Mental Health Legislative Network

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					Executive Summary
What is Mental Illness?
The World Health Organization (WHO) defines mental health as: “A state of well-
being in which the individual realizes his or her abilities, can cope with normal
stresses of life, can work productively and fruitfully and is able to make a
contribution to his or her community.” This state of well-being necessitates an
integrated approach for appropriate and timely care–much more than simply
medical treatment.

Mental illnesses are biological brain disorders that affect about one in four adults
and one in ten children. People affected more seriously by mental illness number
about 1 in 17. Mental illnesses are the leading cause of disability in the U.S. for
ages 15-44; according to WHO, psychiatric disorders account for 5 of the 10
leading causes of disability. Some of the most commonly known illnesses are
ADHD, depression, anxiety, schizophrenia, bipolar disorder, borderline
personality disorder and post-traumatic stress disorder.

Some people need access to basic mental health services. Others need case
management (and/or care coordination) to assist them in locating and
maintaining mental health and social services. Still others need more intensive,
flexible services to help them cope with life in the community.

Minnesota Responds
Although we have increasingly effective treatments and rehabilitation, the current
mental health system fails to respond to the needs of many children, adults and
their families. Access to full mental health benefits is limited. Too often people get
worse while waiting for services, when earlier treatment would help to avoid
complications. Affordable housing, community supports and employment
supports are sorely lacking statewide. Treatment and support to children at their
schools and homes is difficult to obtain. An aging demographic exacerbates the
workforce shortage created by longstanding inadequate wages and benefits for
mental health providers.

The highest cost of these problems is a human one, but there are severe financial
repercussions as well. Lack of care and treatment can result in a high percentage
of adults who are homeless or incarcerated due to mental illness. The problem is
especially striking among youth: 70% of juveniles in the justice system have a
mental health diagnosis.




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Early intervention could result in savings of millions of dollars by The Department
of Corrections (DOC), which now incarcerates adults and children with mental
health disorders.

While the mental health system has been overburdened for some time, recent
events may cause an even deeper crisis. The global economic crisis has resulted in
the loss of jobs, homes, health insurance, and stability for many Minnesota
families. The Mental Health Legislative Network (MHLN) is especially concerned
that in these economic hard times a fragile mental health system will become
broken as more people seek care, as more people are un- or under-insured and if
payment rates are reduced.

The following three issues are among the top concerns for Minnesotans with
mental illnesses and the providers who serve them.

General Assistance Medical Care (GAMC)
Covering nearly 86,000 Minnesotans on an annual basis, General Assistance
Medical Care is a critical resource in providing necessary healthcare to those who
do not have resources, yet do not qualify for other kinds of health insurance. It has
been a safety net for those facing catastrophic injury or chronic conditions, while
alleviating the crisis of uncompensated care for the state’s hospital and health care
systems. Due to budget cuts and unallotment, GAMC will end in March if action is
not taken.

An overwhelming majority of Minnesotans on GAMC have received mental health
services, and we know that many of these individuals are among the state’s most
vulnerable populations. The current plans to transition these individuals to
MinnesotaCare is shortsighted: many will fall through the cracks and re-enter the
health care system in crisis and receive uncompensated care. Hennepin County
Medical Center and other providers have already sounded the alarm that they face
substantial service cuts if uncompensated care continues to rise. In addition, the
MinnesotaCare system faces its own challenges, projected to run a deficit by fiscal
year 2012-2013.

Cuts to GAMC target Minnesotans facing mental illness, poverty, and
homelessness, as well as jeopardizing health care providers.

For more on the GAMC, please see page 5 in the main document.




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Maintenance of Effort (MOE)
County-based services are a critical part of Minnesota’s response to serious mental
illnesses. Since 2006, the state has measured the adequacy of those services by
requiring that counties continue to provide services based on spending made in
2004-2005. This framework is known as “Maintenance of Effort.” While many
counties are facing significant budget issues at this time, services abandoned in the
budget crisis are unlikely to be restored. Mental health consumers and their
advocates are concerned that efforts to reform the MOE system will simply amount
to service cuts by another name.

The elimination of localized mental health services would likely lead to more
costly emergency related services provided by the criminal justice and health
care systems.

For more on MOE, please see page 6 in the main document.

Mental Health Acute Care Needs
The 2008 Legislature directed the Department of Human Services (DHS) and the
Minnesota Department of Health (MDH) to develop recommendations to reduce
the number of unnecessary patient days in acute care facilities. This collective
effort has provided the focus and reasoning behind many of the recommendations
in this document.

The Acute Care Needs Report outlines a significant opportunity to both improve
patient outcomes and manage costs.

When we are able to provide the intensity of services in community settings, a
crisis and hospitalization can be prevented. For those who have been hospitalized,
identifying resources and more substantial discharge planning can prevent
readmission. We believe that the best medical and financial outcomes come from
delivering services in the communities where they are required, not in
concentrating patients into hospital settings.


For more on the Mental Health Acute Care Needs Report, please see page 10 in the
main document.




           For a glossary of terms and acronyms used in this document,
                                 please see page 34.




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Table of Contents

EXECUTIVE SUMMARY .......................................................................................... - 1 -
TABLE OF CONTENTS .............................................................................................- 4 -
CRITICAL ISSUES FOR 2010 ................................................................................... - 5 -
   TERMINATION AND UNALLOTMENT OF GENERAL ASSISTANCE MEDICAL CARE (GAMC) .................... - 5 -
   MAINTENANCE OF EFFORT ................................................................................................................. - 6 -
   STATE OPERATED SERVICES REDESIGN .............................................................................................. - 7 -
   PERSONAL CARE ASSISTANCE PROGRAM ............................................................................................ - 8 -
MENTAL HEALTH ACROSS THE LIFESPAN ......................................................... - 10 -
   MENTAL HEALTH ACUTE CARE NEEDS REPORT ............................................................................... - 10 -
   ACCESS TO EFFECTIVE TREATMENT ................................................................................................... - 11 -
   PUBLIC AND PRIVATE HEALTH INSURANCE COVERAGE .................................................................... - 12 -
   PAYMENT REFORM ........................................................................................................................... - 13 -
   QUALIFIED PERSONNEL: LICENSED SOCIAL WORKERS ..................................................................... - 14 -
   WORKFORCE SHORTAGE .................................................................................................................. - 14 -
   CLINICAL SUPERVISION .................................................................................................................... - 16 -
   CULTURAL RESPONSIVENESS ............................................................................................................ - 17 -
   MENTAL HEALTH DISORDERS AND AGING ....................................................................................... - 18 -
   VETERANS ........................................................................................................................................ - 19 -
   CO-OCCURRING MENTAL ILLNESS AND CHEMICAL DEPENDENCY .................................................... - 20 -
   CRISIS SERVICES .............................................................................................................................. - 20 -
   SUICIDE PREVENTION ...................................................................................................................... - 21 -
   INVOLUNTARY ELECTROCONVULSIVE THERAPY (ECT) ..................................................................... - 22 -
CHILDREN’S MENTAL HEALTH ........................................................................... - 24 -
   CHILDREN’S SERVICES ..................................................................................................................... - 24 -
   EDUCATION...................................................................................................................................... - 25 -
   DAY TREATMENT ............................................................................................................................. - 26 -
   JUVENILE JUSTICE ........................................................................................................................... - 27 -
ADULT MENTAL HEALTH..................................................................................... - 29 -
   EMPLOYMENT .................................................................................................................................. - 29 -
   HOUSING ......................................................................................................................................... - 30 -
CRIMINAL JUSTICE .............................................................................................. - 31 -
   POLICE RESPONSE TO CRISIS............................................................................................................ - 31 -
   DISCHARGE PLANNING..................................................................................................................... - 31 -
   MENTAL HEALTH COURTS ............................................................................................................... - 32 -
   MENTAL HEALTH FATALITY REVIEW TEAM...................................................................................... - 32 -
   INSANITY DEFENSE .......................................................................................................................... - 33 -
GLOSSARY OF TERMS...............................................................................................34


            For additional copies or if you have questions, please contact
           NAMI Minnesota at 651-645-2948, 1-888-NAMI HELPS or the
      Mental Health Association of Minnesota at 612-331-6840, 1-800-862-1799.




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Critical Issues for 2010
Termination and unallotment of General Assistance
Medical Care (GAMC)
GAMC is a state health care program for adults aged 21-64 who are very low
income, do not have dependent children, and do not currently qualify for federal
health care programs such as MA. There are nearly 86,000 persons in Minnesota
relying on GAMC; 70% of them have mental illness, chemical dependency or both.
GAMC enrollees fall into two major groups—those who need hospital coverage for
a catastrophic event; and those with chronic, ongoing health care needs who are
limited in their ability to work, but haven’t quite qualified as “disabled”. Health
care providers, including mental health centers, mental health crisis homes,
emergency rooms and hospitals have relied on GAMC as a way to deter
uncompensated care. Due to a veto and unallotment by the governor, funding for
GAMC will end around March 1, 2010.

Some individuals will be identified by the state and counties as potentially eligible
for MA due to disability. Hopefully, these individuals will be diverted to the State
Medical Review Team (SMRT) process and will receive the necessary assistance to
document their disabilities and become eligible for MA.

DHS has announced that persons on GAMC will automatically have their coverage
converted to “Transitional MinnesotaCare”. During this one to six-month
transition time, the counties will be responsible to pay the monthly premiums.
After that, the person must complete a new application for regular MinnesotaCare
and will be responsible for premiums and co pays. Many individuals who are
homeless, functionally impaired or vulnerable will fall off the rolls at this point in
the process and become uninsured because they cannot afford the premiums or
have difficulty understanding the application forms. They will be unable to get the
care they need and their conditions will worsen. This is expected to critically
burden hospitals, mental health service providers and law enforcement, and lead
to costs that in the long run will outweigh any savings garnered by terminating this
critical program. The addition of thousands of persons to the MinnesotaCare rolls
will jeopardize the viability of the Health Care Access Fund (HCAF), which funds
MinnesotaCare and is already projected to run at a deficit in 2012-13.

While the MinnesotaCare transition plan may sound like a reasonable alternative,
the limited benefits of MinnesotaCare will clearly fail to meet the GAMC
population’s most serious needs. Here are some significant examples:
    GAMC begins the day the county agency receives the application or for
       hospital coverage, the day of hospitalization. With MinnesotaCare, coverage
       does not begin until the month after payment of the first premium. This




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      means that many persons will have serious gaps in coverage, especially
      those who are hospitalized.
     Even if MinnesotaCare coverage is available for hospitalization, the limit of
      $10,000, with a $1,000 deductable for hospital care is far from sufficient to
      prevent heavy debt burdens to the individual and the hospital provider.
     The monthly premium requirement is a significant financial and functional
      barrier to coverage for many persons with mental illnesses and will result in
      these vulnerable persons becoming uninsured.
     MinnesotaCare only covers emergency transportation (ambulance) and
      does not provide special transportation or access transportation to
      appointments. This will be a severe impediment to timely and ongoing care
      for those with chronic health needs.

Policy recommendations:
     Reinstate the GAMC program and provide a secure source of funding.
     In the alternative, extend the GAMC benefit set to MinnesotaCare, including
      realistic hospital coverage and access to transportation coverage.
     Allow MinnesotaCare “same day coverage” to the date of application and
      create long-term alternatives to monthly premiums to prevent gaps in
      coverage.
     Increase provider tax or another alternative to extend or supplement the
      HCAF.
     Monitor the SMRT process to ensure that it is effectively assisting potential
      MA recipients, correctly determining disability status, and transferring
      eligible persons to MA and related disability income benefits.
     Develop health care home models for consistent delivery of needed health
      services and preventive care.

Maintenance of Effort (MOE)
Many mental health services need county funding. In 2006, the legislature
required counties to “maintain” their funding levels at the same amount as they
did in 2004 and 2005. This last session, due to economic crisis, counties sought
flexibility under these MOE provisions.

An agreement was reached that provided clarity on how to determine base levels
and allowed some flexibility on major changes experienced by a county. As the
economic crisis worsens, the MOE system may come under further pressure.
While many counties face financial difficulty, it would be short sighted to allow
further reductions in mental health services and would add additional costs.
The 2009 Legislature required the Commissioner of Human Services to propose an
alternative means of funding and providing services. The proposal will create a
new consolidated county property tax contribution across all mandated health and




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human services programs that will function as an equalized levy. However,
without a specific proposal on the table, advocates are unwilling to abandon MOE.

A competing effort to reformulate state requirements for county services was also
passed in 2009. A State-County Results, Accountability, and Service Delivery
Redesign Council will be established with representatives of counties, legislators
and unions. The council will review and certify the formation of service delivery
authorities (SDA) either in a large county or a group of counties. These SDA’s
could obtain waivers from current laws in order to change the delivery of human
services. There is no guarantee that new delivery methods will work as intended,
or that these changes will not amount to service cuts.

The difficulties faced by many county governments are real. However, the current
proposals to address these concerns are likely to come at the expense of mental health
consumers. Instead of clarity, these proposals have created greater uncertainty over
sources of funding and service provision requirements. Without adequate input from
consumers and their advocates, these reforms run the risk of damaging the mental
health system they are intended to repair.

Policy Recommendations:
   Do not allow any further reductions of county funded human services.
   Require that service changes reflect the input of mental health advocates.

State Operated Services (SOS) Redesign
The 2009 omnibus human services bill required DHS in consultation with
stakeholders, to transform the current Anoka Regional Treatment Center (RTC)
into an array of community-based programs that have sixteen or fewer beds. The
planning was to be completed by October 1, 2009 with a report to the legislature by
November 30, 2009. In early summer, the Governor unalloted over $5 million
dollars from the SOS budget and at this time they are looking at a budget shortfall
closer to $15 million. Thus, DHS is looking to reorganize all of SOS.

Currently, state operated Community Behavioral Health Hospitals (CBHH) are
functioning with about 50% of the 160 beds filled. Of these, assessments indicate
that about 50% of the patients meet the criteria for inpatient acute hospital level of
care. All of these facilities operate on “appropriations-based budgeting”-- the
legislature appropriates funds and the collections go to General Fund to offset
appropriations. Of the ten community behavioral hospitals, four are certified by
CMS to accept Medicaid or Medicare payments—the revenue from creating the
sixteen bed CBHH facilities is far below forecasts, even without the unallotments
and cuts following the 2009 session.

Advocates strongly believe that a consensus needs to be developed on the role of
SOS, the identified needs in each region and how state operated services can work



                                         -7-
with community providers to meet them, and how the needs can be met most
efficiently and cost effectively.
Such significant changes must be vetted through dialogue and shared decision
making with those affected by the decisions, including consumers, family
members, community providers, counties, hospitals, and other stakeholders. As
an arm of the state, potential conflicts of interest must be carefully managed to
avoid undo concentration of authority, potential disruption and dislocation of
existing community-based services.

Policy Recommendations:
    Engage the consumers, family members, community providers, and
      counties in the redesign.
    Preserve financial commitment to mental health services.
    Reform payment models to support and reward best practices and enable
      providers to deliver the right combination of services, at the right level of
      intensity, and in the right locations, regardless of whether it was state-
      operated or not.
    Adopt a plan to de-emphasize the role of the state as a provider while
      strengthening its role as a policy-maker and purchaser.
    Reaffirm the state’s role in a redefined safety net that is based on policies
      and payment practices rather than its provider role.
    Explore “partnerships” that support and strengthen, but not supplant, the
      capability of community providers and local systems of care.
    Fix the policies and financing problems that create or sustain the gaps that
      SOS seeks to fill.

Personal Care Assistance (PCA) Program
PCA services are provided to people who need assistance in their own homes,
which allows them to retain more personal independence and connections to their
community. Today, an average of 14,500 persons with disabilities, including
mental illness, live at home in Minnesota’s communities with the help of PCA
services obtained through the fee-for-service MA program.

Because of growth in the PCA program over time as more persons used this service
option to help them remain in the community, and because of instances of fraud
coupled with poor oversight by DHS, PCA services were significantly cut during the
2009 Legislative Session. Hours of service were cut and restrictive eligibility
criteria were imposed, along with important changes to increase oversight and
reduce fraud. Unfortunately, due to the 2009 legislative changes, many persons
with mental illnesses, both children and adults, are expected to lose this vital
service. Although the 2009 Legislature allocated $8 million in 2012-13 to develop
alternative services for persons with mental illnesses, these alternatives are
unlikely to fill the void created by the new restrictions on access to PCA services.




                                        -8-
PCA services have been available statewide, unlike some mental health services.
Both children and adults with mental illnesses have been able to utilize PCA
services as part of a plan of care to help them function in their home and
community. In part because of the availability of PCA services to persons with
mental illnesses, Minnesota has been able to significantly reduce the use of
institutional services. PCA services are an essential part of Minnesota’s
community support service system for children and adults with mental illnesses
and other disabilities.

Policy Recommendations:
      Amend PCA eligibility criteria as needed to assure that children and adults
       with mental health diagnoses or behavioral problems have continuing
       access to ongoing help in order to function effectively in their homes and
       communities.
      Develop and implement any alternative services in a way that ensures
       assistance without interruption for those who may lose eligibility due to
       2009 changes in eligibility criteria.
      Continue to improve the assessment process to increase the quality of the
       review of the person’s need for assistance, and the implementation of
       services that will maximize independence and recovery for persons with
       mental illnesses.
      Improve accountability with consistent rules, uniform processes and
       standard documentation formats for all PCA services, whether provided
       through fee-for-service or managed care plans and implement annual
       reporting on outcome measures.
      Assure that new requirements for referrals to other mental health and
       support services are properly implemented by training assessors and PCA
       agency staff and providing specific contact information on available services
       accessible within the person’s geographic area. Data on referrals of PCA
       recipients to mental health services and other home care services made,
       subsequent services obtained and client outcomes should be reported by
       counties, tribes and health plans quarterly to DHS for public dissemination.




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Mental Health Across the Lifespan
Mental Health Acute Care Needs Report
The 2008 Legislature directed DHS and MDH to develop recommendations to
reduce the number of unnecessary patient days in acute care facilities. The
workgroup was also charged with developing recommendations on how to best
meet the acute care mental health needs of children, adolescents and adults. An
examination of current and future workforce issues and recommendations to
address any shortages was also a required part of the report.

A set of recommendations specific to each of the three areas was developed. A
good number of the recommendations can be accomplished without legislation or
additional funds. Many of these related to continuity of care issues requiring
improved communication between and coordination among the various levels of
care and including the individual and his/her family in developing and
understanding the plan of care.

This report found that Minnesota needs to address the location, availability, and
nature of intensive services. If this system works more effectively, the state could
reduce preventable hospitalizations in individuals with complex needs. Minnesota
needs to objectively establish goals and metrics that determine where barriers and
pressure points exist within the system, preventing transition across all levels of
care. With a chronic care model of treatment and services, the state can better
address the growing number of individuals with challenging diagnoses, including
complex co-morbidities including medical care and cognitive deficits.

In a crisis situation, individuals tend to either receive services that are escalated
through 911 and emergency rooms, or not receive services at all. Many individuals
lack access to mental heath services outside of business hours, on weekends and
holidays, other than through an emergency room. Hospitals and emergency
dispatchers could increase referrals and improve collaboration with crisis response
teams that can better address these needs. The end result needs to be focused on
delivering services in the communities where they are required, not in
concentrating patients into hospital settings.

Policy Recommendation:
         Direct DHS to implement the findings of the Report and to provide the
          Legislature with the projected costs and savings associated with the
          plan.




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Access to Effective Treatment
Improved outpatient and community-based care consistent with recognized best
practices adds cost and includes numerous non-billable activities, however, the
results are improved outcomes, satisfaction and overall cost-savings. It is
important to note that anticipated federal changes in coverage for targeted case
management could limit these activities, which would hamper the effectiveness of
community supports.

Through research and practice the mental health community has identified
services that are effective in treating mental illnesses. New treatment modalities
must be funded and coverage updated to support known best practices for
Minnesotans who would benefit from them.

The common benefit set developed by the Minnesota Mental Health Action Group
should be a core component of all proposed health care reform plans. The MHLN
recommends a statewide consistent mental health benefit package that includes
proven and effective treatments as the common benefit standard for public and
private health plan coverage. All of the mental health benefits under MA,
MinnesotaCare and GAMC are the same and include services such as Assertive
Community Treatment (ACT), Adult Rehabilitative Mental Health Services
(ARMHS), Children’s Therapeutic Services and Supports (CTSS), Intensive
Residential Treatment Services (IRTS), Adult Crisis Services; and Case Management
or Care Coordination. However, there is limited access to these services under
private insurance coverage.
                                                                                     Formatted: Bullets and Numbering
  Policy Recommendations:
    Add family psycho-education, care management and collateral contacts to
     support an individual treatment plan as components of outpatient
     community mental health clinic services, ARMHS and CTSS.
    Add intensive mental health outpatient treatment, care management and
     collateral contacts as covered services under MA.
    Ensure long-term accountability and solid evaluation of mental health
     programs, providers and treatment outcomes.
    Authorize “person-centered behavioral healthcare home” models for
     children with a serious emotional disorder and adults who live with a
     serious mental illness either through MA or an initiative.
    Promote and support screening and routine monitoring of key medical risk
     factors (such as blood glucose, lipids, and body mass) in mental health
     clinics for people living with serious mental illness.
    Encourage, educate, and support practice agreements and payment reform
     to support two-way partnerships between mental health centers and
     community health/primary care clinics.




                                       - 11 -
Public and Private Health Insurance Coverage
Without access to health insurance coverage, including full mental health benefits,
people have difficulty obtaining the necessary treatment for their or their family
member’s mental illness. While Minnesota has a low percentage of people who are
uninsured, more must be done to ensure universal coverage, with comprehensive
benefits that help avoid financial burden and risk due to illness, including mental
illness.

The current four month waiting period under MinnesotaCare interrupts the
continuity of care that is so important in treating a mental illness. Many people
with a mental illness who are working part-time or at temporary jobs depend on
MinnesotaCare to cover the cost of their mental health treatment.

Each year in Minnesota, approximately 600 youth in foster care become 18 without
being prepared to leave home. Because these youth have been removed from their
families and have not been given permanent families, turning 18 means they are on
their own. According to national studies, 80% of youth in foster care have received
services for mental health during their placement. 54% have a mental health
diagnosis after leaving care. Access to health care coverage of community-based
services are essential to preserve the treatment gains and address emerging issues
so prevalent in this age range.

The Drug Formulary Committee makes important decisions about what medications
are covered under Minnesota’s publicly funded health care programs. It is difficult,
however, to know what drugs are being considered, how someone is appointed, etc.
This information should be readily accessible for all who need it.

Policy Recommendations:
      Eliminate the four-month waiting period under MinnesotaCare.
      Allow children who have inadequate mental health coverage to access
       MinnesotaCare.
      Cover the common mental health benefit set in any “cover all kids”
       proposals.
      Increase the number of consumers in the composition of the Drug
       Formulary Committee.
      Require all new health care access proposals to comply with existing Minnesota
       mental health parity laws.
      Expand the model mental health benefit set to the state employee plans and
       for dependents up to age 25.
      Ensure full access to antipsychotic medications under state regulated
       managed care plans.
      Reduce the effect of asset limits on eligibility for Minnesota Healthcare
       Programs.



                                       - 12 -
      Ensure that any Essential Benefit Set adopted through health care reform
       include comprehensive mental health services at parity with other covered
       care and treatment, the Essential Benefit Set should include the full range of
       services currently covered by MA.

Payment Reform
Mental health services have been historically underfunded and have a
reimbursement system that rarely considers the actual cost of services. When
mental health providers are consistently underfunded, year after year, the quality
of service becomes eroded and ultimately access to mental health services is
impaired. Funding must be increased and methodologies developed that reflect
the true cost of providing much needed services.

Policy Recommendations:
    Include reimbursement of the originating facilities fee for telehealth services
     to cover clinic costs and broadband connections under MA.
    Increase payment rates to providers in a number of areas including rebasing
     and revising method of setting rates for certain services.
    Create payment methods for intensive, continuous, coordinated, “packaged”
     services, “team care”, client registry to track progress, care coordination, co-
     location, family consultation and psycho-education positioned to be
     consistent with “chronic care model” for people with mental illness and
     those with co-occurring mental illness and other health conditions.
    Direct DHS to fix claims edits and oddities that undermine best practices
     and federal compliance and reduce duplicative and conflicting rules,
     licensing/certification, and fidelity reviews.
    Change payment rates for crisis residential services to be cost-related.
    Extend 2007 rate increase to all community mental health center services
     and all mental health professionals.
    Study the impact of paying Community Mental Health Centers (CMHC)
     services similar to Federally Qualified Health Centers.
    Reimburse travel for ARMHS, CTSS, and CMHC satellite offices.
    Reimburse for assessment and treatment planning activities as clinical
     services consistent with Federal HIPAA standards: mental health and
     chemical health screening, functional assessments, collaborative treatment
     planning, direction/supervision of MH practitioners, re-assessments and
     treatment plan modification based on new clinical and functional
     information.
    Add CMHC to the list of providers that routinely receive COLA increases.
    Reimburse staff completing licensure at a clinical supervisor’s rate.




                                       - 13 -
Qualified Personnel: Licensed Social Workers
In 1987, county, city and state social workers were exempted from new licensure
regulations established for all other social workers. Removing this exemption from
licensure is necessary to ensure public protection. When government employed
social workers are licensed, clients and their families may be confident that the
social workers meet professional standards for education, examination,
supervision, and continuing education. The licensing board, rather than an
employer will hold social workers accountable and will resolve complaints the
public makes against incompetent or unethical social work practice.

Licensing complements client protection provided by DHS Fair Hearings process.
Fair hearings focus on decisions made and services offered by county social service
agencies while licensing focuses on the competencies of individual social workers
and maintenance of professional standards.

Policy Recommendation:
      Remove the licensure exemption for county, city and state social workers.

Workforce Shortage
For many years Minnesota has experienced a shortage of providers of mental
health services. As the mental health system has begun to move toward evidence-
based mental health treatment, best practices, and a focus on recovery, the need
for changes in the education and training of the mental health workforce has
become clear. As the population in Minnesota becomes more diverse, the need for
the mental health workforce to reflect the people of Minnesota increases.

Psychiatry, psychology, clinical social work, psychiatric nursing, marriage and
family therapy and professional clinical counseling are often considered the “core”
mental health professions. Currently, 70 of Minnesota’s 87 counties meet federal
criteria as mental health professional shortage areas. Statewide, Minnesota has
about 33 percent fewer psychiatrists per capita than the national average and
shortages in rural areas are particularly critical. The shortage of child and
adolescent psychiatrists is even greater, with 4.6 child psychiatrists per 100,000 as
compared to 6.7 nationally.

Workforce data on the remaining core mental health professions, such as
psychology and social work are limited to licensing information collected by the
state’s regulatory boards. These records also show disproportionate under-
representation in rural counties. Community mental health programs cite large
turnover rates for both licensed and entry-level employees. For example, 45 out of
87 counties show mailing address for five or fewer licensed independent clinical
social workers (LICSW). Of those 45 counties, nine show no mailing address for
LICSWs.



                                        - 14 -
Historically, poor reimbursement rate in public mental health programs has
contributed to the problems of attracting and retaining mental health
professionals. In 2006 and 2007 an increase of 23.7% was approved for
psychiatrists and advanced practice registered nurses (APRN) and “critical access
mental health providers” providing care covered by medical assistance. However,
not included in this increase were essential community mental health services such
as adult day treatment, partial hospitalizations, crisis services, ACT, IRTS, MH-
Targeted Case Management, and certain key service components of CTSS and
ARMHS.

Minority ethnic communities find it difficult to find culturally responsive providers
and therefore do not easily find access to mental health services.

Improved payment to mental health providers increases consumer purchasing
power, attracts qualified professionals to public service and improves earlier access
to treatment and supports saving money and time. Increased reimbursement
enables agencies to hire and supervise qualified workers, which reduces turnover
and also saves time and money. Without adequate salaries, qualified mental health
professionals leave their careers.

Minnesota has had several workgroups designed to address workforce issues
including the Minnesota Psychiatric Society Task Force, Minnesota Mental Health
Action Group, and the Mental Health Acute Care Needs Report Task Force.
Despite these efforts, little progress has been made.

Policy Recommendations:
    Establish an education loan forgiveness program for newly graduated
     mental health professionals and current mental health professionals who
     provide services to underserved geographic areas.
    Change training to include developing expertise in the provision of
     integrated (health care and specialty mental health) care; interactive video
     technologies; and, medical home models that embed care coordination in
     the primary or specialty care practice.
    Improve reimbursement rates for professional services delivered in hospital
     settings as a way to improve recruitment and retention.
    Increase the use of advanced practice registered nurses and physician
     assistants and allow greater flexibility in practice and training incentives.
    Amend the staff qualifications for mental health rehabilitation workers to
     enable workers employed by certified provider entities to start providing
     services with less prior work experience than required in current law. For
     staff who qualify under this change, enhance the on the job supervision and
     training requirements during the first 2000 hours of employment.




                                        - 15 -
      Allow physician assistants, clinical nurse specialists, and nurse practitioners
       the same reimbursement for medication management as psychiatrists.
      Provide additional professional development training or training grants to
       local mental health agencies and licensed or certified community mental
       health programs.
      Teach practical diagnostic assessment, treatment and documentation skills.
      Recruit practicing mental health professionals for mental health training
       programs.
      Offer classes for social work and chemical dependency counselors at tribal
       colleges.
      Provide better training in registered nurse programs on mental illness.

Clinical Supervision
Licensed professionals that provide mental health services include marriage and
family therapists, clinical nurse specialists, professional clinical counselors,
psychologists and clinical social workers. To become mental health professionals,
students study course work in the classroom, and spend hundreds of hours
practicing what they’ve learned in internships under the direction and evaluation
of clinical supervisors. Once they’ve graduated, licensure laws require all new
professionals to practice for two more years under clinical supervision, receiving
200 hours of this specialized training.

Mental health professionals, like teachers and physicians in residency, must
practice under the direction of experienced supervisors as they prepare to serve
clients with mental illness competently and ethically. Book-learning alone isn’t
enough.

In addition to these professional licensing requirements, clinical supervision is a
program requirement for services delivered by non-licensed staff working within
certain certified programs such as adult mental health rehabilitation, day
treatment, partial hospitalization, and children’s therapeutic support and services.
Current payment methods do not cover the added cost of redirecting professional
staff to fulfill this function.

This training and supervision system, critical to public protection, is breaking down.
Due to budget cuts, agencies have been forced to cut back, or cut out providing
clinical supervision to interns and new graduates. Internships for students are
disappearing and fewer qualified supervisors are available to provide essential
clinical supervision to new professionals directly on the job, within clinics or
agencies, where it is most effective. Currently some agencies have instituted a policy
against hiring new graduates because of their low MA reimbursement rates and their
need for supervision. As a result, fewer mental health professionals will be licensed
and fewer Minnesotans needing mental health services will get them.




                                        - 16 -
Policy Recommendations:
    Authorize MA reimbursement for specific client related clinical supervision
     activities required as a condition of payment for a certified program or
     board-eligible staff completing licensure requirements.
    Authorize MA to cover certain clinical aspects of clinical supervision in
     CTSS, ARMHS, IRTS, crisis services, ACT, and Peer Support Specialists.
     This includes collaborative treatment planning with a clinical supervisor
     and practitioner, direction of mental health practitioner by professional,
     assessment updates, and review of client functioning and progress.
    Authorize MA to reimburse for services delivered by a practitioner
     completing their supervised practice requirements for licensure at the same
     rate as would be paid for services by the supervisor.
    Expand the settings within which these licensed professionals can be eligible
     providers of mental health services to include CTSS certified agencies.

Cultural Responsiveness
Minnesota is becoming increasingly diverse. Population changes will have an
impact on both access to and effectiveness of mental health services. Stigma about
mental illness and the lack of culturally responsive mental health professionals are
key factors in addressing access to care.

The Wilder Foundation 2006 study found that youth from minority racial or ethnic
groups were one-third to one-half as likely to receive mental health services as
white youth. Completion of treatment and quality were also different, with African
American youth being less likely to complete treatment.

Mental health treatment disparities were cited in the state’s federal block grant
application as an issue to be addressed. While much of the research in this area has
focused on African Americans, the results may well apply equally to other groups.

In an article in Psychiatric Services, December 2005, the authors cited disparities
in both access to and quality of mental health services for racial and ethnic
minority groups. They found that there was inadequate early detection, high drop
out rates from treatment, and inappropriate use of antipsychotic medications with
African Americans. A 2005 report by the federal agency, Substance Abuse and
Mental Health Services Administration (SAMHSA) stated that while disparities are
reduced, there is a lower use of counseling or therapy by African Americans; and
African Americans with higher income and education levels are less likely to access
mental health treatment.

A 2008 study submitted to the MN Board of Social Work states: “Comparing the
number of licensees who identify themselves from a minority ethnic group with the




                                       - 17 -
numbers of minority populations within the state, it is easily observed that this is
an underserved area of great concern.”

Policy Recommendations:
    Continue funding loan forgiveness programs to prepare providers from
     ethnic minorities with the qualifications to be eligible for third party
     reimbursement, including loan forgiveness and scholarships for
     bilingual/bicultural aspiring providers.
    Ensure children are placed in foster homes or treatment facilities that have
     culturally responsive providers and programs.
    Provide affordable and easily accessible interpreter services for all children
     and families who are not proficient in the English language and need mental
     health services and look at requiring health plans to include a certain
     number of culturally responsive providers in their network.
    Require cultural training and responsiveness as a requirement for licensure
     and licensure renewal.
    Provide grants to allow bridging between mental health community and
     ethnic communities, including stipends for internships for bilingual and
     bicultural providers.
    Continue to fund grants to nonprofit organizations that ensure that
     culturally responsive mental health services are provided to individuals
     throughout the state.

Mental Health Disorders and Aging
In the state action plan, Blueprint for 2010-Preparing Minnesota for the Age
Wave and Beyond, we are advised that the number of Minnesotans over age 65
will double, rising to 1.3 million by 2030, representing 20% of the state’s
population. Among the recommendations for urgent action is reform of health and
long-term care with emphasis on preparing the mental health and substance abuse
systems to meet the increased demand for services for older people.

Today the rate of suicide is highest among older adults compared with any other
age group. In Minnesota, persons 75-84 years of age have the highest suicide rate.
Untreated depression complicates the healing process for hip fractures, heart
attacks and cancer resulting in increased hospitalization, poorer physical function
and quality of life, and impaired pain control (Focusing on Older Adults with Co-
occurring Behavioral Health and Medical Disorders, 2005).

Older persons are more likely to receive inadequate, inappropriate or no mental
health care at all, compared to younger persons. Despite considerable research
demonstrating that there are effective treatments for late-life mental disorders,
there is a profound gap between those findings and the actual clinical practice in




                                        - 18 -
care settings for older adults. (Stephen Bartels, MD, testimony to Policy
Committee, White House Conference on Aging, January 2005)
                                                                                        Formatted: Bullets and Numbering
  Policy Recommendations:
      Improve professional education for geriatric care in the mental illness and
       substance abuse treatment systems.
      Invest in peer-counseling services through mental health initiative grants
       throughout the state.
      Require health plans in Minnesota to provide mental health parity in age
       specific services, reimbursement rates, and individual co-payments in
       Medicaid and Medicare Supplemental plans.
      Take advantage of training funds available through The American Recovery
       and Revitalization Act of 2009 (ARRA) to establish programs for the
       education of mental health professionals to develop specialties in the area of
       geriatric mental health.
      Provide cross training between older adults and providers and mental
       health providers.
      Improve mental health screening and follow-up care in long-term care
       settings and services.

Veterans
Post-traumatic Stress Disorder (PTSD), is an anxiety disorder than can develop
after a person witnesses a traumatic event such as combat. In wars prior to
Vietnam, the disorder was referred to as “shell shock” or “battle fatigue” and was
not very well understood beyond the fact that it limited the soldier’s performance
on the battlefield. Today the disorder is more widely studied. We know, for
example, that PTSD can lead to other mental health problems, such as depression,
social withdrawal, and substance abuse.

There are differing statistics with regard to returning soldiers from Iraq and
Afghanistan. Some state that 1 in 5 have depression or stress disorder and 14% will
develop PTSD. Only about 50% of those affected seek treatment and 50% of those
received appropriate treatment.

Outreach to Minnesota veterans goes beyond what is currently provided by the
federal government; however, more is required to ensure their mental health.

Policy Recommendations:
      Continue funding for the vet connection program.
      Continue funding for the hotline.
      Fund diversion programs and mental health courts.
      Provide support and services for family members during re-integration.




                                        - 19 -
Co-Occurring Mental Illness and Chemical Dependency
Co-occurring disorders have become the expectation rather than the exception,
often complicating recovery. However, various rules, reimbursement methods and
program standards create barriers to delivering services that are evidence-based
practices. Such barriers include services that are not available on the same day;
denials based on confusion over the primary disorder; eligibility conflicts;
inflexible funding that cannot be combined in a program for co-occurring
disorders. As a result, people experience delays in receiving the right combination
of services and frequent relapse.

Minnesota received a Federal grant to assist providers in learning new skills and
modifying their services to provide a continuum of services for consumers with co-
occurring disorders. Among the lessons learned from the project: several changes
to payment methods and rules are needed if these services are to be sustainable
and available.

Policy Recommendations:
     Fund demonstration projects to provide intensive residential services for
      those with serious mental illness and serious chemical dependency.
     Provide reimbursement for a combination of outpatient clinic,
      rehabilitation and case management services consistent with evidence-
      based practice called “Integrated Dual Disorder Treatment.”
     Authorize MA to cover “Screening and Brief Intervention” for alcohol/drug
      abuse by mental health centers, providers of CTSS, primary care,
      emergency rooms, and crisis service providers.
     Provide grants, for services not covered by health programs, to offset the
      non-billable activities and related costs associated with delivering services
      to this priority population.
     Co-locate mental health professionals in detox centers.

Crisis Services
A variety of crisis services provide an essential safety net for persons with mental
illness and their families. Mobile crisis teams can go to a person’s home, assess the
situation and provide services to help stabilize the individual who is in crisis.
There are urgent/crisis services at mental health centers/clinics. Crisis homes
provide a safe place where people can live for a few days while they receive
supportive therapy, stabilization, monitoring and transition to other services.
These are cost-effective ways of dealing with a mental health crisis and can prevent
people from going into the emergency rooms at hospitals or even prevent a police
response.




                                       - 20 -
The 2007 legislative session did realize funding for these important services. But
more must be done to ensure that they are available 24/7 and that people know
about them. The message on most mental health providers’ (small clinics and
private practitioners) answering machine is to call 911 or go the emergency room.
Without one number, it is impossible for them to promote crisis services.

By increasing reimbursement rates for mental health providers, treating mental
health crisis teams as essential emergency responders, and coordinating mental
health services across the state, we can begin to improve the availability of services
throughout Minnesota. We need policies that pay mental health crisis teams in the
same manner as other emergency responders. Firefighters, paramedics and other
emergency personnel are paid to be available 24 hours a day, 7 days a week.
However, crisis teams are usually only paid for each situation they handle. Crisis
services intervene earlier, better, and are less costly than hospital emergency or
law enforcement responses.

Policy Recommendations:
    Continue to provide base funding for crisis teams to ensure their stability
     and require them to bill health plans and publicly funded health care
     programs for crisis services.
    Secure a statewide central call-in number to make it easy for people to
     access crisis services.
    Provide training for 911 operators so that they know about the availability of
     these services.
    Reform payment models to reflect cost of service including adjustments for
     uncompensated care, staffing, travel, and facility expense.
    Provide easy access to crisis numbers in each county.

Suicide Prevention
Minnesota’s suicide rate has increased each year since 2000 with over 500 deaths
by suicide per year, making suicide a leading cause of violent death in Minnesota.
More than 90% of suicides are associated with diagnosable mental illness and/or
substance abuse.

   Many populations have unique concerns related to suicide, and high suicide             Formatted: Bullets and Numbering
rates often reflect the disparities in adequate access to mental health services. Of
all age groups, persons 75-84 years of age have the highest suicide rate, and suicide
is the second leading cause of death for 15-34 year olds; ten percent of college
students report having seriously considered suicide at least once in the past year.
The suicide rate for American Indians is approximately two times higher than for
any other racial or ethnic group. The number of active-duty U.S. Soldiers who die
as a result of suicide is on track to exceed last year’s rate, which was at an all-time
high (as reported by the U.S. Army in September, 2008).




                                        - 21 -
Stigma associated with psychiatric illness, lack of knowledge, and symptom
recognition about clinical depression prevents timely and appropriate treatment
that would save lives.

The impact of suicide on families and communities is devastating. The loss of life
by suicide is inestimable, but public investment in suicide prevention yields public
benefits. For example, the MDH estimates economic savings to the state of
$658,500 for each youth saved by preventing suicide.

Policy Recommendations:
      Restore funding for the MN Statewide Suicide Prevention Plan programs.
      Provide routine depression screening and follow-up care in primary care
       and behavioral health settings.

Involuntary Electroconvulsive Therapy (ECT)
ECT is defined in Minnesota law as an intrusive mental health treatment. The law
places it in the same category as the invasive medical procedures of psychosurgery
and sterilization. Individuals facing this treatment involuntarily are entitled to
substantial due process protections. Minnesota provides a strong level of
procedural protection for individuals who face the possibility of involuntary ECT;
however, the legal standards governing the procedure are scattered in court
decisions and administrative rules rather than in statute. Codifying these
procedural protections would provide clarity and consistency in the law, benefiting
judges, medical professionals, attorneys, and most importantly, patients.

In addition, two important protections are missing from current law. The first
concerns the length of court orders. Minnesota appellate case law requires that an
order for involuntary ECT “contain reasonable time limits” without further
definition. As a result, some district courts have in practice adopted the statutory
standards specific to the involuntary administration of neuroleptic medications.
These standards allow an order to remain in effect for up to a year or even two
where the commitment is indeterminate. These lengthy time limits are not in
accord with current medical practice for ECT, and the burden to request court
review within a shorter period of time is currently on the individual subjected to
the treatment. The length of the orders and process for extending them should be
brought into line with current clinical practice. Timely judicial oversight should be
ensured.

The second gap is in procedures covering emergency administration of involuntary
ECT. Present law is vague and does not provide sufficient guidance to
professionals or appropriate protections for patients. The standards governing
emergency use of neuroleptic medications that allow up to two weeks of




                                       - 22 -
involuntary treatment without court review are not appropriate for ECT.
Procedural protections specific to ECT should be put in statute.

Policy Recommendations:

      Codify into one statute the procedures found in Price v. Sheppard, 239
       N.W. 2d 905 (Minn. 1976), and Department of Human Services Regulations
       related to the administration of ECT to individuals committed to the
       Commissioner as mentally ill or as mentally ill and dangerous.
      Adopt a specific statutory time limit for the duration of court orders for
       involuntary ECT.
      Adopt procedural requirements governing emergency use of ECT, providing
       for expedited court review before treatment.




                                      - 23 -
Children’s Mental Health
Please note that many of the issues described in other sections apply to adult and
child mental health services, including recommendations related to benefits and
coverage, provider payments crisis services, health insurance, and workforce
shortages.

Children’s Services
Despite common misconceptions, children do develop mental illnesses. To qualify
for services under Minnesota law, children are referred to as having an emotional
disturbance or a serious emotional disturbance. Without treatment and supports,
these children often see little success in school or in their social lives. Their
families often struggle with finding services and supports and often pay a great
deal out of pocket.

More funding is needed for children’s mental health services and for supports to
help families keep children in the home. In-home services and respite care can be
extremely effective. Children spend most of their time in schools, making school-
linked mental health services and effective day treatment programs an important
part of the mental health system. It is equally important that we fund programs
which have been shown to be effective in a burgeoning body of research.

For families that need to rely on county funding for care, it is difficult for them to
determine their financial obligations. Each county uses a different fee schedule.

Families of children who need residential treatment must wait for approval from
both the county and health plan if they are covered by Prepaid Medical Assistance
Program (PMAP). Having a consistent time frame for decisions would help
children access these services in a more timely fashion or allow families to appeal if
their request for services is denied.

Policy Recommendations:
    Increase funding for respite care so that families can receive a break from
     caring for a high-needs child and to prevent out-of-home placements.
    Fund the development and implementation of evidence-based practices,
     including practices that address the needs of children that are exposed to or
     are victims of violence, veterans and their families, refugee populations, and
     children with complex treatment needs such as eating disorders and low
     incidence disorders.
    Create a statewide uniform fee schedule across all public programs and
     payers so families clearly understand the costs of mental health services.




                                         - 24 -
    Fund the availability of mental health services for children from cultural and
     ethnic minorities.
    Require proceedings under 260D, children in voluntary foster care for
     treatment to be inaccessible to the public.
    Require county screening team decisions to be made quickly and in writing
     so that families can appeal decisions and not be “in limbo” with treatment
     decisions and include families on the screening team.
    Pay for the county share of residential treatment. Develop additional
     specialty services that are long term, intensive, supervised, highly integrated
     and interdisciplinary for children and adolescents with complex needs, with
     multiple diagnoses and chronicity.
    Reconfigure and pay for specialty hospital beds or residential treatment
     beds that focus on treating highly complex children and adolescents.
    Link the needs of these children and adolescents to program development at
     Child and Adolescent Behavioral Health Services (CABHS) beds.
    Clarify and define additional services that might fill out the service
     continuum at less than a psychiatric inpatient standard of care. This might
     include the expansion of “sub-acute” hospital services and/or the adoption
     of a Medicaid option for more intensive residential services, typically
     identified as “psych under 21”.
    Increase the intensity and availability of community based mental health
     services by increasing funding to pay for intensity and more highly trained
     staff, investigate expanding systems of care model, create other services, like
     ACT, and creating a more intensive case management service.

Education
Children spend their days in school. Children with mental illness do not fare well
in schools. Poor outcomes in schools lead to frequent suspensions, falling behind
in school, truancy, dropping out of school, with the final stop being the juvenile
justice system. More must be done to support school success with these children.

Truancy is an emerging issue. Some families find that their child’s mental illness
makes it difficult to get to school and truancy leads to involvement in the juvenile
justice system, not always a system that can investigate the real reasons why a
student isn’t attending school.

Adolescents with mental illness who do stay in school often find that the existing
transition services don’t meet their needs. There are effective models such as the
Florida Transition to Independence (TIP) program and the PACT4 model, which
work on all of the transition domains of employment, education, living situation,
personal effectiveness, and community life functioning. These young people need
help and support to become successful adults.




                                        - 25 -
Policy Recommendations:
    Provide funding to support children’s mental health collaboratives and
     family collaboratives.
    Fund evidence-based and research driven transition services for
     adolescents.
    Maintain funding for school-based mental health services; update and
     simplify rules to community providers to contract and link services with
     schools.
    Promote best practices in addressing truancy by viewing truancy as an
     educational issue and not a juvenile justice issue.
    Equalize payment rates between services provided by schools versus
     services delivered by community providers for services linked with schools.
    Require the Department of Education to recommend model mental health
     curricula to school districts.

Day Treatment
Day treatment consists of group psychotherapy and other intensive therapeutic
services that are provided for a minimum two-hour time block by a
multidisciplinary staff under the clinical supervision of a mental health
professional. Day treatment may include education and consultation provided to
families and other individuals as an extension of the treatment process. The
services are aimed at stabilizing the child's mental health status, and developing
and improving the child's daily independent living and socialization skills.

Day treatment services are distinguished from day care by their structured
therapeutic program of psychotherapy services. Day treatment services are not a
part of inpatient hospital or residential treatment services. Day treatment services
for a child are an integrated set of education, therapy, and family interventions.

A workgroup on day treatment met during summer 2008 to determine how to
improve access to and quality of day treatment. Several key issues emerged. The
first is that it is important that the words “day treatment” be used only for those
programs that meet the qualifications to receive Medicaid funding. Parents must
be able to trust that when their child is attending a day treatment program, it is
providing therapeutic care and meeting a defined set of standards. Some schools
call their programs “day treatment,” but do not meet these standards.

Second, the group learned that very few of the students in day treatment qualified
for summer school, or extended school year. Knowing that these students are in
day treatment an average of 9 months, receiving between 2 to 4 hours of education
a day, it is imperative that they have access to education during the summer
months to help them catch up with their peers. Studies show that the further
behind a student is in his/her academics, the more likely it is that he or she will



                                       - 26 -
drop out of school. Students in day treatment should automatically qualify for
summer school.

Policy Recommendations:
          Increase funding for day treatment programs.
          Fund summer school and a year round school year for students in day
           treatment and residential programs.
          Provide funding for transportation, including round trip reimbursement
           for parents.
          Limit the use of day treatment term to qualified programs.
          Provide additional funding options for day treatment providers
           including additional MA service codes.

Juvenile Justice
Nearly 70% of youth in the juvenile justice system have one or more diagnoses for
mental illness. This is a critical issue in Minnesota. In 2007 the Department of
Corrections, in partnership with state and local agencies, established the Juvenile
Justice and Mental Health Initiative to improve the outcomes for youth in the
justice system with mental illness or co-occurring disorders.

There was consensus that mental illness plays a huge part in why young people end
up in the juvenile justice system and that the juvenile justice system is not an
appropriate system to serve as the last resort for mental health care. Four themes
emerged from the group:
    The need to collect data that better informs the process and to share data      Formatted: Bullets and Numbering
       without jeopardizing the legal interests of youth as defendants;
    The need for post-screening coordination;
    The need to better engage families and caregivers as partners;
    The need for evidence-based, community-based mental health interventions
       that are effective with justice involved youth.

Policy Recommendations:
      Request the Office of the State Auditor to conduct Cost Benefit Analyses of
       early intervention juvenile justice programs.
      Address racial disparities by reviewing how race, gender and ethnicity may
       impact diagnostic assessments and placement in treatment facilities.
      Employ culturally specific treatment and therapists to ensure equitable
       outcomes.
      Request the State to address racial disparities in regard to diagnosis,
       placement in treatment and treatment success/failure by race, gender and
       ethnicity.
      Analyze statewide needs and resource analysis regarding treatment for
       justice involved youth with severe mental health issues.



                                       - 27 -
   Develop co-occurring (MI/CD) programming for youth involved in multiple
    systems of care (including juvenile justice).
   Change correctional and residential licensing standards to address the
    needs of the population and include licensing mental health professionals
    (i.e. JDAI standards) to respond to the 70% of youth in juvenile justice who
    have mental health and chemical dependency concerns.
   Provide funding for at least one mental health discharge planner at the Red
    Wing Juvenile Detention Facility.




                                    - 28 -
Adult Mental Health
Employment
Many people with mental illness can and wish to work but are not working.
According to recent research, 70% of adults with a serious mental illness would like
to have a job. Employment is viewed as an important part of recovery and
supported employment for people with a serious mental illness is considered an
evidence-based practice.

Unfortunately, for many people with a serious mental illness, employment eludes
them. People with a serious mental illness have the highest unemployment rate,
which is costly to the individuals and to our communities.

Of the adults with a serious mental illness using case management, 75% were
reported to be looking for work or not in the labor force. Barriers to employment
included: stigma and discrimination, fear of losing health benefits, lack of
vocational services and lack of transportation. The unemployment rate and lack of
employment services to assist people with a mental illness is a national and state
disgrace.

The Extended Employment Project for People with Serious Mental Illness (EE-
SMI) uses interagency collaboration, individualized supported employment and
consumer involvement in the planning, development, oversight and delivery of
services. Support services can include: job coaching, facilitation of natural
supports, supportive counseling, coordination of support services, job
development or placement, training in social skills and money management. A key
feature of this program is that ongoing employment supports are provided.
Providers can also help with career advancement and to find a new job.

Fifteen counties do not have access to EE-SMI services and there are long waiting
lists for existing providers. There are currently 23 projects under the state funded
EE-SMI program.

National data show that 70% of those with a serious mental illness depend almost
entirely on Social Security programs for financial and medical support and few
leave the program. The NAMI Triad report found that 71% of people with serious
mental illness were living in poverty with 20% living on less than $5,000 per year.
The state must maintain and increase the number of programs that are effective
and that lift people out of poverty. People with a serious mental illness can and do
work if provided with the necessary supports.




                                       - 29 -
Policy Recommendations:
    Provide additional funding for the EE-SMI to meet the demand
     (approximately $1 million a year).
    Clarify rules for what is allowable under MA related to supported
     employment—modify payment and funding methods.
    Modify ARMHS to support key components of supported employment as an
     evidenced based practice.

Housing
The availability of affordable housing is an acute societal problem. It is
particularly acute for people with mental illness who not only need affordable
housing but also require a flexible array of supports to enable them to live
successfully in the community. For people with serious mental illness, the
shortage of community housing options is a crisis situation that creates incredible
hardship for people and wastes scarce state and public resources.

If an individual is on Social Security and Supplemental Security Income (SSI),
there is not one housing market nationwide they can afford. A Wilder Foundation
study has found that 47% of the homeless in Minnesota have a mental illness. A
major factor leading to homelessness is the lack of affordable housing.

A crisis homeless situation currently exists in Minnesota. High unemployment,
home foreclosures, lost savings, no medical insurance, and lack of necessary
resources and support systems has resulted in many adults and children flooding
our homeless shelters. Many people are turned away because the shelters are full.

A Bridges certificate is a housing subsidy - recipients pay 1/3 of their income for
rent and the Bridges subsidy covers the remainder while waiting for a federal
Section 8 certificate. The allocation for the current biennium will serve an
estimated 542 households at an average cost of $5,000 per year. The long waiting
lists for the federal Section 8 housing certificates has made it even more difficult
for people to get on the Bridges program, with the average time on the Bridges
program going from 2.1 years in 2003 to 7 years in 2008.

Policy Recommendations:
      Continue support and increase funding for BRIDGES certificates.
      Provide immediate emergency funds to cities throughout Minnesota to help
       address homelessness issues.
      Restore $600,000 for Emergency Shelter Funding; $800,000 for the
       Runaway and Homeless Youth Act; and $750,000 for Transitional Housing
       that was cut in 2009.




                                       - 30 -
Criminal Justice
Police Response to Crisis
Criminal justice agencies around the nation have adopted Crisis Intervention
Team (CIT) training with the support of national and local mental health
organizations. In Minnesota CIT training has evolved to include an overview of
mental illnesses and the mental health system; site visits to psychiatric facilities
that accept transports from CIT officers and community mental health support
facilities; daily scenario based role plays with trained professional mental health
crisis role players, facilitated by active or retired criminal justice professionals
trained to facilitate these sessions.

CIT training also includes one-hour presentations by volunteer local experts and
consumers on the following topics: de-escalation and officer safety; hallucination
simulator glasses; medication overview; 24/7 mobile crisis teams and resources;
the family experience and consumer panel; suicide by cop; criminal and civil
mental health court; developmental disabilities: elder issues; childhood and
adolescent disorders; excited delirium; traumatic brain injury; stigma busters;
homelessness; substance abuse; co-existing behavioral health disorders; detox,
chronic inebriates and fetal alcohol; emergency response unit hostage
negotiations; CIT reporting and data collection. In 2008, 69 of Minnesota’s 87
counties received CIT training grants. Most of the counties that received grants are
rural, with the exception of Ramsey County.

Policy Recommendation:
      Fund CIT training for police officers.

Discharge Planning
Many people with mental illnesses experience repeated encounters with the
criminal justice system without ever receiving treatment or support services for
their illness. Many lose their health care and financial benefits after entering the
criminal justice system and upon release have no way to obtain medication or
treatment. People with mental illness are more likely than other inmates to have
been homeless or unemployed when incarcerated and upon discharge into the
community face additional obstacles such as difficulty obtaining medications and
treatment, finding work, re-establishing family relationships and avoiding further
contact with the criminal justice system.

Jails have a higher number of persons with mental illness than prisons, and most
do not have the staff or funding for discharge planning and follow-up. In a 2006
jail survey conducted by NAMI-MN, 60% of jail staff said they frequently see




                                        - 31 -
people with mental illness, and 99% of jail staff believe that untreated mental
illness increases the risk of re-offense. Discharge planning can address the
question of how we can do a better job to lower recidivism rates. Lack of discharge
planning puts a person back into the community without the tools to prevent them
from returning, which compromises public safety, creates a cycle of recidivism that
results in higher societal costs.

Policy Recommendations:
      Hire more prison discharge planners.
      Allow inmates to apply for MinnesotaCare while in jail.
      Fund pilot projects and develop standards for counties to conduct discharge
       planning from jails.
      Facilitate connections with community providers following discharge.

Mental Health Courts
Data indicates that, in Minnesota, there is a large gap between who needs mental
health services while incarcerated and who gets those services. The recent cuts to
the Minnesota Public Defender offices have compounded this problem by
significantly impairing public defenders’ ability to appropriately represent people
and to research other options through jail diversion programs. These cuts
guarantee that more Minnesotans will face incarceration.

There are now two mental health courts in Minnesota, one in Hennepin County
and one in Ramsey County. They seek to increase public safety by addressing the
mental health needs of defendants by reducing recidivism, increasing compliance
with outpatient treatment, reducing emergency room visits and reducing hospital
time. If a person can access a mental heath court, that individual can obtain
treatment and go back into the community with their mental health issues having
been addressed.

Policy Recommendations:
      Fund Mental Health Courts that meet recognized standards.
      Fund additional public defenders.
      Expand the number of jurisdictions with Mental Health Courts throughout
       the state.

Mental Health Fatality Review Team
Modeled after the successful Domestic Fatality Review Team that reviews domestic
violence fatalities, the Mental Health Fatality Review Team in Hennepin County
would review deaths of individuals who had recent contact with the criminal
justice system.




                                       - 32 -
Of significance in the review would be the extent to which a known mental illness -
experienced by the victim or the perpetrator - is a major factor in the death. Based
upon the confidential data acquired through the review, the Team would
recommend institutional reforms to prevent future fatalities.

Policy Recommendation:
      Create a Mental Health Fatality Review Team in Hennepin County.

Insanity Defense
Minnesota law sets the standard that the criminal courts use to determine if a
defendant with mental illness should be held criminally responsible for an offense.
In Minnesota, the mental illness defense, or what is commonly called the “insanity
defense,” is referred to as the M’Naghten test, named for the defendant who was
tried for murder in England in 1843 and judged too mentally ill to be found guilty
of the offense. The standard is that the defendant’s mental illness was so serious at
the time of the offense that the defendant did not know the nature of the act or that
it was wrong. It is important to note that this is a very high standard and is not
used very often in Minnesota. The standard requires a significant cognitive
incapacity. Someone experiencing hallucinations, a thought disorder or delusional
thoughts does not automatically meet the standard. The mental illness must
directly interfere with the defendant’s understanding of the offense at the time the
offense was committed.

Supporters of the M’Naghten standard say that it has stood the test of time,
however, very few attorneys in Minnesota use the M’Naghten standard
successfully. Under the American Law Institute (ALI) standard, "a person is not
responsible for criminal conduct if at the time of such conduct as a result of mental
disease or defect he lacks substantial capacity either to appreciate the criminality
of his conduct or to conform his conduct to the requirements of the law." This
standard requires that there be a diagnosis, and that the person is so incapacitated
by the illness that he cannot appreciate the criminality of his conduct nor control
his actions.

It is important to know that people who meet the insanity standard are not free to
live in the community. People who meet the standard are committed to treatment
and are not released until they have recovered sufficiently and are in better health,
which may actually require more time hospitalized than incarcerated.

Policy Recommendation:
      Change the Minnesota standard to reflect the ALI standard.




                                        - 33 -
Glossary of Terms
Mental health services and concepts are often described with technical terms and
acronyms. This glossary contains some of the key terms used in the document.


      Adult Crisis Services: Emergency services that provide prompt
      therapeutic intervention to those experiencing a psychiatric emergency.

      Adult Rehabilitative Mental Health Services (ARMHS): A
      rehabilitative program for persons who have a mental health diagnosis
      along with their brain injury or other physical disability and could benefit
      from services to regain skills related to independent living, involvement in
      the community or managing their mental health.

      Assertive Community Treatment (ACT): a team treatment approach
      designed to provide comprehensive, community-based psychiatric
      treatment, rehabilitation, and support to persons with serious and
      persistent mental illness.

      Care Coordination: A process that links children with special health care
      needs and their families to services and resources in a coordinated effort to
      maximize the potential of the children and provide them with optimal
      health care.

      Case Management: A collaborative process that assesses, plans,
      implements, coordinates, monitors, and evaluates the options and services
      required to meet the client’s health and human service needs.

      Child and Adolescent Behavioral Health Services (CABHS):
      Provides comprehensive hospital and community-based mental health
      services to children and adolescents who have a serious emotional
      disturbance and whose needs may exceed the capacities of their families
      and local communities.

      Children’s Therapeutic Services and Supports (CTSS): A flexible
      package of mental health services for children who require varying
      therapeutic and rehabilitative levels of intervention to address the
      conditions of emotional disturbance that impair and interfere with
      individuals’ abilities to function independently.

      Community Behavioral Health Hospitals (CBHH): provide short
      term, acute inpatient psychiatric services.




                                        34
Community Mental Health Centers (CMHC): Providers of
comprehensive mental health services, offering inpatient, outpatient, home-
based, school, and community-based programs to individuals and families.

Drug Formulary Committee: An advisory group that makes decisions
on which drugs will be covered by Minnesota’s publicly funded health care
programs.

Electroconvulsive Therapy (ECT): The administration of a strong
electrical current that passes through the brain to induce convulsions. It is
usually only considered after a patient’s illness has not improved after other
treatment options are tried.

Essential Benefit Set: A recommendation for what services should be
covered under health care plans, currently under revision by a DHS
workgroup for presentation in 2010. Designed to promote the use of most
effective treatment plans and options. Inclusion of adequate treatment for
mental health issues has been a historical problem with many health care
plans.

General Assistance Medical Care (GAMC): General Assistance
Medical Care is a health care program that annually serves around 70,000
adults without children in Minnesota.

Health Care Access Fund (HCAF): Originally created by the
Legislature to be a dedicated funding source for expanding insurance
coverage. It is the primary source of funding for the MinnesotaCare
program. Statute requires this fund be kept solvent, including by transfer
from the General Fund for shortfalls in 2010-2011.

Intensive Residential Treatment Services (IRTS): A time-limited
residential mental health service for patients in need of restrictive settings
and at risk of significant functional deterioration. IRTS are designed to
develop and enhance psychiatric stability, and the ability to live in a more
independent setting.

Maintenance of Effort (MOE): State requirements for county spending
on social services, based on historical levels.

Medical Assistance (MA): Minnesota’s Medicaid program. They
provide payment for health care services on behalf of eligible low-income
individuals with limited income and high medical expenses.




                                   35
Mental Health: Defined by the World Health Organization as “a state of
well-being in which the individual realizes his or her abilities, can cope with
normal stresses of life, can work productively and fruitfully and is able to
make a contribution to his or her community.”

Mental Health Fatality Review Team: Systematically analyzes deaths
of people with mental health issues to determine if the deaths could have
been prevented and to make recommendations for education, training, and
prevention.

Mental Illness: A medical conditions that disrupt a person’s thinking,
feeling, mood, ability to relate to others, and daily functioning.

MinnesotaCare: A state program that provides subsidized health care
coverage to low and moderate-income families and individuals.

Personal Care Assistance (PCA): A program which provides services to
persons who need help with day-to-day activities to allow them to be more
independent in their own home.

Prepaid Medical Assistance Program (PMAP): A health care
program that pays for medical services for low-income families, children,
pregnant women, and people who have disabilities.

State Medical Review Team (SMRT): A unit of the Department of
Human Services that determines disability in consultation with medical
professionals appointed by the commissioner. A primary function of the
SMRT is certifying disability for people who are applying for Social Security
Administration (SSA) disability benefits.

State Operated Services (SOS): A division of the Minnesota
Department of Human Services. It consists of an array of campus and
community-based programs serving people with mental illness,
developmental disabilities, chemical dependency and traumatic brain injury
as well as people who pose a risk to society.




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