In the Michigan mental health system during the
last twelve years, policies were adopted by the administration and the
legislature which were intended to follow the national path of deinstitutionalization,
decentralization and integration into the community of persons afflicted
with severe mental illness and children with emotional disorders.However,
in Michigan these initiatives resulted in a fragmentation of the system
and loss of long-term care for many of the persons in need of such care.
Furthermore, there have been insufficient services
available in the community to meet the needs of many persons with severe
mental illness.Failure to utilize
properly the most effective medications and services delays the recovery,
and sometimes exacerbates the symptoms of persons with mental illness,
thus significantly increasing the required levels of care and the cost
of the public mental health system.
Inadequate treatment and services also contributes
to unnecessary pain and suffering of persons with mental illnesses.The
symptoms of mental illness not only interfere with the ability of an ill
person to work, but they also impair the health and ability of family members
to perform effectively in their jobs, thus resulting in a loss of productivity
to Michigan employers, loss of tax dollars, and increased costs of health
care in general.Insufficient treatment
and services also gives rise to an increasing number of persons with mental
illness who are in jails and prisons, or homeless or whose illness results
in death.
Even during the better economic years of the mid-90’s,
the administration was focused on attracting business and jobs to Michigan,
building roads and prisons, and reducing taxes by restricting budgets in
other areas, including the already stringent mental health budget.
As part of that cost-cutting policy, Michigan has
recently introduced managed care for the delivery of mental health services
for persons on Medicaid.This, along
with a policy of decentralization and privatization has resulted in a shifting
of responsibility and control from the state to the local community mental
health programs, and in turn to contracting agencies.This
has produced multiple layers of administrative overhead, duplication of
efforts, fragmented and ill-defined programs and loss of control over the
management of public funds.The management
of these funds is thereby removed from public scrutiny otherwise enabled
by the Freedom of Information Act, the Open Meetings Act and competitive
bidding.
Especially in view of the recent economic recession
and the large state budget deficit, these policies of abdication of responsibility
and decentralization of the Michigan public mental health system have resulted
in a further breakdown in the quality, appropriateness and accessibility
of services for persons with serious mental illness.
Michigan will now begin a new state administration.This
provides the opportunity to make the system more efficient, more accountable,
and more responsive to the needs of Michigan citizens.Based
on the experiences of our members and insights into the current administration
of the public mental health system we propose the following changes.
DCH Economies of Scale
1.The
Department of Community Health (DCH) should achieve economies of scale
through improved operating efficiencies and elimination of duplicated effort
(including activities of CMHSP contractors) in administration, development
of policies and standards, development and delivery of training programs
and development and management of information systems.
DCH Leadership
2.DCH
should provide medical leadership and have primary responsibility for adoption
and implementation of advanced medical practices, training programs, treatment
and support programs and review of medical practices.
3.DCH
should conduct pilot programs to validate, refine and establish standards
for improved treatment and rehabilitation programs and techniques.Non-standard
programs of any CMHSP should only be allowed with approval, close supervision
and evaluation by DCH.
4.DCH
should conduct public education and awareness programs to combat stigma
and develop public sensitivity to the plight of persons with mental illness
and their families, the need for treatment and services, and the need for
research.
Standards of Care
5.DCH
should prescribe clear, consistent, state-wide (a)level-of-care
protocols, (b) criteria for determining need for treatment, (c) program
design and performance standards, (d) qualifications for persons providing
direct care and services, and(e)
mandatory services based on the degree of a person’s disability, a hierarchy
of needs, and the current level of funding.
6.Prior
authorization should only be required for extraordinary treatment or services
and only if delay involves no risk to the patient.DCH
level of care protocols should provide sufficient guidance for physicians
to make appropriate treatment decisions.
Accountability for Service Delivery
7.At
least annually, DCH should perform statistically valid studies to determine
the total needs and unmet needs for services in each CMHSP catchment area.These
statistics should be broken out by persons who qualify for Medicaid, those
with private health insurance and those who don’t qualify for Medicaid
and don’t have private insurance.Unmet
needs should include persons underserved or inappropriately served by the
CMHSP as well as unmet needs of persons with inadequate private health
care insurance coverage .
8.DCH
should contract for independent review of CMHSP programs to obtain objective
measures of outcomes, appropriateness of services to clients receiving
them, compliance with program standards, quality of services delivered,
quality of life of clients and those around them and effective management
of funds.
9.DCH
should define required CMHSP reports to be provided to CMHSP board members
and the general public to assure accountability for financial management,
program performance and quality assurance.
10.DCH
should enforce Mental Health Code requirement for each CMHSP to have a
pre-booking jail diversion program.
11.DCH
should be required to place in receivership (i.e., take away board authority)
any CMHSP that mismanages public funds or fails to provide adequate and
appropriate treatment and services to the priority populations as defined
by standards set by DCH and approved by the legislature.
Funding
12.DCH
should maximize funding for services to persons with mental illness from
alternative sources.State funding
should match all available Federal funds such as Medicaid and vocational
rehabilitation.
13.Because
persons with mental illness are not same percentage of the population across
the state, CMHSP funding should reflect the need for services in the associated
community and the level at which the CMHSP meets that need.
14.DCH
should report to the legislature the extent to which a proposed mental
health budget will affect the quality of care and the extent to which persons
in need of services will be unserved or underserved.
Role of CMHSP Board
15.CMHSP
board members should represent community interests, take action to prevent
the recurrence of treatment and service failures, and ensure the quality
and effectiveness of services funded by the CMHSP.This
responsibility should not be delegated to administrators and contractors
as promoted by the Carver Governance training program.Board
members should have access to CMHSP staff, service programs and recipient
grievances and rights complaints to obtain first-hand information on the
effectiveness of CMHSP administration and programs.
16.The
CMHSP board should insist on regular and timely reports on finances and
services for consideration by both the board and the public.
Continuity of Care
17.DCH
should implement regulations and enforcement measures to ensure that transitions
of clients between agencies and systems of care are appropriately coordinated
including the transitions from children’s to adult services, hospital to
community services, jail or prison to community services, and between community
agencies as a result of relocation, changes in contractors or changes in
service needs.
18.CMHSP
case managers should participate in timely treatment planning for their
clients hospitalized, incarcerated or losing access to CMHSP services.
19.DCH
should provide a mechanism by which each CMHSP will identify and provide
appropriate services to citizens of their catchment area when they are
committed for hospital care or incarcerated in jail or prison.
Scope of Services
20.Each
CMHSP should be committed to responsive treatment based on funding priorities
for all persons in their catchment area suffering from a mental illness
including persons living with their families, persons with private insurance,
and persons who do not recognize their need for treatment.The
system should complement alternative support systems and funding sources
to provide needed services not otherwise available.
21.The
CMHSP should assure that the basic needs of persons suffering from a mental
illness are met including food, clothing, safety, shelter, physical and
psychiatric medical treatment and dental care.
22.CMHSP
services provided to individuals should be based both the Mental Health
Code requirement that priority be given to persons with the most severe
forms of disability, and Maslow’s needs hierarchy.
23.Each
CMHSP should make available acute hospital and long-term, sub-acute hospital
care for persons whose psychiatric symptoms merit that level of care without
requiring that they meet commitment standards.Units
providing such care should be within a reasonable driving time of the person’s
immediate family.
Treatment Plans
24.The
individual treatment plan should identify all of the treatment and supports
the client needs to function in the community and promote recovery.The
treatment team should either provide those supports, ensure that those
supports are provided by others or document why the need must remain unmet
due to funding restrictions.
Outreach
25.DCH
and the CMHSPs should have a joint responsibility to educate the public
about the medical basis for mental illness and make the community aware
of the symptoms of persons who should receive mental health services and
the services that are available.
26.The
CMHSP should respond to family and community concerns about individuals
evidencing symptoms of mental illness.The
CMHSP should go into the community, assess the need of an identified person
and attempt to serve a person in need even though they may not be receptive.Furthermore,
the CMHSP should take responsibility for obtaining commitment orders for
persons who meet commitment criteria including those with an inability
to attend to their basic physical needs as provided by the Mental Health
Code.
27.The
CMHSP should be responsible for obtaining and enforcing alternative treatment
orders for persons who fail to recognize their need for treatment.
Role of Families and Advocates
28.Representatives
of consumer and family advocacy groups should have an active role in the
development of policies and programs and monitoring of performance of the
Department of Community Health, CMHSPs and contracting agencies.An
advisory committee of consumers, families and advocates should be established
excluding mental health system employees, board members or service providers.Representatives
should be chosen by the advocacy groups, not by DCH, a CMHSP or a contractor.
29.Families
should be given the opportunity to choose their level of involvement in
the lives of mentally ill family members and should be able to grow old
with the peace of mind that their family member will continue to receive
needed treatment and supports.Clients
should not lose nor receive diminished financial aid when they live with
their families.
30.Failure
of a treating professional to accept and give reasonable consideration
to input from a client’s family or close associates regarding the client’s
symptoms should be considered a serious violation of both the concerned
person’s and the recipient’s rights.
Medical Decisions
31.Medical
decisions, including the medical necessity for support services, should
be made by a physician after face-to-face contact and with the informed
consent of the patient or their legal representative.Denial
of services that may be medically necessary should require a physician
to have face-to-face contact with the client and to document an appropriate
diagnostic evaluation.An overriding
change in the order of a treating physician should only be allowed with
the agreement of two other physicians after face-to-face examination of
the patient.
32.DCH
should establish a peer review system (review of professionals by their
peers) to monitor use of prescription medications by individual physicians
and to assure that clients receive prompt and effective mitigation of symptoms.Physicians
should not be constrained by a formulary or requirement for prior approval.
Client and Family Rights
33.Clients
and their advocates should be given informed choice in the selection of
services, professionals, direct care providers and accredited provider
agencies.CMHSPs should maintain
a resource center and appropriate handout material so that clients and
advocates know what services are available and appropriate for the client’s
disability.This information should
be considered in DCH reviews of CMHSP performance to ensure that clients
are given appropriate, informed choices.
34.CMHSPs
should implement procedures by which clients with impaired judgment will
have independent patient advocates with preferences to establish family
members as guardians or engage participation of family members motivated
to act in the best interest of the client.Patient
advocates should be part of the treatment team.Patient
advocates should be independent of the CMHSP and its contractors, and the
services of professional advocates should be reimbursed by the CMHSP at
a reasonable rate.
35.DCH
standards, programs and policies should recognize mental illness as a long-term
disability like diabetes or multiple sclerosis, and should ensure that
short-sighted efforts to cut costs do not deny clients the opportunity
for recovery nor put them at risk of losing the treatment and supports
that have enabled recovery.
36.All
clients with a mental illness should be referred for diagnostic procedures
necessary to rule out physical causes of their disability such as tumors,
poisons and endocrine disorders.
37.DCH
should develop a brochure for families and other interested persons regarding
their rights such as the right to give information to treating professionals,
the right to receive information about the illness, the right to be treated
with dignity and respect, the right of families of children to pay a reasonable
amount for services, the right to file complaints an dgrievances, and how
to initiate a Medicaid appeal.This
brochure should be given to any person who accompanies a person seeking
treatment, to family members and to other interested persons.
The following important changes are considered
to be beyond the scope of the current public mental health system organization
and would require significant changes in responsibilities and funding.
1.Legislation
or contract language should require that all agencies, public and private,
receiving public funds for the delivery of mental health services, directly
or indirectly, should be subject to the terms of the Freedom of Information
Act (FOIA) and the Open Meetings Act.Appropriate
and timely notice should be provided for meetings using telephone recordings,
web pages and email subscriptions.Notice
should occur no later than when board members are notified.Charges
for documents provided under FOIA should be at a standard rate comparable
to generally available commercial copying services.
2.All
publicly funded contracts should be let through open bidding including
those let by CMHSP contractors.DCH
should establish policies to prevent conflict of interest in both the bid
selection process and contract oversight.
3.There
should be no delegation of risk by CMHSPs to contractors or clients. CMHSP
contracts with local providers should be fee for service.Control
of costs should be through review of individual cases for the appropriateness
of services provided to the condition of the recipient.
4.The
CMHSP should pay for appropriate mental health services provided to all
citizens of their catchment areas in jails and prisons unless the service
is covered by the client’s private insurance.
5.DCH
should promote the adoption of legislation for mental illness parity in
private health care insurance to reduce the diversion of people from private
to publicly funded services and to promote early intervention for persons
with mental illness thus improving the long-term prognosis.
6.The
State of Michigan should implement licensing of direct care workers to
assure proper qualifications, on-going training, and proper conduct.Employers
should be required to report misconduct so that workers cannot avoid responsibility
by seeking employment with another service provider
7.The
Office of Recipient Rights should be separated from the Department of Community
Health, CMHSPs and contract providers, and should employ rights officers
across the state to monitor, investigate and impose penalties for rights
violations.
8.CMHSPs
should be re-organized so that funding and management of programs is not
divided between the CMHSPs responsible for Medicaid spending and those
left with only responsibility for expenditure of general funds.
9.A
system of mental health courts should be established to provide specialized
disposition and follow-up of persons with mental illness who are charged
with a crime.
10.Legislation
should be adopted to require the recognition of advanced directives regarding
choices of treatment, services and service providers by CMHSPs and other
mental health service providers.
11.The
Michigan Medicaid program should be revised to provide entitlement for
medically necessary services that have been defined as alternative services
under Chapter 3 of the Medicaid Manual.
12.The
legislature should adopt a more sensible approach to meeting the need for
persons to continue receiving Medicaid benefitsfor
a life-long disability when they are able to become employed.