Public Education & Policy :: Mental Health Services Act

Mental Health Financial Challenges in Building a Recovery Oriented System

Recovery values are overtly stated in Section 7, 5813.5 (d) of the Mental Health Services Act:

(d) Planning for services shall be consistent with the philosophy, principles and practices of the Recovery Vision for mental health consumers.

(1) To promote concepts key to the recovery for individuals who have mental illness: hope, personal empowerment, respect, social connections, self-responsibility, and self-determination.

(2) To promote consumer-operated services as a way to support recovery.

(3) To reflect the cultural, ethnic, and racial diversity of mental health consumers.

(4) To plan for each consumer's individual needs.

The DMH reflects this recovery vision in its 5 Essential Elements for Three-Year Program and Expenditure Requirements for Community Services and Supports Plans, August 1, 2005, submitted by the counties. (pp. 6 -8.)

Community collaboration

Cultural competence

Client/family driven mental health system for older adults, adults and transition age youth and family driven system of care for children and youth

Wellness focus, which includes the concepts of recovery and resilience

Integrated service experiences for clients and their families throughout their interactions with the mental health system:

"These five fundamental concepts combine to ensure that through MHSA-funded activities, counties work with their communities to create culturally competent, client/family driven mental health services and support plans which are wellness focused, which support recovery and resilience, and which offer integrated service experiences for clients and families."

What are the financial challenges of meeting these goals on an on-going basis?

The largest financial obstacle in protecting resources for recovery based services is the enormous State and County financial investments in hospitals, skilled nursing homes, and inpatient facilities, based on involuntary treatment and producing chronicity and recidivism.

Treatment Patterns

A. Recovery based mental health services: Person and, most importantly, those around him/her believe in recovery, engage in person centered voluntary services, have a full option of rehabilitative, psychosocial services available and accessible, including peer connections and peer-run services, enlist a personal assistant (as opposed to a case manager) if chosen, and use medication as a tool, by choice. (Much of this description is taken from Laurie Ahern and Daniel Fisher, M D. Ph D, Personal Assistance in Community Existence, a Recovery Guide. National Empowerment Center, Inc. 1999.)

B. Traditional Mental Health Services: The typical treatment cycle for persons experiencing severe mental distress is involuntary treatment of some length, extensive and maintenance use of medications, no or little follow up supports and services in the community, recidivism, and chronic "mental illness." This treatment cycle has the full weight of the mental health bureaucracy behind it, including the hospital and professional infrastructure.

As described by Laurie Ahern and Daniel Fisher, M.D., Ph D, "Then they (people with mental illness) are most often placed in a psychiatric hospital; and a course of intense professional treatment begins. The person looses their major role(s) in society and begins the career of a mental patient."

Financial Patterns

According to Steve Fields, Executive Director of Progress Foundation in San Francisco one psychiatric bed in San Francisco General Hospital costs 4 times more than at an acute diversion crisis residential house, which is voluntary and based on a psychosocial rehabilitation model. Of the people who went to the crisis residential house after 2 years away from the crisis facility only 8% returned to the hospital. On the other hand, it is safe to say that San Francisco General Hospital breeds recidivism.

In response to the subject of financing a recovery based system, a consumer e-mailed the following: "I also think that the only way to begin transforming the systems towards recovery concepts is to stop funding ONLY the acute side of mental health. The system has done this for years and no one really benefits from this approach. For example, in (the particular) County, the inpatient/acute and sub acute budget exceeds 100 million when the entire budget is only 200 million. I'm not sure how to articulate it all, but it seems lopsided corrupt to me. "This particular County has put more resources in community programs than most counties. It is logical to assume from the example of this "progressive" County, that in all Counties the bulk of the funds are going into the most ineffective and hurtful services.

Although these percentages have changed with the advent of MHSA funds, the same lopsided allocation of resources applies to the State Department of Mental Health. In Being There: Making a Commitment to Mental Health, the Little Hoover Commission states that (as of 2000-01) 96.4% of the department's staff provide long term care in institutions, while only 1.2% assist counties with mental health services.(p.38, November 2000.)

Clearly, most of our resources are put into treatment patterns that have negative results for consumers, and perpetuates, in fact, multiplies itself - in-patient facilities, involuntary treatment, and recidivism. There is no end to this escalating cycle of ineffective use, in terms of person outcomes and financial accountability, of funds.

Having the finances to build a recovery based system means attacking the financial juggernaut that in patient and institutional care has on the mental health system. It means drastically reducing in patient treatment so as to have the finances necessary to build voluntary community based consumer driven services.

AB 2034 Demonstrates How to Build a Recovery System

AB 2034, the model for the base of the MHSA has demonstrated that recovery person centered services are both people effective and cost effective.

Descriptions of the personal and financial success of the AB 2034 programs follow:

• The number of days of psychiatric hospitalization since enrollment dropped 55.8%
• The number of days of incarceration dropped 72.1%
• The number of days spent homeless dropped 67.3%
• The number of days of full-time employment increased 65.4%
• The number of days of part-time employment increased 53.1%

The results document not only the personal success of clients, but the ongoing cost effectiveness of AB 2034 programs. This report estimates that an annual program expenditure of approximately $55 million for 35 local programs has been offset by an estimated savings or cost avoidance of approximately $24.7 million from reduced psychiatric inpatient days and reduced incarcerations. Additionally, we conservatively estimate an additional $2.7 million in savings/cost avoidance as a result of the reduced use of emergency services. More and more go back into housing, jobs, community supportive services, etc. (my emphasis)

From "Effectiveness of Integrated Services for Homeless Adults with Serious Mental Illness", A Report to the Legislature as required by Division 5, Section 5814, of the California Welfare and Institutions Code, May 2003, pp. 3-4.

With more and more resources going into housing, jobs, and the whole array of voluntary comprehensive services, the perceived need for costly in patient and involuntary services will drop drastically.

An additional financial barrier to providing incentives for person centered, recovery based services is the restrictive medical model based Medi-cal requirements. This is an example of financial incentives supporting treatment patterns that have negative consequences for consumers.

Because so much of mental health resources go to in-patient facilities, along with other factors, the Counties have minimal resources for voluntary community based services. Therefore, many Counties are extremely dependent on Medi-cal funding. However, because of the medical model base of Medi-cal, many essential housing, job, and community supportive services are not covered by it. This is especially true of client run/peer support services. Generally, the most effective services are the least supported by Medi-cal. Once again funding resources are going to treatment patterns that have negative consequences for consumers and create long term "mental patients."

In fact, the President's New Freedom Commission on Mental Health recommends the realignment of programs to meet the needs of consumers and families. "The Federal government must also provide leadership in demonstrating accountability for funding approaches and in removing regulatory and policy barriers. The funding and regulatory systems should advance the goal of making the mental health system consumer- and family-driven and should encourage choice and self determination." (Achieving the Promise: Transforming Mental Health Care in America, Final report, July 2003, p.38.)

Mental health services are guided by funding streams, entrenched institutional self-interests, and the stereotyping of people with mental disabilities as either violent or not capable of making decisions for themselves and thus in need of supervision. Instead, a transformed mental health system must be guided by the recovery vision which includes choice and self determination and an array of services that address the needs of the whole human being.