For the past year I have been participating in a work group regarding Older Adults focusing on the extent to which the Mental Health Services Act (Prop 63/MHSA) has resulted in developing a system of care for that population. Recently I was interviewed, mainly in my capacity as a co-author and principal drafter of that law with questions about our expectations, how it is going, and what needs to happen.
At about the same time, I became aware of a major planning process and series of investments of $850 million over 4 years in New York City (ThriveNYC). New York’s population is about 9 million – a bit less than LA – but their funding may be greater than LA, so it is probably comparable in terms of budgets.
New York’s mayor has an adult child who is now a spokesperson for youth mental health challenges; their entire family speaks often, so the prioritization of mental health naturally got a big boost there. From the documents on their initial plan, with six principles and 54 specific new actions, and their 150 day update, it looks a lot like what a comprehensive county MHSA three year plan and annual update could look like with most of the areas of investment being very similar to priorities in California.
From these discussions and the break in legislative sessions, it seemed like a good time to share not only what I said for that interview but a broader sense of where I see things at this point, and to stress the need for more big-picture planning.
Planning: Counties Need to Estimate Needs for CSS Services and How Much it Will Cost to Serve All Who Need the Services
How many people are likely to need Community Services and Supports (full service partnership) services but are not getting them? Every county should know this, but few do. How can this be calculated? The best starting place is the number of 5150s for adults and older adults (plus incarcerations) and child welfare and special education placements (plus hospitalizations and juvenile justice) for people not getting comprehensive MHSA or EPSDT services.
Simple need analysis and budget gap planning should be a basic function in each county. But is it? A recent Orange County Consultant RFP is one effort to address this.Once that report is completed it should provide a starting point (complementary to the New York report) for other counties to consider. I am not aware of similar efforts in other counties. I wonder if it would be a good time to bring together key stakeholders statewide to determine what makes the most sense.
An example of the need for planning directly relevant to older adults was stated by the UCLA interviewers who told me that they heard that counties disregard the fact that older adults represent 20% of the population. It was stated that counties think the need for CSS level services is quite small for that age group, based upon the study showing that people with severe mental illness died on average 25 years younger than other Medicaid recipients. Is this valid? The interviewers did not know and my sense is that a starting point is for counties to check the demographics of hospitalization and incarceration data.
Prevention and Early Intervention: Reducing the pipeline to CSS services and hospitalizations. What are the most strategic investments? How do we integrate with SUD prevention and early intervention?
The primary purpose of the PEI part of the MHSA was to make early identification and treatment of potentially severe mental illnesses the norm instead of the exception. If this happens, fewer people will need the higher levels of care in CSS, fewer people would be hospitalized, and fewer kids would be in special education or child welfare due a neglected serious emotional disturbance. Is this happening in any counties? Do we know? If it was happening would we know why?
From my work and past blogs I noted that two obvious places to make this happen are through primary care (and emergency rooms for those entering the health care system there) and schools.
There are lots of state and local efforts to build these systems but I have not seen county behavioral health PEI plans for which this is a high priority to take to scale. Are these the most important and cost effective strategies? Are there others? Can we develop more integrated behavioral health approaches combined with alcohol and drug prevention and early intervention?
It should be noted that a primary mental health diagnosis is not required for use of PEI funds, since any behavioral health problem can become a severe and disabling mental health problem. The ability to develop prevention and early intervention for substance use disorders (and related mental health) for youth is a top priority of the hundreds of millions of new funding likely to become available should Proposition 64 (marijuana legalization) be approved by voters on November 8th.
Again it seems like a good time to bring people together to develop an approach to facilitate more proactive county planning focused on the most effective strategies.
Serve Everyone, Give them Everything Start Early
Right after the Act passed, we said these were the main goals. They still are. While the money is being spent in the way we thought it would our progress has been limited, mainly due to the recession and 1991 realignment structural problems that were generally fixed in the 2011 realignment.
Exactly how we do that is going to take a lot discussion but we at least have to ask the questions; so far I don’t see that happening very much. Do you agree? If not why not?
Am I asking the right questions? Am I proposing the right actions? I want to know your thoughts and ideas.