slots, which embrace the integrated treatment model. Right now, the lack of availability typically means that many eligible persons either go to jail or to an inappropriate drug treatment placement where they often fail.
Staffing levels at satellite units in the state correctional system have increased substantially in recent years, especially with respect to discharge planning services. Overall, however, most advocates continue to see a shortage of Intermediate Care Program beds, crisis beds, beds at Central New York Psychiatric Center and sufficient clinical staff.
Interestingly, the 5.07 plan does not mention the Executive Budget's proposed increase in Intermediate Care Program beds, Special Treatment Program beds, and the creation of two Behavioral Health Units (BHUs), which reportedly would result in 107 beds to be used as an alternative to Special Housing Units for persons with a mental illness. Clearly, this represents a necessary beginning to more properly address the mental health needs of eligible persons, and to provide a much needed treatment-centered alternative to "The Box". We would hope that a multi-year plan would not only lay out this commendable beginning, but also project a measured expansion to meet the needs of the 7,500 persons with a mental illness who are now incarcerated in state prisons. The highly regarded Community Oriented Reentry Program at Sing Sing with about 30 beds, for example, is noted in the report, but lacks any mention of a plan to increase its size over time.
The 5.07 Plan reviews the initiatives which OMH has taken over the last 20 years relative to police training, correction officer training, suicide prevention training, and Project Link in Rikers Island. Recent initiatives noted, which are equally commendable, include assistance and support to the Brooklyn Mental Health Court, the development of an in-service refresher training program for police officers, and the jail mental health services workshops for correctional staff and treatment staff. Not mentioned, but deserving so, however, is the funding for local correctional facilities which facilitates discharge planning from local correctional facilities and the Medication Grant Card program which assists persons with a mental illness when they are first released from jail.
These and many other areas, however, also beg for greater attention now and in the years to come. Our experience in advocating in criminal justice cases has clearly shown us the need for training probation officers, public defenders, prosecutors and judges about mental illness and the treatment system. OMH must take a stronger leadership role in this area.
As for discharge planning, we trust that OMH understands the Brad H decision sufficient to recognize its potential applicability to all other correctional facilities across the state. Assistance to local jurisdictions in this matter would seem called for. NAMI-NYS also would support an OMH initiative in the area of jail diversion and mental health courts. Sufficient community services must be in place, however, for such initiatives to work. Too often the reprise from court officials is "divert to what?"
Here is yet another reason why an over-arching, multi-agency plan is needed: to bring such services in synch with criminal justice services.
The plight of persons with mental illness in adult homes is another multi-agency dilemma that would benefit from a truly comprehensive plan.
As a member of the New York State Coalition on Adult Home Reform, NAMI-NYS endorses the recommendations contained in the coalition's 5.07 Plan testimony, which you will hear later today. Developing more housing for people with psychiatric disabilities; developing a service model and guidelines for providers; continuing to improve licensing and oversight; having a more prominent role when impacted homes close; planning better for the needs of adult home residents, and increasing the staffing of the adult home team at OMH are essential if OMH is to meet its responsibilities to residents of adult homes with mental illness.
We also want to make a few specific points:
More collaboration with mental health advocates is needed, such as the creation of inspection teams that include NAMI family members. The Commission on the Quality of Care for the Mentally Disabled must provide greater financial oversight of mental health providers as well as adult home operators, in order to ensure that funding is being properly spent.
When homes close, OMH must ensure that residents' mental health needs are taken care of, as a first priority. The adult home scandals resulted from the transfer of patients from mental health facilities into these homes. The patients were transferred but not the care. OMH must not let that scenario happen again.
Finally, OMH must share the findings of its need assessments of adult home residents. In order to have a legitimate discussion about finding a way out of the adult home mess, stakeholders, including the members of the state's Adult Homes Workgroup, need to know how many people need what kind of services. Again, transparency is key to good planning and decision-making.
Public education is another very important priority to us. NAMI-NYS has been providing public education about mental illness for more than 20 years, and a great deal of it has been funded by OMH. We appreciate the plan's recognition that education is a vital component to promoting public mental health. We also stand ready to participate in new efforts on this front as described by the plan, particularly the new statewide suicide prevention program and the Suicide Prevention Education Awareness campaign that is a part of it. We are very pleased that such a program will finally be carried out throughout the state and pledge to do whatever we can to make it successful.
There are many reasons why the 2004 5.07 Plan gives us hope for better things to come. It strikes us as a transitional document. It has more about planning, yet it is still not yet a plan. We hope this fish with fowl-like features will be able to "take wing" in the future.
Throughout our testimony, I have said "we like this but for that." We hope we'll have fewer concerns next year.
We look forward to participating in the planning process, and we hope to help the plan grow as a basis for meaningful discussion.
Without an over-arching, multiple-agency plan for this plan to fit into, however, there will still be wide gaps in the map to the future of mental health care in New York State.
Thank you again for the opportunity to appear today and present this statement.
Evelyn Roberts, Ph.D., Executive Director
National Alliance for the Mentally Ill of New York City, Inc. (NAMI-NYC Metro)
My name is Evelyn Roberts. I'm executive director of the National Alliance for the Mentally Ill of New York City (NAMI-NYC Metro), on whose behalf I'm speaking today. We support the testimony of NAMI-New York State just presented by David Seay. Instead of repeating their points, we would like to comment more specifically on three issues of particular concern to us. These are: family psychoeducation, the conflicting interpretations of client confidentiality in OASAS versus OMH programs, and PROS.
It is generally agreed that family psychoeducation programs (FPE) are an evidence based best practice for the treatment of adults with serious mental illness and can have a significant positive effect on treatment outcomes. OMH, through its Family Institute for Education, Practice, and Research, is providing intensive consultation and supervision in the delivery of the McFarlane FPE model to selected providers across the state, including several in New York City.
We have had some involvement with the New York City providers who are participating and have been impressed with their-willingness to implement family psychoeducation programs in their agencies and to otherwise invite family participation in the treatment process. This demonstrates a very strong and commendable commitment on the part of participating agencies, for while the consultancy and supervision are provided by OMH free of charge, agencies are receiving no funding to develop and provide family psychoeducation programs to their clients and families.
But not all agencies for whom it would be appropriate to institute family psychoeducation programs can afford to do so. There are also agencies that would prefer not to bring families into the treatment process-for reasons of treatment philosophy, patient confidentiality concerns, conflicting program priorities, lack of staff and other resources, or simple resistance to change. These agencies need encouragement, incentives, and support.
While OMH recognizes the value of family psychoeducation and recommends that "'all programs serving adults diagnosed with schizophrenia should offer family educational services," it clearly has a limited capacity to both provide this consultancy and supervision and to provide funding or other incentives to encourage providers to develop family psychoeducation programs. What, then, is OMH's plan to implement family psychoeducation among this much broader base of providers across the state?
We would welcome the opportunity to hear more about this long-range plan and to work with OMH to develop it.
The second issue on which we wish to comment is that of integrated treatment for co-occurring substance abuse and mental health disorders. NAMI-NYC Metro applauds efforts by OMH and OASAS to move together toward an integrated treatment model, which is an evidence-based best practice that combines mental health and substance abuse interventions at the level of the clinical interaction. As OMH has noted, integrating treatment is not just a matter- of combining treatments but of modifying traditional interventions-from two very different treatment traditions and cultures that are often in opposition with each other on key principles.
One of the areas in which these two treatment cultures clash is that of client confidentiality. The specific concern is with confidentiality regulations and how they are interpreted differently by mental health providers under OMH and how they are interpreted by substance abuse providers under OASAS. Both OMH and OASES are subject to HIPAA privacy regulations, which stipulate that a family member of an adult client cannot obtain information about their family member without the client’s consent. NAMI-NYC Metro respects the use of confidentiality regulations to protect a client’s privacy.
However, as OMH interprets it, the HIPAA regulation does not necessarily mean that without client permission the family member is barred from having any input into the client’s treatment or that the provider cannot listen to and record information provided by family members about a client. In fact, New York State Mental Hygiene Law requires family involvement in treatment planning, because there is a presumption of therapeutic benefit. As long as privileged information is not reciprocated by the provider to the family member, everyone is in the clear.
(We note here that despite OMH’s position, we continue to hear complaints from family members that providers are refusing to listen to them – citing client confidentiality – when they attempt to provide information about their loved ones medical and psychiatric history, or provide other relevant and often vital information which could illuminate specific issues regarding a client’s health, treatment and recovery. For example, many family members keep records of their loved ones medication history. With this knowledge, presumably providers could circumvent the often belabored trial and error approach to finding effective medication, saving all involved parties aggravation, discomfort, time and money.)
OASAS’s position on client confidentiality is far more limiting. Under OASAS policy, no substance abuse provider can "implicitly or explicitly" relay information on a client. For example, if a family member called a substance abuse provider to give that provider information relevant to the client's treatment, the simple act of listening to the family member would be understood to imply that the client is receiving services there--a violation of OASAS policy.
This contradiction is one of several between the two different treatment cultures that causes problems for MICA consumers, family members and providers in integrated treatment programs, with the potential to sabotage treatment outcomes. We feel that it should be addressed without delay.
The third issue on which we wish to comment is PROS. While we are pleased that OMH has designed a plan with the goal of ensuring that consumers of mental health services obtain services that are the most appropriate and effective in facilitating recovery, we have reservations about aspects of both the proposed evaluation process of the initial implementation of PROS, as well as the impact the implementation will ultimately have on consumers' access to necessary services.
We are pleased that OMH has demonstrated its commitment to the quality of PROS by allotting funds to evaluate the impact of PROS implementation in its early stages. We are concerned, however, about the information that will not be captured in such data collection. We believe that Medicaid claims data is likely to tell only part of the story and will be unable to adequately assess the quality, appropriateness, and outcomes of services received. NAMI-NYC Metro believes that OMH should consider funding a more extensive evaluation that would ask whether PROS is meeting the individualized service needs of consumers in an integrated, coordinated manner, as the program intends. For example: "Does the individualized recovery plan target all areas warranting services." "Were the services provided effective?" A more extensive evaluation might include, for example, a survey of consumers and family members.
NAMI-NYC Metro is also concerned that the evaluation process as planned will miss those consumers who do not receive Medicaid. We understand that OMH has estimated that 20% of providers' services recipients are not enrolled in Medicaid. While many providers have expressed a willingness to document their provision of services to those who do not receive Medicaid-that is, by performing "shadow billing"--we worry that in reality, when push comes to shove, the complexity and enormity of the new billing process, particularly for smaller providers that may be doing Medicaid billing for the first time, may deter providers from engaging in additional billing solely for the sake of research. It is NAMI-NYC Metro's hope that OMH can provide incentives and support to providers to perform shadow billing so that the evaluation most comprehensively captures data on the entire mental health population seeking services.
NAMI-NYC Metro's other primary concern pertains to the impact the implementation of PROS will have on consumers' access to services. Currently, small and large providers alike receive a fixed amount of money for the services they render. Since PROS will encourage providers to increase their services so as to increase their income, and will prevent other providers from providing duplicate PROS services to the same consumer, we fear, for instance, that some smaller, geographically remote providers will be unable to remain fiscally viable. This may result in hurdles to those consumers living in the more remote areas of the city in accessing services. Similarly, providers that currently serve large immigrant populations may find that they do not have a high enough Medicaid penetration rate to remain open. In that respect, we are concerned about the resulting lack of culturally appropriate programs available to immigrant populations.
Again, if some consumers ultimately do not access services either because of geographic obstacles or because culturally appropriate programs are no longer available, an evaluation that looks only at Medicaid claims data, rather than consumers' actual experiences, will be insufficient in measuring this deprivation of services to many who need them.
On behalf of NAMI-NYC Metro, I thank you for this opportunity to speak today.
Associate Director of Greenwich Village Youth Council
My name is David Kaplan and I am the Associate Executive Director of Greenwich Village Youth Council ("GVYC"). I'd like to thank Commissioner Carpinello for providing an opportunity for input into the OMH Family Support planning process.
As background, I'd like to point out that I worked closely with Anita Appel and Susan Thaler ten years ago when our Family Support contract was awarded to GVYC. I have worked closely with OMH and DHMH as we have developed the current structure of our family support program on Eldridge Street, which is called the JOY Center. Through the FSS program we run at JOY we have been empowered to in turn empower an entire community. I have seen the difference in the past ten years not so much in the surrounding area or in the issues faced by our youth and families but in the role that our community center has been able to play. Our staff now our former youth members who came up through the program and have chosen to give back the center by working there full-time.
The JOY Center families are primarily single-mother/grandmother households, many at or below poverty level. There is often drug and alcohol abuse and neglect and at times abuse of youth in the household. Our community is immersed in crime, drug abuse and drug dealing, gang involvement, teen pregnancy, and isolation. It is not surprising that the trends are in the direction of school drop out, suicidal ideation, despair, hopelessness, drug addiction, and a range of other mental health challenges.
The FSS Program Model is an incredible model of community empowerment -- it gives back to the communities and programs reaching at-risk youth and families the power to define the issues of the day and the best way to address them for that particular community. It is decision making in the valley not from the mountain top. The Parent Advocate is a central component but so is the approach that says we trust you to figure out what works best in your community to avoid jails and institutions for your at-risk youth. Many of our youth have been able to overcome some fairly serious mental health challenges and remain with their families in the community.
It has been a privilege for me to be a part of this program and to watch a community struggle and grow and take ownership. Without true community based programs like JOY many at-risk street-involved youth and families would go without services, food, and crisis and emergency services. But they'd also be alone. The program at the JOY Center allows parents and guardians of youth in crisis to receive free support and respite services, education about resources, a warm hug, and compassion and love.
In this way, our youth are accepted for who they are and are not forced to be in costly institutions where they don't belong. It allows communities like ours to be truly empowered, to take care of ourselves, and to teach our youth that we can care for them.
Continued and enhanced funding for these programs is crucial. At a time when budget cuts and shortfalls challenge us fiscally, I can tell you that these programs are incredibly cost effective and efficient, costing hundreds of dollars per youth per year instead of tens of thousands of dollars per youth per year.
Invest in and trust communities. Don't trust bricks, concrete, and metal bars to solve a thing.
And thank you for this opportunity.
Deputy Managing Director of the Department of Government & External Relations at UJA Federation of New York
My name is Anita Altman, and I am the Deputy Managing Director of the Department of Government and External Relations at UJA-Federation of New York. UJA-Federation of New York is a federated network of almost 100 health and social service agencies. We are proud of our family of agencies, which each year serve more than 1.5 million residents of the New York metropolitan area.
We want to express our appreciation to Commissioner Sharon Carpinello and the Office of Mental Health for recognizing in this plan that there is a growing epidemic of eating disorders; acknowledging the need for the state to become actively involved in public health education and advocacy to foster its prevention; and for spotlighting the outstanding innovative work of F.E.G.S., a member agency of UJA-Federation, which has with its program, Full of Ourselves: Advancing Girl Power, Health, and Leadership, been helping young girls to develop both healthy minds and bodies.
At the same time, we are here to urge OMH to place a much-warranted focus on geriatric mental health, taking a leadership role in addressing the complex needs of our state's senior population. OMH has produced a white paper on Aging in New York, which itself makes the case. It shows that the rapid increase in numbers of seniors- projected to increase by 19% at a time when total population is expected to grown by less than 5% and the anticipated growth of diversity will greatly challenge and overwhelm the service system unless the groundwork for change begins now.
And what should that focus include?
OMH must take the leadership on geriatric mental health issues, creating a position that will be able to focus on them, and help mobilize the resources to address them. OMH should act as the advocate on mental health in dealing with other state agencies that have oversight and compliance responsibility for nursing and adult homes.
Creating Better Access
Service must be tailored to meet the needs of older adults. Services must be client centered, recognizing that traditional venues for the delivery of mental health services do not necessarily work for seniors. Services need to be integrated into settings where seniors are located, whether at home or in congregate programs such as those in senior centers. Educational programs targeted at destigmatizing mental health interventions-services and medication, and informing about their efficacy, need to be addressed to the seniors and their families. OMH needs to recognize, acknowledge the need for and champion these changes.
Improving Competency and Capacity
Service capacity must be increased, through the expansion of the training both of dedicated mental health professionals to work with seniors- psychiatrists, psychologists, social workers and psychiatric nurses- and, of their primary care physicians and other health care professionals, who currently are ill-prepared to identify, diagnose or provide treatment for mental illnesses. Skills and sensitivity training about geriatric mental health issues should also be provided to all those working with older people in various settings. OMH should provide the leadership and help advocate for these changes.
The financing structure needs to be redesigned to allow for flexibility in billing and a broader range of services eligible for billing. Redesign should ensure that care be integrated, that health, mental health and aging services can all be made available under one roof. Reimbursable mental health services, provided by licensed professionals, should be made available at senior centers.
The primary sources of funding of geriatric mental health services, Medicare and Medicaid provide such inadequate rates for these services, particularly outpatient, that many private providers opt out of the program. Public funds do not provide adequate support for the much-needed mobile, in-home services, social adult day care and respite services, and other care-giver supports. OMH needs to help focus attention on these issues, and work with the advocates to help build a system that can respond more effectively.
We need to incorporate research into practice, to help us better understand what makes for effective programs.
There is much to be done in the field of geriatric mental health. It is time that the New York State Office of Mental Health mobilizes its expertise and resources, and provides the leadership so desperately needed. Incorporating geriatrics into OMH's Five Year Plan is only the first of many steps that need to be taken.
Phillip A. Saperia, Executive Director
Coalition of Voluntary Mental Health Agencies, Inc.
Good morning. My name is Phillip Saperia, and I am the Executive Director of the Coalition of Voluntary Mental Health Agencies. The Coalition is the umbrella advocacy organization of New York's mental health community, representing over 100 non-profit community based mental health agencies. Our members constitute a broad cross section of outpatient service delivery agencies in New York City -of every size and service modality- serving more than 300,000 clients in the five boroughs of New York City and its environs.
The Coalition would like to thank the Office of Mental Health for initiating formal briefings across the State concerning the 5.07 Plan for 2004-2008. These briefings allow for respectful interchange between OMH and other stakeholders about how the Plan is developed and suggestions for making the document more useful in the future. These briefings should serve as the first step of a long-awaited mechanism for public input between OMH and other stakeholders that is so critical if we are to more effectively address the needs of mental health consumers across the State.
I would now like to address the Plan itself. In analyzing the narrative and the accompanying data and charts it becomes clear that the Plan addresses in varying levels of detail the range of services currently in existence for mental health consumers. Unfortunately, the Plan does not highlight unmet need. The decision by the Executive to issue the Plan simultaneously with the Governor's Executive Budget means that the budget development may be ill informed by objective needs assessment and the planning process. The Coalition strongly believes that the Plan might more accurately reflect and definitively address the needs and concerns raised in the Plan were it released in October, in compliance with the current law. While we would like the Plan to discuss the current array of services, it must also show the unmet need in the community and perhaps, point the way to addressing that need.
The key component of any Plan that seeks to firmly address the issue of "unmet need" is reliable data, particularly relating to populations, geographical considerations, cultural issues, safety and costs. Allow me to give just a few examples where the community mental health sector would greatly benefit from the collection of, and subsequent attention to, the kind of data that illustrates what our providers and their consumers face each day.
Housing for mental health consumers is a matter of concern throughout the State, but perhaps nowhere more so than here in New York City. Vast numbers of mental health consumers currently seek refuge in the City's array of homeless shelters and drop-in centers, while others reside in the notoriously dangerous adult homes that have been the subject of much scrutiny in recent years. Still others live with aging relatives, constantly flirting with eviction and homelessness. For the purposes of today’s hearing, however, we would like to focus on the Supported Housing model and the inadequacy of its funding by the State.
For several years now, a large contingent of advocates and providers (including the Coalition) has pointed to the sharp discrepancy between the contract rates paid for Supported Housing and the actual cost of renting an apartment and providing services. In New York City, where rents commonly approach and even exceed $1,000/month, providers are finding it nearly impossible to provide adequate housing and meaningful services for the contracted rate of $11,300/year. In fact, a growing chorus of providers tells us that unless an immediate rate adjustment is made to the Supported Housing program, they will be forced to turn back their unaffordable leases, effectively putting tenants onto the streets and into the homeless shelters. With over 38,00 men, women and children currently living in the New York City shelter system each night, the loss of even one Supported Housing program would only compound that misery for New Yorkers living with psychiatric disorders.
In short, what is needed is the collection and organization of data that would accurately reveal the discrepancies in each geographical region between the contract rates and actual costs for the Supported Housing program, as well as the need for additional housing units based on existing data for homelessness in each region. Instead, readers of the Plan learn only that the level of community-based housing has increased by 60% since 1995, and that the number of units, including those in development, will total 31,000 by the end of Fiscal 2004-2005. And while the Coalition is gratified that the Governor recognizes the importance of creating more housing, including the development of 600 additional units of Supported Housing in his 2004-2005 Executive Budget, there needs to be a similar commitment to funding these units to reflect actual costs, particularly in New York City where rental costs have skyrocketed over the past several years.
It is essential that the Plan include the wealth of information collected by LGUs and information shared by local stakeholders in order to compare regional differences and identify differential needs. New York City in particular has very unique needs and demands, owing in part to the sheer number and diversity of consumers (and providers). In order for the Plan to more accurately reflect this diversity, OMH should collect and analyze current data on the large number of immigrants, the uninsured, and the working poor - in short, those individuals in New York City most likely to be Ineligible for Medicaid. This fact is of great concern to The Coalition since more and more programming will come under Medicaid's domain. There is no mention in the Plan of the implications of such a large shift to Medicaid. The Plan does acknowledge the role of OMH's Multicultural Advisory Committee in helping to shape the agency's mental health care for New Yorkers from diverse ethnic backgrounds, but there is no mention of how the particular needs of immigrant consumers fit into the State's plan for PROS, for example. Nor is there mention of the implications of such a large scale shift to a Medicaid-funded system at a time when federal caps on Medicaid continue to be discussed in Washington, D.C. and when local governments are groaning under its burden. Absent this attention to the particular needs of each region, the Plan lacks complete information about the diverse universe of consumers and the corresponding struggle of providers to assist them.
We are concerned that the Plan does not appear to address the particular needs off geriatric mental health consumers. This population will soon demand a more sizeable portion of OMH's resources, yet there is no mention of their issues or the State's arrangement to provide for them in the Plan. The emergence of baby boomers into this population category will increase the numbers of aged in proportion to the population and make the need for services even more critical.
The Coalition applauds SOMH's efforts to introduce evidence-based practices. However, we are concerned that the State continues to promote evidence-based practices without regard to geographic location. Very simply, the research, population and geographical areas upon which the evidence is based does not account for factors of racial, ethnic and cultural diversity that typify the New York City populations served by the City's providers. It is also questionable whether there are adequate resources within the immediate New York City environs to provide the essential training and ongoing clinical supervision to providers that will be necessary to implement EBPS consistently and effectively. In fact, New York City's providers are engaged in programs and service delivery models that may be considered "promising practices." They serve many special and diverse populations under particular urban circumstances. These should be considered for testing and development since they may rise to the level of "Evidence-based."
We do recognize, and applaud, OMH's desire to shift resources away from costly and underutilized State-run psychiatric institutions and divert them instead to community-based services. The Coalition, together with several other advocacy organizations throughout the State, publicly supported the notion of a bi-partisan blue-ribbon commission to study, and ultimately act on, this issue. And while it doesn't appear likely that this commission will take shape in the coming fiscal year, we continue to support the State's efforts to engage in this form of long-term planning on how best to re-allocate its psychiatric resources.
We would be remiss if we failed to mention that the Community Reinvestment Act, which re-allocated funding from underutilized State psychiatric beds into the community mental health sector, was a shining example of the State's pursuit of long-term planning. As beds were closed and funding made available, the State worked with the local stakeholders in deciding how best to allocate these resources.
We also applaud OMH's recognition of suicide prevention as a major mental health issue, and commend Commissioner Carpinello for her recent efforts to draw public attention to this effort. Her recent promotion of the Suicide Prevention Education Awareness Kit (SPEAK) demonstrates OMH's effort to recognize a growing mental health issue, identify the populations most likely to be affected, and allocate the resources necessary to overcome this crisis.
In sum, the state planning process has been broken for many years now. We applaud efforts to re-invigorate it with this new planning document, briefings and hearings. An adequate planning process one we believe is vital to a dynamic mental health sector such as ours - ought to rely on publicly available data that is produced in a timely fashion. It ought to solicit, organize and analyze data that consider financial modeling and reflect county needs. It ought to be a forward-looking document that identifies existing service gaps. And, and it ought to include real efforts to address the future needs of the system.
Ultimately, for the Plan to be effective, an effort must be made to identify, collect, and analyze data to address the needs, both current and future, of mental health consumers and the providers who serve them. This must be a transparent process, and it must be done with an eye towards the unique characteristics of each geographical area. The planning ought to be done throughout the course of the year, and should be viewed as a "bottom-up process and one that facilitates the collaboration between LGUS's, stakeholders and OMH. In short, the 5.07 Plan needs to better conform to the letter and the spirit of the law.
Good morning, my name is Raymond Schwartz, and I am testifying on behalf of Venture House. Venture House is located in Jamaica, Queens and operates a certified clubhouse program that provides rehabilitation and recovery services to people with mental illness. Venture House also operates a supported housing program. I am also co-chair of the New York Association of Psychiatric Rehabilitation Services Public Policy Committee.
The opportunity to comment on the mental health planning process is greatly appreciated. Developing a partnership between consumers, providers, local and State government is critical to creating a plan that will meet the needs of the residents of New York State.
Our comments will focus on two general topics: the overall planning process and specific services areas.
The Plan, as released in January, 2004 is an important step in effective planning. The January Plan provides a broad range of data essential to the planning process. The Plan is in reality a report or picture of the mental health services in New York State. The next step is to construct an assessment of the strengths and challenges of the mental health service sector in New York State and then develop and identify goals, both short- and long-tem, with measurable outcomes. A mental health service plan, if you will, for New York State. Making sure we complete our annual service plan review, assessing progress towards the identified goals and revising or changing goals and developing new outcomes, will be critical to insuring that the needs of New Yorkers are met.
We do not underestimate the challenges that creating a plan focused on outcomes presents, especially in the public sector. Planning for New York State is a complex task, with competing interests and a diversity of groups and needs, based on language, ethnicity and geography, all framed by finite resources. The State Office of Mental Health also has to create a plan as part of the State government and the political and policy decisions that the current administration makes. Yet a plan that is meaningful and serious must identify needs, construct time frames, and identify the mechanisms needed to reach the goals.
The planning process will be improved by expanding data collection efforts. Certainly the current plan and the appendix provide important information. There are areas in the plan where needed data is not provided. Much of the data is derived form Medicaid based billing. Medicaid recipients are not the only people who need to use the public funded or regulated mental health system. Veterans, people on Medicare, private insurance or without insurance all use State-regulated and/or funded mental health services. What portion of the total users are not Medicaid recipients? Are there different utilization patterns and needs based on insurance type, socioeconomic status, English language proficiency, ethnicity, or access to quality health care? The information gathered that begins to answer these basic questions is essential to creating a plan for mental health services that address the needs of the residents of New York State. The proposed Personalized Recovery Oriented Services program is predicated on Medicaid funds and is the most recent example of the bias toward Medicaid funding that result in the limiting of access to services for people without Medicaid.
The second area of my comments is directed at specific service needs. A critical area that is essential to anyone's mental health is decent housing. The plan does not acknowledge the well-documented needs for additional supported housing designed for people with mental illness. Many thousands of additional units are needed. The planning process must also examine the current models of housing that the State Office of Mental Health funds to determine the changes that are needed to meet current consumer needs and must include the consumers in the review process. The ongoing financing of housing must be included in the review. Providers are currently reducing services to residents of State funded housing programs or reducing the size of the programs because funding has not increased to meet costs. Consequently, the number of housing units identified in the current plan is not real.
As part of the housing reforms that are necessary, the needs of those individuals with mental illness living in adult homes cannot be ignored. The New York State Coalition on Adult Home Reform will present testimony that we fully support.
A large group of people with mental illness is ignored in the current plan. Parents with mental illness have a range of needs that are not addressed by this Plan. People with serious mental illness are parents, and the implicit assumption that people with mental illness do not have children demonstrates a serious bias of the public mental health system. Thousands of people with serious mental illness have children and are not provided with services to meet their needs. The State Office of Mental Health has published data over the years on the needs of parents with mental illness but their special needs have been largely unaddressed. Supported housing that is designed to accommodate families, parenting skills, rehabilitation programs with access to day care, and clinical services that understand both the adult parent and the child's needs are among the services needed.
The Plan recognizes the need to improve mental health services to people in State prisons who need mental health services. We strongly urge the that the Office of Mental Health articulate a plan that will develop mental health services for prisoners without the use of the "Special Housing Units" or solitary confinement, that will actually treat the illness the prisoners have and provide services to ease the transition to the community including linkages to services and housing. Solitary confinement is inhumane and exacerbates symptoms and the State Office of Mental must plan to eliminate its use and replace it with humane treatment.
Coordinating care and improving access to needed services is critical to insuring successful community living to people with mental illness and the Office of Mental Health has worked to improve services to address care coordination. A very important gap still remains to be addressed and that is access to quality health care. Success in the community requires good health and too many people with serious mental illness do not have access to quality health care services and health education, especially around nutrition and smoking cessation. Providers certainly need to expect to become well informed about health care services in the areas they are located in and try to facilitate access to health care services. However, this area requires a more thoughtful and comprehensive approach that addresses capacity, special needs of people taking psychotropic medications, coordination of public health education efforts, and better education of program staff and consumers and coordination with other governmental departments.
Workforce retention is a problem for consumers and providers and is not addressed by the Plan. Low staff salaries and high staff turnover do not foster the creation of quality mental health services. While it is important to hold providers accountable for the services provided and measure providers on agreed performance measures, it is equally important to hold the Office of Mental Health accountable to provide adequate resources to providers to provide the agreed upon services. Planning that does not address the need to provide funds for competitive salaries undermine the effort to create quality services and is disrespectful to the people who seek services.
The opportunity to participate in planning for mental health services is appreciated and we are willing to participate on an ongoing basis. The values of rehabilitation and recovery, consumer choice and individual rights informs our approach in developing services and insures that we maintain an open, inclusive and responsive attitude and process in assessing our programs and delivering services. These values are critical in planning as well. Thank you.
Family Support Parent Advocate of the JOY Center
My name is Janet Guzman and I am the Family Support Parent Advocate of the JOY Center on Eldridge Street. This program has been run for the past 15 years by Greenwich Village Youth Council. I have been Parent Advocate for the past three years.
I'd like to thank Commissioner Carpinello for providing an opportunity to provide input in this Statewide planning process.
I have not only loved being able to educate the families in my community in a way they understand and accept. I have myself benefited from the free services offered by JOY.
Without true community based programs like JOY many at-risk street involved youth and families would go without services, food, and crisis and emergency services. The program at the JOY Center allows parents and guardians of youth in crisis to receive free support and respite services, education about resources, a warm hug, compassion, and other crisis services.
In this way, our youth are accepted for who they are and are not forced to be in costly institutions where they don't belong. It allows communities like ours to be truly empowered, to take care of ourselves, and to teach our youth that we can care for them.
Families should have more options like the JOY Center so they can decide what types and kinds of services they want for their kids.
It is obvious to everyone from the area of the LES that these simple cost-effective programs truly save lives. More money should be invested into the communities directly through Family Support Programs like the one and JOY and existing programs should be given more funds so they can do more good works in the communities most in need.
Thank you for this opportunity.
Executive Deputy Commissioner for Mental Hygiene Services
New York City Department of Health and Mental Hygiene
Good morning. I am Dr. Lloyd Sederer, Executive Deputy Commissioner for Mental Hygiene Services at the New York City Department of Health and Mental Hygiene. I am pleased to be here today to comment on the importance of the statewide and local planning process, as stipulated in Part 5.07 of the NY State Mental Hygiene Law. I will also describe the progress of the New York City Department of Health and Mental Hygiene (DOHMH) in strengthening local mental health planning.
I would like to start by commending the State for holding informational briefings and hearings to further public debate about its recently released plan, and more generally, its efforts to create a more robust State planning process. The recently released 2004-2008 State plan is a welcome first step in that direction.
A collaborative, comprehensive and inclusive public planning process is critical to the local government's ability to effectively exercise our statutory role of planning, monitoring and evaluating services for people with mental illness. I view this idea as the driving force behind the recent initiative of the Conference of Local Mental Health Directors (CLMHD) to engage the State Office of Mental Health (SOMH) in a dialogue to establish a stronger public mental health planning process. New York City has actively participated and supported the Conference's call for a renewed focus on a locally informed State planning process, as is required by State law.
I would now like to describe the progress made through the Conference-led planning initiative. We at DOHMH are particularly pleased that SOMH has adopted a population-based data-driven approach to mental health planning. Such an approach expands the planning focus
of recent years beyond the existing service system, and those utilizing it, to include those possibly in need who are not presenting for services. We are committed to using our local planning process to better describe unmet need, and to develop recommendations for resource allocation, capacity expansion, and programmatic priorities in NYC. We are hopeful that one outgrowth of the work between the Conference and OMH around mental health planning will be an agreement on a "bottom-up" process whereby the state plan will be shaped by local recommendations.
I am pleased that the State has agreed to adopt a planning framework similar to the planning framework we have developed for New York City. Its four elements are: (i) prevalence, (ii) capacity, (iii) utilization, and (iv) quality. I will now comment briefly on each of types of services and where.
- Prevalence data enable us to develop estimates of the number of individuals affected by mental disorders within a community, and thereby estimate the need for services. While not a precise enough measure for planning, prevalence rates are a first and valuable step toward establishing the need for services.
- Capacity tells us about existing resources to meet service need. Actual capacity can also be deconstructed into service type, geographic distribution, cultural competence and other factors to help us understand our system’s potential for who can be served with what types of services and where.
- Utilization data let us know who is actually being served and, equally important, by deduction, an approximation of who is not. Utilization data can describe service usage patterns according to client characteristics and service characteristics. It can also illustrate the relationship between service demand and service capacity.
- Data on quality serve to answer questions about appropriateness of, consumer perceptions of, and the outcomes of care. For example, can we determine if people with a specific diagnosis, such as schizophrenia, are getting the services recommended by the schizophrenia PORT study (like access to atypical psychotropic medications and family psycho-education?) And how do we know the experience or perception of these individuals of the care they are getting? Consumer perception of care is a key quality indicator because positive consumer perception of care is associated with treatment/service adherence, which predicts improved outcomes. Finally, how do we know what are the actual outcomes being achieved? Are individuals with schizophrenia being housed, employed, and do they report satisfying social relationships? We regard these as key questions to answer in order to determine if quality has been achieved.
The State's interest in revitalizing the planning process coincides with the invigorated planning the City has been engaged in. The merger of the Department of Health and the Department of Mental Health, Mental Retardation and Alcoholism Services, as well as internal restructuring within the Division of Mental Hygiene, has enhanced our ability to engage in population-based, data-driven public mental hygiene planning. As I have mentioned in previous testimony, we have used existing resources to create within the Division a new Bureau to oversee planning, evaluation, and quality improvement. Our planning capacity has been further enhanced by collaboration with the Department's Division of Epidemiology. We now have some capacity to collect primary prevalence and community-based data in New York City. In addition, the Division's new organizational structure now links the three data-driven processes -- planning, evaluation and quality improvement -- so that mental hygiene planning can be informed by both program evaluation and quality improvement activities. Let me now describe a few examples of our current planning efforts.
Through the Department's annual Community Health Survey (UHS), we now have the opportunity to gather neighborhood-level data pertaining to mental hygiene. We include mental health questions in the survey each year. For the past two years, we selected a series of six questions (called the K6), which screens for Serious Mental Illness (SMI). The K6 was designed to identify persons who are likely to have both a diagnosable mental disorder and significant impairment; it is highly correlated with diagnostic measures of major depressive disorder, generalized anxiety disorder, schizophrenia and other mental disorders.
The CHS is randomized and has a large enough sample size (10,000) to generate neighborhood-level estimates of the prevalence of SMI. In 2002, we found that approximately 6.4% of adults age 18 or older reported distress consistent with SMI, with the rate varying throughout the city, from 2.2% (Southern Staten Island) to 13% (Fordham). 2003 data from the survey show an overall decline in the citywide average estimated prevalence rate of 5.0% for SMI. These findings have enabled us to understand not only the magnitude of individuals in NYC most likely in need of mental health services, but in addition, how SMI selectively impacts certain neighborhoods more than others. We are also able to track findings over time, looking for trends.
In 2003, we also used the CHS to gather data on barriers to treatment. Twenty three percent (23%) of those with probable SMI indicated they needed treatment for a mental health problem, but had not received it within the past year. Cost was the most common barrier reported (36%), followed by a combination of barriers such as co-occurring disorders, lack of support, and the time and effort required to access services (16%). Next ranked at 12% each were two barriers: not wanting treatment, and shame/fear and personal beliefs. Interestingly, about half of those reporting barriers also reported having received counseling and/or medication during the same time period.
I am very pleased to mention a groundbreaking new survey about to be conducted by the Department -the New York City Health and Nutrition Examination Survey (NYC HANES). The HANES is a national survey that the Department is adapting for use in NYC. The survey, which is being conducted this summer, will consist of a brief physical exam and a two-part interview of 2,000 randomly selected persons. The interview portion of the survey will include questions on depression, anxiety, and drug and alcohol abuse. NYC HANES will be the first survey to generate citywide prevalence estimates for depression and anxiety, and provide more refined information about alcohol and drug use in NYC.
We have taken the prevalence findings from the Community Health Survey and combined them with derived prevalence estimates based on national "best estimates" to create a report titled:
Prevalence and Cost Estimates of Psychiatric and Substance Abuse Disorders and Mental Retardation and Developmental Disabilities in New York City. The purpose of this report, which was released last year, was to gather in one document estimates of the number of New York City residents with mental hygiene disorders (which include mental health, substance abuse, and mental retardation and developmental disabilities) and their current utilization of services. We have received enthusiastic feedback from the City's local mental hygiene community, which seeks such data for their planning purposes, as well as from elected officials at the city and state level. At the same time, this report highlighted for us how limited available information is and thus the need for more reliable local data, captured at regular intervals.
Level information about individuals receiving mental hygiene services in New York City. Only with client-level data will we be able to answer three pivotal planning questions: 1) Who is being served? 2) What services are being provided? 3) And what are the results of these services? We plan on collecting some basic data elements such as program admission and discharge dates, diagnosis, ethnicity, age, gender and zip code. Client-specific data will be identified with a unique encrypted marker, which will allow us to track data on individuals without compromising their privacy.
The Division of Mental Hygiene has also engaged in services research as a means of collecting planning data. Prompted by consistent though anecdotal reports of inadequate capacity among outpatient clinics serving children in the Bronx, we designed and conducted a survey and were able to document and describe the limitations of the existing service system in meeting the needs of a very vulnerable population of children. Average waiting time for entry into clinical treatment was shown to be six weeks. Of even greater concern, only 43 out of every 100 children referred for clinical treatment received any at all. These survey findings spawned a task force that has been charged with developing an action strategy to address capacity and service needs. I would add that from a methodological perspective, this survey was useful in that it taught us a lot about studying capacity, including the use of provider mail surveys.
Let me now turn to our Division's number one priority for this year, our recently launched quality improvement initiative, Quality IMPACT. Its goal is to promote and improve the quality of mental hygiene services provided to residents of New York City. Quality IMPACT is a cornerstone of our reinvigorated planning process. We are committed to implementing a data-driven quality improvement process that includes the broad participation of all stakeholders. The initiative, Quality IMPACT: Improving Mental Hygiene Programs and Communities Together, is being launched in FY05 (this July 1Stand will involve 36 mental health programs and 28 mental retardation, developmental disabilities programs during its first year. For FY05, the key improvement areas are: consumer perceptions of care, cultural competence in mental hygiene services and co-occurring disabilities (One project will focus on adults who have mental health and substance abuse issues while the other will focus on children who have mental retardation and/or developmental disabilities and also have a mental health disorder).
We have adopted and will promote a continuous quality improvement model of rapid cycle interventions aimed at identified problem areas, and will use data to assess the impact of the intervention as well as opportunities for further improvement. This initiative will allow us to plan around the quality, not just the quantity, of services. It will enable us to add quality to cost effectiveness in our decision-making regarding the allocation of mental hygiene resources in New York City. Contract procurements and renewals, and other local government functions will be reformulated within our quality improvement framework. Our goal is to ensure that consumers and families receive the most effective services provided in an accessible, timely and thoughtful manner.
I will end my comments today by encouraging the State Office of Mental Health to build a process for statewide planning that incorporates the elements of prevalence, capacity, utilization and quality, and that commits to support planning at the local level. Support for local planning could include: the collection and provision of analyzed data to Local Governmental Units (LGUs); the provision of consultation and technical assistance to LGUs; SOMH staff assignments to LGUs to serve planning functions; funding LGU planning staff; and populating the data warehouse with date needed for local planning. I am afraid that without such support, the SOMH’s best intentions to revitalize the planning process will not provide the essential tools to support and enact local planning, and thus not realize the “bottom-up” approach envisioned by the State Mental Hygiene Law. To provide this support will make success likely; to not provide it will likely result in our falling very short of our collective aims.
In closing, on behalf of DOHMH let me state that we look forward to continued progress toward a data- and population-based planning process that will be exemplary in its content and utility. We urge the State to partner with New York City and other localities in support of this vital goal. Thank you for the opportunity to present testimony today.
Senior Assistant Vice President
NYC Health and Hospitals Corporation
Good morning Mr. Simons, my name is Joyce Wale. I am the Senior Assistant Vice President for Behavioral Health at the New York City Health and Hospitals Corporation (HHC). HHC is the largest single provider of public behavioral health services in the United States and is the backbone of New York City's system of care for the poor and uninsured. HHC has over 22,000 psychiatric discharges annually and almost 9,000 detox discharges. Further, almost one-quarter of HHC's outpatient visits are for Behavioral Health services.
These statistics only tell part of the story of HHC's role in treating mental health consumers. HHC serves the most seriously impaired, treatment resistant, and costly mental health consumers in the city. Our consumers are frequently homeless, people with co-occurring disorders of mental illness and substance abuse, and may be involved with the criminal justice system. In this regard, HHC fulfills a public mental health service function similar to the State.
I would like to commend the State Office of Mental Health (SOMH) for developing a comprehensive plan that shows a level of commitment to a collaborative planning process that providers had not experienced with prior 507 planning. The Corporation has testified on numerous occasions that population-based planning and Medicaid and other relevant data were needed in order to determine the needs of both communities and subgroups within those communities. This comprehensive plan adopts that approach and is the first plan in a long time that gives a clear picture of the current system using data to help tell the story.
There are four areas critical to the New York City Health and Hospitals Corporation that I think the plan needs to address more fully: (1) planning for system redesign to address the utilization of inpatient care; (2) interagency collaboration; (3) services for children and adolescents; and (4) opportunities for flexible financing.
I. Planning for System Redesign to Address the Utilization of Inpatient Beds
In Chapter 4, the plan presents New York State and regional data on rates of readmission and bed utilization that are high compared to other states and national averages. These data are extremely helpful because until now HHC has only had access to data on its own readmission rates. Having this information sheds more light on the need to develop community-based services targeted to consumers who are high users of inpatient and emergency room services. Yet, the plan fails to provide direction in the service redesign and incentives that would enable health care systems to target services to this population and produce better outcomes.
In order to reduce general hospital inpatient psychiatric bed use, the plan needs to incorporate two approaches. First, the plan should address the need for additional crisis residential, respite and other program capacity that could divert hospitalization and reduce readmissions. A more comprehensive review of psychiatric emergency services is needed. Despite the development of the Comprehensive Psychiatric Emergency Programs (CPEPs), the crisis residence component of the CPEPs is totally ineffective, often providing no access or alternatives to hospitalizations. Although there has been a dramatic increase in Assertive Community Treatment Teams and case management slots, the reality is the quite often a housing alternative is needed.
Second, HHC is also very concerned about the current stats and impact of additional downsizing of the State Psychiatric Centers (SPCs), particularly in terms of access to long-term care. HHC has reduced it reliance on the State as an option for discharge planning. Corporate-wide over the last four fiscal years, HHC has transferred approximately two hundred fewer consumers per year. At the same time, occupancy for HHC psychiatric inpatient services remains at 95-100%. Inpatient lengths of stay have not decreased. On average, HHC facilities experience a two week period from referral to acceptance and another 35 days until the transfer occurs. There is currently no formal mechanism in place for hospitals or health care systems to jointly plan with the State in their geographic area on discharge planning issues.
The Corporation believes that these factors indicate a need to examine the discharge planning options available to the State Psychiatric Centers as well as HHC inpatient units. HHC and SOMH face similar problems. There is a lack of resources for consumers with complex clinical problems, histories of treatment resistance and legal and physical health care concerns. The Corporation believes that a missing service component from the system is a transitional service targeted to consumers who need a more structured clinical environment than is provided in a community residence and that will assist them in making a safe transition from an inpatient service to the community.
It is also critical that additional capacity for residential, treatment and support services be targeted to the most seriously impaired. HHC appreciates that the SOMH RFP for SRO housing for adults with serious and persistent mental illness does give priority to acute care providers. However, SOMH should join with the Local Government Unit in targeting resources to develop community-based treatment alternatives geared to the most difficult to serve consumers. HHC looks forward to the opportunity of working with the residential provider community and State Psychiatric Centers in the development of more specialized and supportive housing programs targeted to difficult-to-place consumers and reducing readmission rates.
II. Interagency Collaboration
As the plan notes, co-occurring mental health and substance abuse disorders are common. There is strong evidence base that supports the need for integrated treatment for people with dual disorders. In addition to continuing the training initiatives for professionals on integrated models of service delivery, SOMH must take a leadership role with the NYS Office of Alcoholism and Substance Abuse Services (OASAS) to plan, develop, and evaluate integrated models of mental health and substance abuse service delivery. SOMH and OASAS need to work together to plan a full continuum of integrated models of mental health and substance abuse services, including acute care, residential treatment, and outpatient programs. Model programs should be incorporated in the comprehensive plan such as intensive case management services that provide assessments, referrals, crisis intervention, and medically-supervised substance abuse treatment. Harm reduction, stress management, recreation and vocational services are also an integral part of the care needed.
Another interagency collaboration issue that the plan fails to address is the need for more services for people who have a developmental disability and a mental health disorder. Generally, these individuals are being brought to the emergency room because the family or the residential provider can no longer manage the individual’s behavior. While the total number of these individuals on adult and child/adolescent inpatient units may not be large, they tend to have very long lengths of stay. These cases highlight the need for SOMH and OMRDD to develop community emergency/respite services capacity to house and support these individuals on a short-term basis until services can be added to the home or an alternative setting is found. A hospital is not the appropriate level of care for these individuals. There are some individuals that need ongoing services supported by both State agencies. Services for these individuals need to be described in the plan.
III. Services for Children and Adolescents
While the Plan outlines the recent expansion of community-based services, including a large number of programs in public schools, it raises an important concern: the children's system is not well coordinated. Effective child and adolescent services require multiple agency involvement. The plan does not identify where gaps exist, nor does it articulate plans for expansion of models which are shown to have good outcomes and reduce treatment costs. For example, problems remain in accessing HBCI and ICM slots, and there is only one ACT program for children. In addition, while Kids Oneida program is often cited as a success story, the program has not been replicated.
In August 2003, the New York City Department of Health and Mental Hygiene published the "Children's Mental Health Needs Assessment in the Bronx." The report documents a severe shortage of clinic treatment slots for children and dire issues pertaining to access, but the OMH plan does not address clinic treatment. Further, there is no capacity for clinic access for prevention of mental illness in collaboration with schools and pediatricians.
Clinical services and supportive housing for 18-25 year-olds remains a gaping need that is not addressed by either the child or the adult plan. A strategy should be developed to help those in need of mental health care, during the transition from the child to the adult mental health system.
IV. Opportunities for Flexible Financing
Critical components that are missing from the plan are the financing strategies and mechanisms that will support the service expansions outlined in the plan. SOMH needs to explore opportunities to work with Center for Medicaid Services (CMS), other State agencies, and the managed care industry related to tying financial incentives and flexible financing as part of enhancing a community-based system of care.
In addition to the financing strategies and mechanisms also missing from the plan, are provisions for the uninsured. There needs to be a continued focus on enrolling patients in insurance programs, e.g., Medicaid, and Family and Child Health Plus. With regard to children, almost all should be eligible.
A recent examination by the United Hospital Fund and the Robert J. Wagner Graduate School found that 20% of New York City Medicaid patients were high and ultra high cost patients who consumed 70-80% of the New York City Medicaid expenditures.
The UHF/Wagner analysis found that 4,738 adult disabled (non-HIV/AIDS, non-SNF/ICF, Non-SA/Schizophrenic) patients cost Medicaid more than $497 million or almost $105,000 each in 1999.
- 69.3% of these ultra-high cost patients had chronic disease diagnoses (diabetes, cardiovascular disease, lung and/or multiple chronic diseases)
- 47.8% had psychiatric conditions
- 86% had multiple hospitalizations and 75% had used multiple organizations.
As a comprehensive healthcare provider organization, HHC has the ability to look at mental illness within the context of an individual's total medical care. HHC believes that the SOMH Comprehensive Plan should incorporate several demonstration projects targeted to high-cost Medicaid patients with mental illness/substance abuse conditions along with other medical co-morbidities. Each demonstration project could provide a package of services that includes housing, case management, medication management, substance abuse, health and mental health treatment, and other supports and services based upon the individual patient's needs and goals.
The goals of each demonstration project would be to reduce Medicaid expenditures; improve patients' health outcomes, quality of life and likelihood of successful community tenure; and to reduce acute hospitalizations, Emergency Room use and multiple provider systems. The expenditure reduction strategies that are part of the demonstration would test comprehensive healthcare delivery models and fully track and analyze patient outcomes and resource utilization. After which, the principle of gain sharing would be applied in which some of the cost savings would be reinvested into the service system to expand the models to greater numbers and/or categories of patients.
Again, I commend the State Office of Mental Health for an inclusive planning process and for the incorporation of data and quality of the comprehensive plan. I look forward to working with SOMH on the statewide planning process and on including the ideas I described in my testimony.
Good afternoon, my name is Loretta Cerbelli. My son Kevin Cerbelli was gunned down inside a Police Station while he was in the midst of a mental crisis on October 25, 1998. He died as a result sometime later at Elmhurst Hospital, the same hospital he had been an inpatient multiple times during the last year of his life in addition to an earlier hospitalization. He also attended the Mental Health Outpatient Clinic at the Hospital since 1989 up until the time of his death.
As a parent of a son who suffered from Schizophrenia I am very aware of the seriousness of this form of mental illness and the extent of debilitation it causes to those suffering it without adequate treatment. The importance of quality care and helping my son obtain the services he required had always been my primary concern as it is with other parents for their children or family members.
While reading through The Statewide Comprehensive Plan for Mental Health Services for 2004-2008 I found there were several areas of shortcomings in regards to the provision of care, medication, and services being provided or that are to be provided during the afore mentioned years.
It was a bit perplexing to me why the case of Olmstead vs. L.C. is referred to time and again when the issue of inpatient care was addressed. More notable is the fact The Office of Mental Health is continuing their endeavor to decrease the length of hospital stays by using this case as a basis for its' actions. It makes me wonder if this is at all appropriate when the cases of re-admissions from 1997 to 2001, in the New York City area for both 30 day and 180 day time frames, are the highest in this State. It gives cause to wonder if the correlation between the two is an indicator that this practice is lacking in providing adequate and quality care to those hospitalized? While the Olmstead vs. L.C. seems to be exploited as a means of returning people back into the community more quickly are the consequences of this the reason the rate of re-admissions is so high?
Community based care might be the right alternative for sane after a short hospitalization but is it for those with "serious mental illness" such as schizophrenia patients who require longer hospital stays in order for their illness to be adequately addressed? Is forcing the use of this case outcome upon those in dire need of long term hospitalization being illegally applied inappropriately to out back costs? Are these patients well enough to return to the community after a short hospital stay? Is this an accurate judgment call in regards to preserving quality of care or twisting a verdict around to suit their own purposes?
Is the Office of Mental Health focusing more on curtailing expenses and relieving society of a burden, as they state, rather then on the wellness and illness of the patient and his or her individual needs? The primary focus should be on the illness and the necessity or her to be able to function adequately when discharged into the community.
The Office of Mental Health is all consumed with eliminating hospital beds, closing mental health facilities and cutting costs and at what consequences? They seem to feel it is better to free up a bed prematurely to make way for another patient in need of the space thus another revolving door policy is in the making. Does it seem rational their solution to short-on hospital stays in order to free up bed space because beds are already so limited patients are not receiving the adequate care they deserve and require justifiable or sound reasoning? To continue to seek to eliminate more beds and have less mental health facilities it seems they are heading for a greater mental health crisis then presently exists.
How can shorter hospitalizations be the solution when so many of these patients being forced out too quickly have to return within a short period of time for further hospitalizations? Doesn't it make more sense to provide the appropriate care to begin with and avoid the possibility of re-admissions by doing so? The quality of care they are promising is impossible if there aren't enough beds or hospitals to provide the services being promised. One cannot work without the other. It is the person with the "serious mental illness" who is going to suffer in the end, feel frustration they aren't doing well and lose faith in their care providers for failing them in the first place.
How can this be classified as a commitment to promoting and preserving wellness and reasoned to be the most intrusive service from being the promotion of recovery promised and the potential for recovery will not be realized through these practices. This certainly does not seem to be in the lines of the scientifically proven "evidence based treatments and practices" referred to so often throughout this Plan. If anything it is lacking individual needs and services. Wellness cannot be achieved without the proper care no matter how much is written on the topic and the illness incorrectly treated.
Each "seriously mentally ill" person is a unique individual. The duration of a hospitalization should be based upon each individual’s personal need, severity of their mental illness and responsiveness to treatment. They cannot be categorized as a group in order to justify providing them with evidence based practices and then speak of accountability for results. What kind of results are we speaking of? Unmet needs?
It's also appalling and inappropriate the Office of Mental Health implies their reason for making such disparaging changes is to free society of a burden. The stigma people have placed on mental illness is enough for people to bear but to also be categorized as being a burden on society is deplorable?
Another shortcoming I found within the Plan is that of the clinical trials utilized on outpatients and inpatients. When a patient is stabilized, doing well and living a normal life it's astounding medications are changed in order to find out, by trial and error, if other medication would have the same desirable outcome.
Why put a person's mental well being at risk in order to experiment on them, have them regress, cause the need for further hospitalizations when well enough should have been left alone? It doesn't make a bit of sense for any "serious mentally ill" person to be subjected to trials, when their appropriate medication regime to subside their illnesses symptoms and debilities had already been established as being the most appropriate for him or her to maintain a normal life as possible.
Best practices are best served when clinicians adhere to what best serves the patient and not what best serves them. This practice is not in the best interest of patients and should be frowned upon. Companies want their medications made use of for clinical trials for inpatients and outpatients and will press on for their use.
This practice should be handled on a personal preference basis and all patients made aware of the clinical trial at hand. If a patient isn't willing to be part of a test group he or she should have the right to decline. Trials should be solely centered upon, a volunteer basis only and not used on unknowing patients who have already been stabilized. It's immoral to toy with a person's mental status for the sake of experimentation and uncertainty.
It's by far worse when, as a result, a person regresses, has multiple hospitalizations and still not returned to his or her former regime of medication for what is called the sake of science. What happened to the sake of the patient? The consequences of this practice can be detrimental to the unknowing patient who can deteriorate rapidly as a result of not having the medication that is appropriate for their illness and their well being. A “seriously mentally ill” person’s well being should be the primary concern of all clinicians and not the promotion of new medications. The illness and wellness of the person should always be the primary goal.
There is mention of the Family Psychoeducation program and the education of family members on various aspects of mental illness, symptoms, medications, services and programs available to patients. The value and need for communication and participation of family members with doctors, case manager, etc., wasn’t mentioned. There isn’t a great effort in noting the importance of feedback from family in the care of a family member.
When there is a break down in communication or a disagreement pertaining to the care or medication being prescribed, family members aren’t provided with another avenue in which there are able to have their concerns addressed. The Office of Mental Health doesn’t make provisions for a means where family members have the opportunity to communicate with someone other then the person assigned in order to address urgent needs and have them met.
There might be many services available and many types of programs available but there isn't an alternative means available to family members to reach out for help to procure them when there is a quagmire present. As a result the patient suffers as well as family members because of the frustration of not being able to reach anyone other the person in disagreement.
There should be a failsafe program in place in order for family members or the outpatient or inpatient to have an alternative panel or person to whom they cans express their concerns.
When a wall of disagreement is built and there aren't any other options of communication available and the well being of an inpatient or outpatient is at sake it's a void that demands to be filled. When the Office of Mental Health addresses the need for family members to be education it also needs to address the education of clinicians to regard the value of family members input of concerns seriously and the need for concerns to be addressed or investigated.
The Office of Mental Health also repeatedly lists the number of services and programs available to outpatients. The only means these services or programs are attainable are through case managers. These are not programs or services one can apply for or obtain on their own but require the recommendation or referral by case managers.
When there is a breakdown in communications with case manages over desired services for a family member it is another reason for the need of another avenue of communication to obtain the same. The same exists with the problem of doctors and medication. This requires a system or source to be made available to family members and patients in order to address their concerns when not possible through assigned people. If the focus is to be on the well being of the patient then there should be alternative avenues of communication made available to family members and patients who are not making progress with assigned staff for the best interest of the patient.
A probable solution to this problem might be through the Assertive Community Treatment (ACT) for the schizophrenic patient. Due to the fact it consists of a multi-disciplinary team there is a wider avenue of communications between a group rather than with an individual. There also seems there is more individual attention given to a person’s specific needs with a greater area of expertise involved which would allow for more knowledge of the person’s degree of schizophrenia and the individual attention it requires. It also provides a greater hope a family member will be able to obtain services, which are direly required to aid in their recovery process.
As much as schizophrenia is a classified mental illness we are aware the degrees of it can vary as well as the individual affects it has on people. It is not an illness that can be generalized because of the many forms it can take. A toothache is a toothache but schizophrenia is not something that can be generalized. Just as each person’s unique so does it go with schizophrenia. It’s more likely why some medications work for some and not for others. It’s the main reason when the perfect regime of medications found for each individual patient it should be adhered to.
Another problem associated with the discharge of inpatients with "serious mental illness" is the lack of available supervised residential placement slots. One segment of the Plan addresses how the number of housing slots has increased by 7,760 from 1995 to 2003. In reality this amount to 862.22 slots a year which is by far short of what is actually needed.
While the Office of Mental Health continues to close down long term stay mental health facilities and decrease the number of available hospital bed. and shorten hospitalizations it isn't focusing upon the priority need to provide supervised residential plan meet slots required by "seriously mentally ill " people.
It's very apparent these people are being pushed into community based treatment programs as an alternative to longer hospitalizations but there aren't enough required supervised housing slots available in which them can reside. While their hospital stay is shortened it's very apparent they require a placement such as this and it Should be made mandatory due to the fact they haven't received the appropriate time or care to attain "wellness" for their illness before being sent out into the community.
While expense is the primary reason for short-term hospital stays being sent into the community without the required needed support is not the answer but the problem. A monthly visit to see a psychiatrist to obtain medications and monthly visits to caseworkers is not ample care being provided to these people. It certainly isn't providing the means for recovery anti most times does lead to another hospitalization within a short period of time.
Intensive case managers would be a solution but too often they aren't provided to those outpatients who require their supervision. The "seriously mentally ill" person is left to flounder on their own without the support and supervision they require. This falls way short of the quality care being promised and certainly does not live up to best practices guidelines. As much as this is discussed throughout the Plan, the Plan doesn't address how this is to be attained in the manner in which the system is presently operating.
There are many promising goals expressed throughout the Plan but it lacks discussion on how these will be implemented. Many statistics are provided and it astounds me how some of them were arrived at. that is obvious is the fact it's quoted only 6% of the population of the mentally disabled are placed in supervised residential settings. This alone is an indicator of how the system is failing the "seriously mentally ill". It also emphasizes the dire need for the immediate expansion of these slots. There is certainly a residential crisis at hand that isn't being addressed adequately or realistically. If the comparison of it being of lesser cost then long term hospitalizations then why aren't these placements growing as rapidly as the need for them? If community based treatment is the desired option of the Office of Mental Health then it should ensure the greater need is met for the Plan to be accomplished.
It doesn't seem there is actually a continued emphasis on effectively serving hose with the highest service needs will be met or remotely possible until this issue is seriously addressed and action taken to improve this crisis situation ASAP. If supervised housing for these people isn't a priority during the present time it's doubtful it will be in the future. This problem has been in existence for many years and has not been remedied to date so how is anyone to think it will be in the future? It seems the subways, shelters and prisons are the present day solution to housing problems for "seriously mentally ill" people.
As the number of hospital beds for the mentally ill diminish and mental health facilities are being shut down the population of the mentally ill increases in communities. Many become homeless due to the fact of inadequate discharge planning and the lack of supervised residential slots available.
The lack of affordable housing is another problem and the majority of these people don't have money on hand for rent and security deposits in order to obtain an apartment. Services are hard to come by because they lack permanent addresses necessary to obtain the services they require.
They also don't have the medical coverage required to obtain the medication they need and relapse as a result. Most often they will face confrontations with the police, especially in New York City when our police department handles most of the EDP (Emotionally Disturbed People) calls. Most times they are arrested and don't receive the care they require in order to recover. They are soon released and the process begins again.
In New York City there is much needed reform within the NYPD in regards to their handling of EDP calls. They are greatly lacking in training, policy and procedures when it comes to the mentally disabled population. They have been handed the responsibility of handling a great number of these calls per year yet haven't yet brought their standards up to handle these calls properly. Out of ignorance and lack of training too often people are gunned down or injured when the situation was avoidable.
The Office of Mental Health does not seem to be playing a large role in directing their attention towards the matter of the NYPD and their handling of EDP calls. The consequences are the growing number of avoidable deaths and injuries occurring. One of the primary focuses of the Office of Mental Health should be geared towards the preservation of the lives and safety of these people within New York City.
Granted since the implementation of The Police Mental Health Program (PMHP) in 1986, great strides have been accomplished in various counties within Upstate New York and Long Island. Many are now utilizing or in the process of implementing programs such as the Memphis Project in order to safeguard the lives of people in crisis.
In New York City there is a great reluctance on the part of the NYPD to move ahead and adopt a similar program or modify current policy and procedures and increase training when mental health situation are involved. Our police department has stagnated and procedures and training as others see the great necessity for change. The consequences are the continued unnecessary loss of the lives and injuries to people in crisis.
If the Department of Mental Health played a greater role in helping procure the needed reform within the NYPD the chances of accomplishing this goal would greatly increase. If the Department of Mental Health is concerned with providing quality care and services to the mentally ill population it should also be involved in securing the lives and safety of the population as well.
As the responsibility of the NYPD increases in handling many more EDP calls, their responsibility towards safeguarding the lives and safety of this population should also increase. The great majority of deaths and injuries occurring axe unnecessary, avoidable and axe the result of inadequate training.
I attached a copy of The Kevin Cerbelli Proposal for Change that was submitted to the NYPD, at their request, on July 12, 2003, for the purpose of facilitating settlement negotiations. The NYPD is aware any interests are beyond monetary damages and include fundamental policy changes in the manner n which the NYPD interacts with people with mental illness. My primary concern is safeguarding the lives and safety of the mentally ill population and putting an end to these unnecessary and avoidable deaths and injuries.
This proposal details the changes in policy, procedure and additional training at Police Academy level on how they can effectively handle EDP calls without taking lives and causing injuries needlessly and senselessly. It also emphases the importance of the NYPD to hold the lives of EDP's as valuable as that of any other person.
It is my hope you will recognize the importance of this Proposal, the need for the Office of Mental Health's further involvement in safeguarding the lives and safety of this population. Hopefully to also become more active toward achieving a more human and desirable way the NYPD presently handle confrontations with those in the midst of a mental crisis.
I anticipate you will also see the need for the changes of procurement of weapons being moved higher up on their list of procedures when in these confrontations. When firearms are secured as reflexive fire against a person in crisis and causing the circumstances of contagious gunfire are eliminated.
As with your efforts to make the public more aware of mental health illnesses, issues and remove the ignorance and four from the public, I and many others are striving to do the same within the NYPD. There is a dire need for them to upgrade their policies, procedures, guide book and increase training time spent on handling EDP calls. There is also the need to have more non-lethal weapons on band and training for the same as they do for the use of guns. An expert in the field of mental health on duty 24 hours a day in each Precinct is needed as they presently have for domestic violence situations. These would enable the removal of the fear, ignorance and stigma of mental illness that is currently present within the NYPD due to their lack of training.
You seek to improve the services and programs you provide to the mentally ill population. You are implementing the use of electronics in the form of the Wireless Tablet PC's to improve patient care your end goal is towards the well being and wellness of the mentally ill and "severely mentally ill" population of New York. It is also your goal to include accountability within your guidelines and we are focusing on the same area in a different situation.
The focus of providing continuing quality care and enabling people to live in wellness is the ultimate goal we are all seeking along with their right to life. Though I have pointed out some shortcomings within your Plan there are many potential positive goals the Office of Mental Health, I am sure will achieve.
Thank you for the opportunity to be able to testify along with many others in our attempts to provide suggestions of changes we feel will enable your Plan to produce even more positive outcomes. There are goals you presented which don't require addressing and stand admirable.
Chief Operating Officer for Administration
Institute for Community Living, Inc.
Good afternoon, I am Kathleen Sweeney, Chief Operating Officer for Administration for the Institute for Community Living, Inc. ICL is grateful for the opportunity to provide testimony regarding the NYS Office of Mental Health's 2004-2008 Statewide Comprehensive Plan for Mental Health Services.
In addition to its role as a direct provider of housing, treatment, rehabilitation and support services for individuals with mental disabilities in New York City, ICL is also an active member of the Coalition of Voluntary Mental Health Agencies and strongly endorses the Coalition's testimony regarding the OMH Five Year Plan.
ICL recognizes that SOMH in partnership with local mental health authorities has a significant responsibility for the development and implementation of a public mental health system that encompasses a wide range of individuals throughout the whole span of life. In order to successfully address the many areas of need inherent in such a broad arena, we believe that there are three requirements: (1) a planning process that is imbedded in the recognition of each phase of life and that captures need (as opposed to prevalence) among diverse communities and populations; (2) Identification and delivery of interventions that work for diverse populations and communities; and (3) a continuous quality improvement process that measures and supports efficacy as well as efficiency across communities and populations.
ICL supports the SOMH efforts reflected in the Five Year Plan to contribute significant resources to research, development and implementation of Evidence Based Treatment and Best Practice interventions that can be shown to be effective for targeted populations and communities. We also support efforts to enhance treatment and intervention models where needed, to address the needs of the targeted communities.
There remain, we believe, significant barriers to the realization of a comprehensive and effective public mental health system in each of the life phases:
Barriers to services for Children:
Current research and experience tell us that the most effective interventions for children with serious emotional disturbance include the entire family system and are planned, strategic, and intensive in nature. The most widely utilized support for services for children with SED in the public mental health system has been and continues to be Medicaid. Yet, until recently, Medicaid regulations did not allow for reimbursement of these needed family-based intensive interventions. We applaud the recent modifications in the OMH Regulations that begin to address the need for family interventions, and support the continued restructuring of the system as needed to support these vital interventions.
In order to avoid ever escalating numbers of children who develop SED and grow into adults with serious mental illness, early identification of children at risk, and prevention interventions work best. We know that early identification and prevention is best delivered in schools. We also know that the current system of reliance on Medicaid is an ineffective mechanism to ensure the delivery of these services. First, use of Medicaid requires a diagnosis; secondly, Medicaid does not generally reimburse providers for purely preventive services (in fact, funding for preventive services from any source has been almost nonexistent); thirdly, even if there is a diagnosed condition and the required intervention is treatment, the kinds of contacts that work in engaging these children, e.g. brief contacts in the halls, "chats" in the lunchroom that are effective strategies for building relationships with these children are difficult to document as reimbursable under Medicaid regulations. Ellen Busick, the Chief Executive Officer of the National Center on Family Homelessness has noted that serious mental illness is adulthood is highly predictable among children who are exposed to trauma with no effective interventions. Unfortunately, many children who would be served in the public mental health system have to deal with trauma resulting from domestic and/or community violence, or myriad forms of neglect.
Barriers to services for Young Adults
We believe that preventive services for teens and young adults is also required to better ensure a reduction in the onset of serious mental illness in later life. In addition, for those young adults who are already receiving services or are identified as in need of intensive services, more and more specialized transitional housing and treatment models that are specifically geared to the needs of a young adult population are needed.
Barriers to services for Adults
NYS has developed an extremely effective supported housing program. Eighty-five percent of individuals who enter a supported housing program remain. However, escalation in housing market rates threaten this stability as well as the availability of sufficient housing in the future, increasing the potential for initial or repeated episodes of homelessness among adults with serious mental illness. ICL recommends that:
- OMH consider the inclusion of rental increases in the 41.38 property costs that are a "pass through". This would guarantee stability in the existing housing stock as well as better affordability for both existing and future supported housing;
- Incentives be provided to private developers to develop low income supported housing in collaboration with non-profit providers.
As noted in the five year plan, SOMH has initiated a series of mechanisms to ensure that adults with high needs receive priority services, including housing services. ICL is supportive of these efforts, and in fact has participated in the task force for SPOA in NYC and has targeted significant new housing resources for long-term shelter stayers with serious mental illness, a priority population. However, we believe that the resources that OMH recognizes are needed to provide needed services for these individuals have not been readily available. ICL recommends that OMH expand the availability of and develop a system of "set-asides" of ACTT, case management and other resources to be utilized by housing providers for hard to serve/high need individuals tied to the availability and placement of these individuals in housing.
We strongly agree with OMH's commitment to employment services for adults with serious mental illness. In this regard, we believe that more financial support is required to develop employment services that are responsive to their needs and desires. We would also recommend that OMH explore ways in which, with providers, to encourage employers to provide job opportunities for persons with mental illness and perhaps to develop a central "job bank" for consumers.
I have been talking a lot about barriers, and fragmentation of services has certainly been one of them. However, I would like to say that the OMH PROS initiative, when implemented, will we believe, go a long way to integrate outpatient, rehabilitation, community support, vocational and employment services for many individuals.
Barriers to services for Older Adults
Finally many of us can identify with the current and anticipated service needs of this last group, the older adult. There are two subpopulations that we are concerned with:
Individuals who have a long history of SMI and who are aging. These individuals are developing co-morbid medical conditions. The lack of coordination of health and mental health treatment results in overall poor care with poor outcomes and at considerable cost.
People who are aging and developing mental health conditions secondarily to the process. These people require interventions that are specific to their needs. OMH's 2015 plan begins to address the needs of the "Boomer" population who need or will need mental health services. ICL supports the recommendations of the geriatric committee of the Mental Health Association for the appointment of a point person within OMH to further develop and coordinate services for older adults.
Let me conclude by saying that ICL is looking forward to working closely with SOMH as well as the City Department in furthering services for people in need of mental health services in all phases of their lives. Thank you.
Mental Health Services
Jewish Association for Services for the Aged
The Jewish Association for Services for the Aged, JASA, is the largest, not for profit, publicly funded agency serving the needs of the elderly in the greater NY area. JASA offers a broad continuum of programs to help maintain a high quality of life for elders living in their homes and communities. These programs include case management, housing, licensed mental health services, legal services, adult protective services, homecare, senior centers, and special services for caregivers, victims of abuse, and recent immigrants.
JASA has been a provider of mental health services since 1984 and now sponsors two licensed outpatient clinics and two psychosocial programs for the elderly. Consumers of JASA programs include those suffering from life long mental illness such as schizophrenia as well as those who are struggling to cope with late life challenges and depression. These persons, ranging in age from 55 to 98, include many who are physically frail and homebound. Unfortunately, JASA is one of very few downstate agencies with a discrete geriatric service and the agency's clinic capacity is only about 200 persons. It is clear from our experience in other service venues such as NORC programs, senior centers, and housing sites that many more aging individuals need mental health services.
This testimony, on behalf of the diverse and growing cohort of persons over 60 years of age, urges the New York State Office of Mental Health to take a leadership role in designating funding and establishing program initiative opportunities for services to older adults, an underserved population. JASA's Board of Trustees, staff and consumers note with dismay the lack of focus on geriatric mental health needs in the NYS Comprehensive Mental Health Plan.
Aging well involves finding fulfillment in family, friends and meaningful activity. It can be a time of genuine renewal and gratification. It can also be a time of daunting challenges, requiring greater resiliency and energy than at any other period of life. A societal ageism that questions an older person's capacity for change, as well as a generational self-consciousness about seeking treatment, are additional burdens. Even those individuals who have coped well during previous life crises may find that they struggle. The high incidence of depression in the elderly is now widely documented. Those who have suffered from severe and persistent mental illness are significantly more vulnerable when losses related to physical health, social supports and financial security occur.
Older adults rarely present with a mental health issue only. Ill health (whether chronic or sudden onset), isolation from family and friends, and financial needs are usually prominent in the presenting situation. Stabilizing a client's mental health functioning may require extensive case management and, in cases where individuals are difficult to engage, resolving a social service need often facilitates mental health service delivery.
JASA's outpatient clinic programs have been designed to provide an integrated and cohesive response to meeting mental health and multiple case management needs. All clinical and case management services are available on site in the clinic or in the home. Under the supervision of the Clinic medical director, the primary therapist, a social worker psychotherapist, leads the treatment team and also directly addresses case management issues, whether it is to access entitlements or arrange for homecare. Of course, the case management services are not reimbursable and are only available in the Bronx clinic, a program that has modest deficit funding. Frequently, JASA social workers have had to address social service needs that other mental health agencies have ignored because of the lack of reimbursement for time spent on such services.
Up until recently, JASA was fortunate to have a staffing pattern that also included a nurse. This enabled the Bronx clinic to help clients address health needs. Unfortunately, this position was eliminated because of a funding shortfall.
An integrated mental health service and social service model is effective, but it still falls short of a true "one-stop" service model that would improve service access and utilization by incorporating mental health treatment, social services and physical health services at one site. Such "one-stop" service delivery could be available in home as well by utilizing a NORC/Aging in Place model of service delivery (the visiting team may include a psychiatrist, social worker and community nurse). It may also be accomplished by establishing an integrated service at non-mental health sites frequented by elders, including senior centers. JASA recently secured philanthropic funding to establish a community outreach program at NORC sites, to enhance existing community nursing and social services and engage difficult-to-serve elders who would benefit from, but are wary of, mental health treatment.
JASA proposes the establishment of a planning coalition, bringing together representatives from OMH, SOFA, NYC DFTA and members of the provider/consumer community to partner and effectively plan for coordinated services to the growing aging population. This effort would identify service needs, maximize existing resources/services, advocate for funding, and would be more likely to result in an integrated and comprehensive approach to the delivery of services.
JASA is also advocating for the designation of OMH secured funding to promote community based initiatives. JASA recommends that OMH help identify funding resources to reimburse agencies for "non-reimbursable," but necessary services.
In light of the specific needs of the elderly and the broad diversity (including such factors as age, functional ability and culture), special geriatric staff and peer training programs should be established and research conducted in best practices regarding most effective treatment approaches. The availability of training for non-mental health medical practitioners is also necessary - general practitioners frequently over or under medicate their patients.
JASA urges OMH to take the lead in establishing geriatric mental health as a priority issue for New York State.
Council of Senior Center & Services of New York City, Inc.
My name is Raquel Romanick and I am the Legal Advocate at Council of Senior Centers and Services of New York City, Inc. (CSCS). First, on behalf of CSCS, its member agencies and the 300,000 elderly people they serve, we would like to thank the New York State Office of Mental Health for holding these hearings today and for recognizing the importance of creating a comprehensive plan to address the mental health needs of New York's aging population.
CSCS is the central organization in New York City representing 265 member agencies providing community-based services for 300,000 older New Yorkers. Services provided through our member agencies include congregate and home delivered meals, housing, mental health services, case management, home care, multi service senior centers, social adult day services, transportation, Naturally Occurring Retirement Communities (NORCs), information and referral, assistance for immigrants, computerized benefits programs, educational and cultural activities, counseling, health promotion programs, legal services, opportunities for volunteerism and intergenerational programs.
In order to put my testimony into context, I would like to share some demographic information:
- There are 1.3 million people over the age of 60 in New York City
- In 2006 the baby boomer generation begins to turn 60
- The 2000 census reports a 5.1 % increase in the 75+ age group and an 18.7% increase in the 85+ population in New York City since 1990. The 85+ age group in the fastest growing segment of our city's population.
- Minority elderly compromise 47% of the elderly population, up from 35% in the 1990 census.
- Nearly 20% of New York City's seniors live in poverty - almost double the national rate. Another 23% live at or near the poverty level.
- Poverty and near poverty rates are glaring - 41 % of Latino elderly, 31 % of African-American elderly, 29% of Asian elderly and 14% of White elderly live in poverty.
- It is estimated that from 2000 to 2030 the number of older adults, nationally, with mental illnesses will grow from approximately 7 million to approximately 14 million.
- 25% of older adults with chronic illnesses have clinically significant depression.
- Health care costs are double for people with mental illness.
- Only 22.5% of older adults with mental illnesses get treatment from mental health professionals.
- Older adults commit suicide 50% more often than the general population and at considerably higher rates as they age.
These facts demonstrate that the state's current mental health policy is inadequate to meet the needs of a diverse senior population. The creation of a comprehensive geriatric mental health policy agenda is needed to effectively address the unique needs and characteristics of the older population both today and in the years to come.
The Current System Fails to Address the Needs of the Elderly
Across the board, senior service providers consistently rank mental health needs as a major priority. These unmet needs are overwhelming senior center leaders, settlement houses and home health providers. The private sector is feeling increasing pressure from lost productivity due to family responsibilities for elderly and disabled relatives, many of who suffer from dementia and other mental disorders.
The existing mental health system is premised on the notion that individuals in need of treatment for mental health concerns will not only recognize that fact, but will take steps necessary to visit a doctor or mental health professional. There are many reasons why this system has been unsuccessful in reaching and treating older persons.
- The senior population is increasingly diverse. For many, cultural values create a stigma on mental illness. Language barriers and cultural differences often stop seniors from seeking the help they need.
- Many seniors are uncomfortable with the idea of obtaining treatment for mental health in a clinical setting.
- Many doctors and senior service providers lack the training to recognize mental illness amongst older individuals.
- Many individuals do not know where to go to get needed mental health services.
- Many older New Yorkers are homebound, and are therefore unable to access resources in the community.
- Many New Yorkers lack the financial resources to pay for treatment.
Addressing the Problem
New York State must begin the process of developing a comprehensive geriatric mental health plan in order to adequately meet the needs of an aging population. Any such plan should contain a multi level approach aimed at seniors, service providers, families and health care providers.
Public education is essential to inform seniors as to the symptoms of mental illness and to combat the many misconceptions surrounding mental illness and the resulting social stigma and isolation that may result. Any such education campaign should inform seniors as to where they can go to get help and provide information as to the many effective treatment methods that exist.
Funds should be allocated to provide mental health services at senior centers, and to train case managers and home care workers on mental illness. As these providers are community based, they are often the first people seniors and their families turn to in a crisis. Furthermore, these communities based providers often understand the language and culture of the individuals they serve.
Additionally, as the need for geriatric mental health professionals continues to grow, the shortage of such educated and trained individuals will become increasingly more pronounced. Funding should be allocated both to educate the public of the growing need in this area and to provide incentives for individuals choosing to specialize in this area.
A plan needs to be created to address the mental health concerns of homebound seniors. These individuals need a mobile set of services that can treat them in their homes.
As the number of senior citizens throughout New York increases, the number of family caregivers will certainly increase as well. Family caregivers provide a valuable service and systems and supports need to be created to assist them. In 1997, the national economic value of informal care giving was $196 billion. Furthermore, over the next 10 years, 54% of Americans are expected to be responsible for the care of an elderly relative. Care giving responsibilities of employees are a growing concern of corporations across the nation. Active steps must be taken to protect the well being of caregivers and their ability to contribute to the workforce. Respite programs such as adult day services, home care and caregiver support groups are important mechanisms for strengthening this informal support network.
The existing government structure separates the aging, health and mental health systems. By isolating the expertise of each system we cannot create the integration of services so clearly needed to improve care. To fully address the mental health needs of the current and future senior population, we need to find a way to bring together the aging, health and mental health systems, providers and advocates to build a system that is both comprehensive, efficient and successful.
Again, I would like to thank the New York State Office of Mental Health for holding this hearing today and for recognizing the importance of geriatric mental health issues. We look forward to working with you to ensure that older New Yorkers and their families are able to get the help they need and deserve. Please feel free to contact us.
Dr. Robert Giugliano
Director of Mental Health, Covenant House New York
Good afternoon. I am Dr. Robert Giugliano, and I am the Director of Mental Health at Covenant House New York, the state's largest provider of services to homeless, runaway, and at-risk youth. On behalf of the administration, staff, and the young adults we serve, I thank the Office of Mental Health for this opportunity to comment on OMH's Statewide Comprehensive Plan for Mental Health Services for 2004-2008.
Covenant House appreciates Commissioner Carpinello's approach to statewide planning presented in the 2004-2008 Comprehensive Plan, in particular, the movement toward population-based planning. Population-based planning takes into account planning across age groups and for those, to quote Dr. Perlman, Chairman of the Mental Health Services Council, "for whom targeted service design historically has been lacking." While the planning process is inclusive, transparent, comprehensive, and data driven, we wish to raise some questions about its representativeness as well as the responsiveness of OMH to the long-standing gaps in housing and services for young adults between the ages of 18 to 25 with mental illness and co-occurring substance abuse disorders.
Section 7.01 of the Mental Hygiene Law states, in part, that It shall be the policy of the state to conduct research and to develop programs which further prevention and early detection of mental illness; to develop a comprehensive, integrated system of treatment and rehabilitation services for the mentally ill. Such a system should ... assure the adequacy and appropriateness of residential arrangements for people in need of service... (emphasis added)
On behalf of the almost 1,000 mentally ill homeless 18 to 21 year olds who have been served by Covenant House's Mental Health Day Program, we must again bring to OMH's attention that it continues to fail to live up to the above stated statute with regard to both the appropriateness and adequacy of housing and services for young adults with mental illness. Covenant House's Mental Health Day Program opened in 1996 in response to the increased presence of 18 to 21 year olds in our Crisis Center shelter who presented with serious mental illness and histories of psychiatric hospitalization. In addition to facing the adversity of coming from severely challenged families who couldn't hold on to them or who may have actually throne them out, these young men and women also face the adversity of coping with mental illness.
Many of our 18 to 21 year olds have had histories of psychiatric hospitalization, suicidal ideation and attempts, co-occurring substance abuse disorders, and psychotic disorders compounded by the stress and trauma associated with being homeless and living on the street. Some of these highly vulnerable and victimized 18 to 21 year olds have already been in the adult shelter system - a dangerous social environment that is totally unresponsive to their needs. Some of them have been in the criminal justice system - another social institution that does not provide adequate or appropriate care for the mentally ill young adult. In fact, the failure of the state and local mental health system to provide adequate and appropriate services and housing for the mentally ill has contributed to the unprecedented number of mentally ill persons in the criminal justice system.
With one thousand mentally ill homeless 18 to 21 year olds in our crisis center shelter over the last 8 years and no appropriate or adequate place to send them, we can only conclude that the mental health system has neglected these young people and continues to the impairment of mentally ill young adults, particularly the poor and homeless, by not providing housing and services that are designed in consideration of their particular developmental needs. The mental health system has known for years about the clinical imperative of having appropriate and adequate housing and programming for young adults but has not taken the initiative in responding to these needs. The mental health system has also known for years about the challenges involved in developing adequate and appropriate housing, programming, and services for young adults but has ignored these challenges.
What does the failure of the mental health system actually mean for the 18 to 21 year olds we serve? The lived reality for these young people is that their only discharge option from our shelter may be living on the street or living with a mentally ill older adult 40 to 45 years old on the average. Neither choice is in their best interests. The street, with its increased probability of further decompensation and hospitalizations, and the adult residential system contribute to socializing these young people into the role of homeless mentally ill adults. Neither choice offers what mentally ill young adults need, namely, structure, support, treatment and programming in a social environment that is organized and designed around the psychological and social reality of young adulthood. By analogy, a college campus is a social environment that provides age-appropriate structure, support and programming. However, that which is prohibited on all of the state’s college campuses - namely 18 and 19 and 20 year olds living with 40 and 45 year olds - is the very policy and practice of the Office of Mental Health when it comes to young adults with mental illness who are in needs of housing.
OMH’s commitment to making population-based planning a “cornerstone of an improved planning process” is, hopefully, the beginning of a process that will result in housing and services designed specifically for mentally ill young adults. However, this commitment must be actualized in the form of concrete decisions and policies. Toward that end, the following recommendations are offered:
- OMH should set aside 10% of current adult residential beds, beds in the pipeline and proposed beds for young adults.
- OMH should provide adequate levels of funding for supportive services for young adults currently in housing.
- Young adults will continue to be neglected unless and until their needs are represented in an organized and ongoing manner in OMH.
- Truly inclusive and representative planning necessarily must include young adults having a voice in the process. Where in the process, graphically represented on page 19 of the Comprehensive Plan, are young adult providers and consumer presented?
- All data and reports on mental health services and housing should be formatted to include 18 to 21 and 22 to 25 year old age groups rather than the current practice of reporting on 18 to 34 or 18 to 65 age groups.
Executive Director of the Mental Health Association of New York City
My name is Giselle Stolper. I am the Executive Director of the Mental Health Association of New York City. Today I am also representing the Mental Health Association of Westchester. Both organizations, as you know, have long histories of mental health advocacy, public education, and direct service, reaching tens of thousands of people every year.
We appreciate the opportunity to speak today in response to The Office of Mental Health's (OMH's) 5-year plan. Our testimony will be divided into two sections. First, we will comment on the broad future directions discussed in the plan. Then we will discuss the planning process.
The Future Directions of the NYS Office of Mental Health
Commitment To Ouality: We have been concerned for many years about the uneven quality of services in NYS and are extremely supportive of OMH's commitment to translate state-of-the-art clinical knowledge into practice. Although we agree that evidence-based practices should be widely disseminated to reflect the commitment to quality, we also believe that there are sound practices and promising practices which have not yet been studied and for which there is not, as yet, an evidence base. These practices should not be discounted because of lack of research. In addition, we are concerned that there are often vast differences between the conditions under which evidence is collected for sophisticated practices and the conditions under which providers have to practice. Interaction between the researchers and the practitioners on the line should, therefore, be a two-way street, with each learning from the other. Despite these concerns we remain enthusiastic about the Winds of Change initiative.
Commitment to Community-Based Services: Since their inception, Mental Health Associations have fought for the right of people with serious mental illnesses to live in the community and for provision of the outpatient treatment and supports that they need to lead satisfying lives in the community. Thus we are extremely supportive of the overall community mental health policy of NYS. We also support OMH's broad efforts to develop a diverse array of community-based treatment and support services, particularly those services which are designed to reach out and to engage people with serious and persistent mental illnesses who tend to reject, or are unable to use, more traditional services. We, of course, support more rapid expansion of community services and regret that this year's budget calls for a reduction of state funding for some rehabilitation and peer support services--a sad regression for New York State. We also have some concerns about the continuing trend to use Medicaid to pay for community support services that do not use a medical model and, therefore, may have to sacrifice critical aspects of their programs to comply with new regulations. The effectiveness of rehabilitation services supported by Medicaid should, we believe, be monitored very carefully.
Future of State Hospitals: We generally agree with OMH that there are state hospitals which can be closed without loss of service capacity and that these savings should be taken and used to expand community-based services. We supported the proposal to establish a Bi-Partisan Commission on State Hospital Closure and regret that it appears to be dead in the State Legislature. It is important, however, to understand that this has happened because of concern that closings will not be conjoined with expansion of community services, because of concerns about impact on local economies and the state workforce, and because of concerns about the composition and authority of the Commission. All of these are concerns which the State administration should address. (We have attached an OP-ED which includes suggestions about how to make a commission on closures work effectively.)
Housing: Perhaps the greatest concern of community mental health advocates today is the need for additional housing. It is critical to address continuing problems of transinstitutionalization-to adult and nursing homes and to jails and prisons. It is also critical to address the growth of homelessness, the burden on families, the abandonment of young adults leaving foster care, etc.
The plan indicates that OMH will develop approximately 5000 new units of housing for adults with mental illness over the next few years. Unfortunately that falls far short of the current and predictable future need, which we roughly estimate as at least 35,000 more units than existed at the end of 2003. (Other estimates run as high as 70,000.) Admittedly our estimate is rough, which is why we have urged OMH to do a new housing needs assessment to replace the one done in 1993. But whatever the exact number, at the current pace of housing development-roughly 1000 per year-it will take at least V4 century to meet housing need. That is far too long to wait, we believe; and, therefore, we have urged NYS to declare the next decade "The Decade of Mental Health Housing Reform" and to commit to meeting housing need by 2015 by vastly increasing the pace of new housing development. (We have attached our position paper on housing.)
Co-occurring disorders and need for integration: People with co-occurring mental and substance disorders are among the hardest people to serve adequately, but evidence has been available for years indicating that integrated treatment is the most effective approach. Some progress has been made in this regard; but significant progress is stalled in part because current regulatory and financial structures do not support integration. We hope that OMH will redouble its efforts to develop such structures in cooperation with OASAS.
Children and Adolescents: Both the MHA of NYC and the MHA of Westchester have worked closely with OMH on the development of a community-based service system for seriously emotionally disturbed children and adolescents. And we continue to support the overall program directions that OMH has developed. We, of course, would like to see more rapid expansion of service capacity. We are particularly concerned about the need to expand and remodel the outpatient system for kids. (We have attached a proposal for a multi-year approach, which we developed jointly with other child mental health advocacy organizations.)
Older adults: We were very distressed that this year's 5.07 plan virtually ignored the mental health needs of older adults. This is a vastly underserved population now. When the elder boom hits, a crisis will ensue unless extensive planning efforts begin soon. We urge OMH to focus considerable attention on this population by creating a Bureau for Geriatric Mental Health headed by an Associate Commissioner, by beginning a process of developing service models that can meet the unique mental health needs of older adults, and by advocating for integrated approaches with other state departments.
Broadened population of concern: This plan announces OMH's intention to expand its attention from adults with serious and persistent mental illnesses and children with serious emotional disturbances to other populations with mental health problems as well. We fully support this expansion of priorities and particularly support the suicide prevention initiative.
The Planning Process
Data-driven, population-based planning: We are extremely pleased that OMH has made a commitment to a data-driven, population-based planning process; and we would be pleased to work with OMB to enhance this process in the coming years.
Needs assessment and quantified service plans: We believe that the fundamental goal of population-based planning is to identify need and to develop quantified plans for new and modified services. We fully understand the difficulty of needs assessment and that it is not as simple as subtracting utilization from prevalence. Nevertheless, we believe that data that were not used in this year's plan could lead to a closer approximation of need. We suggest that next year's plan include data on:
- Demographic trends including population growth
- Prevalence, stratified by age and socio-economic categories
- Utilization in both the public and the private sector including not only the number of individuals served but also data which identify service drop outs
- Workforce Projects
Process and timing: This planning document suggests that the 5.07 plan should be released, as it was this year, at the same time that the Governor's budget request is released. We disagree. We think there should be a plan before there is a budget and propose that the plan should be released even earlier than required by 5.07 so that there is time for public comment prior to the Governor's completion of his budget request.
In general we believe that there should be strong public input into the development of the plan beginning with local planning meetings attended by OMH field office directors, continuing through a planning cabinet including the field office directors, and culminating in public hearings on a draft plan attended by the Commissioner.
Were there "world enough and time," we would offer more detailed suggestions on the planning process. But for now we will only add that this plan is an important step forward, an encouraging promise of progressive improvement in the planning process. And we repeat that we are prepared to work with OMH on subsequent steps.
Thank you again for the opportunity to testify today.
Comments or questions about the information on this page can be directed to the Office of Planning.