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TENNESSEE DEPARTMENT OF MENTAL HEALTH AND

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TENNESSEE DEPARTMENT OF MENTAL HEALTH AND Powered By Docstoc
					                  TENNESSEE DEPARTMENT OF MENTAL HEALTH
                      AND DEVELOPMENTAL DISABILITIES
                                     and the
                     TDMHDD PLANNING & POLICY COUNCIL
                         FY 2010 Joint Annual Report
                          July 1, 2009 – June 30, 2010




INTRODUCTION:

The Department of Mental Health and Developmental Disabilities (DMHDD) is the state’s
mental heath, substance use disorders, developmental disabilities, and opioid authority
and is responsible for system planning; setting policy and quality standards; licensing
personal support services agencies and mental health and alcohol and drug services
and facilities; system monitoring and evaluation; disseminating public information and
advocacy for persons of all ages who have mental illness, serious emotional disturbance,
substance use disorders, or developmental disabilities. DMHDD also licenses intellectual
disability services and facilities.

DMHDD serves adults with mental illness and children with emotional disturbance by
planning, promoting, and contracting for an array of community mental health services,
which are complementary to the mental health treatment services provided through the
Bureau of TennCare. Community mental health services include prevention, early
intervention, support services, rehabilitation, recovery and forensic services, and juvenile
court evaluation services. DMHDD also provides a wide array and varied intensity level
of substance abuse treatment services for children and adults with specialty services for
women and persons with HIV. Prevention services are targeted to children and youth
and include an array of school and community-based prevention programs, professional
training, and evaluation activities. Substance abuse services are provided through a
statewide network of more than 145 community and faith-based providers.

       DMHDD administers two federal block grants from the U.S. Department of Health
        and Human Services, Substance Abuse and Mental Health Services
        Administration (SAMHSA). One that provides services for adults with mental
        illness and children with serious emotional disturbance, and another for persons
        with substance use disorders.
       DMHDD maintains private, state and federally funded grant contracts with
        private, not for profit community mental health and substance abuse agencies
        and other organizations that provide a variety of services that are either not
        available or not fully supported through TennCare to enrollees and for non
        TennCare members who need services provided by DMHDD.




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         DMHDD administers the Behavioral Health Safety Net of TN program which
          addresses core mental health service needs for uninsured persons with serious
          and persistent mental illness (SPMI) who meets eligibility criteria.
         DMHDD operates five state psychiatric hospitals referred to as Regional Mental
          Health Institutes (RMHIs).
         DMHDD provides statutorily mandated inpatient and outpatient forensic and
          juvenile court services through a combination of direct service through the RMHIs
          and contracts with community providers.
         DMHDD provides assistance to individuals when a behavioral health crisis
          occurs. Tennessee has a 24/7 crisis system that includes seven crisis
          stabilization units which provide services to individuals 18 years of age and older.
         DMHDD contracts with five agencies to operate medically-monitored
          detoxification units. The units provide short-term cost-effective alcohol and
          detoxification services 24-hour, seven days a week.

The Department of Mental Health and Developmental Disabilities Planning and Policy
Council was created by the General Assembly which set membership requirements and
responsibilities in Tennessee Code Annotated, §§33-1-401-402. Membership includes
service recipients and their family members, representatives for children and youth, the
elderly, advocates, service providers, state agency representatives, and two legislators
appointed by the Speakers of the respective houses.

The Council meets quarterly and is charged with assisting DMHDD in planning a
comprehensive array of high quality prevention, early intervention, treatment, and
habilitation services and supports; advising the Department on policy budget requests;
and developing and evaluating services and supports. The Council annually reviews the
adequacy of the mental health and developmental disability law, Title 33, to support the
service systems; makes recommendations for inclusion in the Department’s three-year
plan; annually reviews the federal Mental Health Block Grant and the federal Substance
Abuse Block Grant; and, in conjunction with the DMHDD, reports annually to the
Governor on the service system and departmental programs, and facilities.

ACCOMPLISHMENTS:

SERVICE IMPROVEMENTS

        Behavioral Health Safety Net of TN (BHSN) - DMHDD administers the BHSN
         which addresses core mental health service needs for uninsured persons with
         serious mental illness (SMI) who meets eligibility criteria. DMHDD partners with 18
         community mental health agencies across the State to provide essential mental
         health services to the persons in this program.

         DMHDD offers core mental health services to those who meet program eligibility
         requirements. The BHSN is designed to meet basic medication and treatment
         needs of these individuals and includes assessment, evaluation, diagnostic,
         therapeutic intervention, case management, pharmacologic management, labs


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     related to medication management, and pharmacy assistance and coordination.
     Approximately 29,000 individuals received services through the BHSN program
     this fiscal year. The top three services utilized were case management,
     pharmacologic management, and psychotherapy.

     The DMHDD Planning and Policy Council played a significant role in shaping the
     program: advocating for flexibility in the service package based on consumer need,
     inclusion of critical medications in the formulary, and expansion of the eligible
     population and continues to review the implementation outcomes of the BHSN.

   Medically-Monitored Crisis Detoxification (MMCD) Units – During the past year,
    DMHDD contracted with five agencies to open Medically-Monitored Crisis
    Detoxification units. These units provide short-term alcohol and drug detoxification
    services 24 hours, seven days a week. The units are cost effective because they
    offer intensive 24-hour evaluation and withdrawal management, including
    observation, monitoring, and treatment, in a less restrictive setting than a hospital.
    The units are clinically effective as MMCD providers will refer their patients upon
    discharge to treatment providers and follow-up to ensure that individuals maintain
    their scheduled appointments, and continue in substance abuse treatment.

   Crisis Stabilization Units (CSU’s) – Tennessee currently operates seven (7) crisis
    stabilization units located in Chattanooga, Cookeville, Nashville, Memphis, Jackson,
    Knoxville and Johnson City. This service provides short term crisis resolution
    services to individuals age 18 years of age and older who are in need of behavioral
    health crisis services and are at risk of requiring emergency hospitalization. CSUs
    offer intensive, 24-hour mental health treatment in a less restrictive setting than a
    psychiatric hospital and is less costly. In addition, these facilities offer walk-in triage
    capability which has proven most beneficial in keeping individuals out of
    Tennessee's emergency departments unnecessarily. More than 16,000 individuals
    have been triaged and linked to appropriate services through the CSU walk-in center
    between July 1, 2009 and April 30, 2010.

    A total of seven hundred and fifty six (756) individuals ages 18 and over have been
    admitted for a short term stay within one of the seven crisis stabilization units
    statewide between July 1, 2009 and May 31, 2010 in the crisis stabilization units.

    DMHDD funds capacity for uninsured individuals and monitors services rendered to
    individuals who meet the admission criteria. Currently, approximately 65% of all
    individuals served in the CSUs are uninsured.

    The DMHDD Planning and Policy Council continue to advise the Department on
    issues related to crisis services.

   During FY 09-10, the department, in conjunction with the Bureau of TennCare,
    worked with stakeholders to identify ways in which crisis response efforts could be
    streamlined to utilize existing resources in a more efficient and cost effective


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    manner. These methods are referred to as Community Face-to-Face Response
    Protocols and went into effect on July 1, 2010.

   Tennessee's Creating Homes Initiative combines state leadership, regional housing
    development/funding experts, and local partnerships to develop affordable,
    supportive homes for people with mental illness. Since 2000, over $388 million has
    been leveraged, resulting in the development of over 9,400 housing units. People
    with a history of mental illness living in supportive housing have an average 80%
    reduction in the number of psychiatric hospitalization days compared to the year
    before entering supportive housing.

 Peer Support Specialists – DMHDD has certified 144 Peer Specialists since the
  inception of the Peer Specialist Certification Program in FY ’08. Peer support
  services as provided by a Certified Peer Specialist are Medicaid-billable services in
  Tennessee. The Department has held numerous outreach presentations to inform
  MH providers and potential consumer-applicants about the certification program. It
  has both conducted and sponsored trainings for peer specialists to meet ongoing
  education requirements of certification. The guidelines and standards, along with
  application and certification forms, are available on the DMHDD website. The Office
  of Consumer Affairs has implemented program improvements to simplify the
  certification process and to provide certification status information to prospective
  employers. The state certification program is run by a Certified Peer Specialist and
  a review committee comprised of Certified Peer Specialists that provide oversight for
  the program. DMHDD Planning and Policy Council continue to endorse this
  program.

 Family Peer Support Specialist – DMHDD, in collaboration with NAMI TN and
  Tennessee Voices for Children, launched “The Family Support Specialist
  Certification Program” in May 2009 which provides state certification for individuals
  who provide direct caregiver-to-caregiver support services to families of children and
  youth with emotional, behavioral, or co-occurring disorders. Certified Family Support
  Specialists are able to use their unique experience to inspire hope and provide
  support to others who are facing similar challenges. To date, thirty persons have
  been trained as Family Support Specialist.

   A recent change in Tennessee’s mental health law (Title 33) makes admissions to
    the State’s Regional Mental Health Institutes (RMHIs) subject to the availability of
    suitable accommodations. This means that a RMHI has the capacity, as reasonably
    determined by the commissioner, and the medical capability, equipment, and staffing
    to provide an appropriate level of care, treatment, and physical security to an
    individual in an unoccupied and unassigned bed, thus ensuring quality care and
    maintaining accreditation by the Joint Commission and certification by CMS.

    During FY 2010, out of 13,475 RMHI referrals only 325 individuals were subject to
    ASA delayed admission, and in all of these cases beds capacity existed elsewhere
    within the RMHI system to immediately accommodate these individuals. 143 of


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    those subject to delayed admission accepted the offer of an immediate placement at
    the nearest available RMHI, and 179 requested instead to be placed on a waiting list
    for the current RMHI. 86% of the waiting list referrals were resolved within the first
    24 hours.

   On June 30, 2010, DMHDD launched the RMHI Telemedicine Pilot Project with
    Western Mental Health Institute (WMHI) and a remote site in Henry County. The
    project will enable WMHI to conduct remote second Certificate of need (CON)
    evaluations of appropriate individuals in Henry County. The goal of this project is to
    expedite the assessment process, avoid unnecessary transportation to RMHIs of
    individuals who do not meet criteria for emergency involuntary admission, and
    eliminate the current assessment wait time for law enforcement upon arrival at an
    RMHI.

   Grant Award – In September 2009, DMHDD was awarded a six-year $9 million
    dollar grant by the U.S. Substance Abuse Mental Health Services Administration for
    duplicating the system of care model called the K-Town Youth Empowerment
    Network. This will be a collaborative effort of several agencies and services to work
    with children who have a mental or emotional problem. The goal of this program is
    to help children with extra challenges successfully transition to adulthood.

   Grant Award – In November 2009, DMHDD, in partnership with the Tennessee
    Administrative Office of the Courts, was awarded $196,742 for a Mental Health
    Justice Collaboration Grant from the Bureau of Justice Assistance. The grant will be
    used to implement the Tennessee Integrated Court Screening and Referral Project.
    This is an evidence-based intervention project that addresses the mental health and
    substance abuse needs of children and youth who come into contact with the
    juvenile justice system in Tennessee. The project aims to serve approximately
    6,000 children and youth with non-violent charges in 10 Tennessee county juvenile
    courts. The grant will offer a special emphasis on rural jurisdictions with female
    clients.

   DMHDD entered into a partnership with the Board of Probation and Parole (BOPP)
    for the provision of $2.225 million dollars in substance abuse treatment services to at
    risk technical probation and parole violators in an effort to divert this population from
    incarceration in State prison. Administered by DMHDD, community substance
    abuse treatment providers across the State will provide services in the
    DMHDD/BOPP Community Treatment Collaborative. This combined effort is part of
    the Joint Offender Management Project (JOMP), a broader collaboration between
    Department of Correction (DOC) and BOPP.

   Grant Award – In April 2010, DMHDD received a grant in the amount of 11.5 million
    from the U.S Substance Abuse and Mental Health Services Administration to reduce
    alcohol binge drinking among the state’s 14-25 year olds. The grant funds the
    Tennessee Partnership for Success project in 20 substance prevention coalitions
    across the state over the next five years. The goal of the project is to reverse the


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    state’s upward trend in binge drinking; prevent the onset and progression of
    substance abuse among 14-25 year olds; strengthen prevention capacity and
    infrastructure at the state and county levels.

   Grant Award – Due to the worst flood ever recorded in history in Tennessee, the
    Substance Abuse and Mental Health Services Administration awarded a $380,000
    grant to DMHDD to provide immediate crisis counseling to individuals impacted by
    the flood. DMHDD worked with five community mental health centers in Middle and
    West Tennessee to offer individual and group crisis counseling, public education,
    community networking and support, and both adult and child needs assessments
    and referrals. DMHDD will apply for RSP to provide expanded services for one year.


ANTI-STIGMA/EDUCATION

   On May 4, 2010 just a few days after the flood, the DMHDD released information on
    how to cope with trauma geared toward Tennesseans coping with the immediate
    after effects of severe flooding across most of the state. Many news organizations
    including newspapers, radio, and television distributed this information to the public.

    DMHDD issued a press release on May 26, 2010 regarding the Crisis Counseling
    grant Tennessee received from SAMHSA to make available mental health services
    to Tennesseans coping with the traumatic events of May's floods. This release was
    covered by many newspapers, radio stations, and television news stations across
    Tennessee.

    On June 8, 2010, DMHDD's Office of Communications held a crisis counseling
    conference call with media organizations across the state, FEMA, TEMA, and
    Centerstone to inform, update, and distribute information about how to help children
    cope with trauma. This conference call was in response to the May flooding. In
    addition to this call, DMHDD also made available for download on the website
    several different SAMHSA flyers with information on how to cope with trauma, how
    to help children cope with trauma, and how to deal with stress.

    During the months of May and June, the department reached out to many
    organizations active with flood recovery efforts including the Red Cross, TEMA,
    FEMA, etc.

   Anti-Stigma Campaign – DMHDD continues the “Overcoming Stigma Campaign” to
    spread positive messages regarding resiliency and recovery with a focus on the arts.
    On June 7, 2010, DMHDD and the Middle Tennessee Mental Health Cooperative
    sponsored the third Annual Art for Awareness Day at the Legislative Plaza which
    featured the work of consumer artist throughout the state. This event provides a
    great opportunity to share artwork and stories of recovery and resiliency by persons
    healing from mental illness and substance abuse.



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    Reducing stigma and increasing knowledge regarding resiliency and recovery is an
    important focus of the DMHDD Planning and Policy Council.

   In an effort to reduce the stigma of mental illness and substance use disorders,
    DMHDD hosted the second Operation Immersion training on November 5 and 6,
    2009 in Smyrna, TN. DMHDD partnered with the Tennessee National Guard and
    the Tennessee Veterans Task Force to present this one-and-a-half day training,
    which focuses on military culture and issues unique to Tennessee National Guard
    Service members. The training provided and opportunity for behavioral health care
    providers to experience life from the military perspective.

   DMHDD sponsored two Recovery and Resiliency Symposiums in August 2009 and
    October 2009. The symposiums on mental health recovery and resiliency offered
    education and training in Murfreesboro, TN and Oak Ridge, TN. Each location
    feature nationally and locally known experts dedicated to making a positive change
    in the lives of persons with mental and/or substance abuse diagnosis

   DMHDD and the Davidson County Metro Public Health Department hosted
    “Silencing the Silent Epidemic: Suicide Prevention and African American Faith
    Communities” to raise awareness of suicide on March 15, 2010. The conference
    featured national experts in the areas of suicide prevention, mental health and
    substance abuse issues. Faith leaders and others were encouraged to continue
    raising awareness of suicide and suicide prevention in their communities.

   This past year, DMHDD sponsored Tennessee’s Teen Institutes in three regions of
    the state. The Teen Institute is conducted as a summer camp through three
    community agencies to promote healthy choices and a substance abuse free
    lifestyle. Approximately 600 youth were served across the state including many
    inner city youth as well as youth from rural areas.


INTERAGENCY COLLABORATION

   DMHDD recognizes the need for services and supports for persons with
    developmental disabilities especially for those who are not diagnosed with
    intellectual disabilities. DMHDD participated in the Developmental Disabilities (DD)
    Task Force which was charged with conducting a statewide needs assessment,
    assessing the capacity of the service system and developing a plan to provide cost-
    effective home and community-based services and supports for persons with
    developmental disabilities other than mental retardation. After a year of research,
    discussion and planning; the Task Force issued its report, “Fulfilling the Promise,”
    which contained recommendations to achieve a comprehensive home and
    community-based service system for persons with developmental disabilities other
    than intellectual disabilities. One of the recommendations in the report was to
    transfer responsibility for planning and service provision for persons with DD from



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     DMHDD to the Division of Intellectual Disabilities Services which was endorsed by
     the DMHDD Planning and Policy Council.

     In 2010, legislation was passed (Public Chapter 1100) that creates a new
     Department of Intellectual and Developmental Disabilities effective January 15,
     2011. This legislation transfers responsibility for planning and service provision for
     persons with developmental disabilities from DMHDD to the new Department.
     DMHDD and the DMHDD Planning and Policy Council view this as a positive step
     in attaining services for this population.

   The Council on Children’s Mental Health Care was established to design a plan for a
    statewide system of mental health care for children where mental health services are
    child-centered, family-driven, and culturally and linguistically competent, and to
    provide a coordinated system of care for children’s mental health needs in the state.
    This council has begun taking steps to design this plan and has completed its first
    report to the Legislature in July 2010. Commissioner Betts co-chairs the Council,
    along with Linda O’Neal, Executive Director of the TN Commission on Children and
    Youth.


CHALLENGES

   Budget - The FY 09 - 10 approved budget reflected 22% in DMHDD state dollar
    reductions and reallocations, including reducing capacity at the RMHIs, reducing
    policy and program staff, and community program grants. After critically examining
    current programs and services, DMHDD decided to focus on preserving services and
    programs that target the Department’s high priority populations and programs with a
    substantial impact on reducing psychiatric hospitalization. Non-recurring funding
    add-backs in the amount of $18 million mitigated these reductions for FY 09 -10.

    As a result of current revenue shortfalls in Tennessee, DMHDD is faced with a net FY
    10 - 11 budget reduction of nine million. The impact of these reductions has been
    minimized through a reinvestment of two million in non-recurring funds for FY 10 -11.

    DMHDD continues to make every effort to find ways to both conserve and augment
    existing funding while working to ensure continuation of important basic mental health
    and substance abuse treatment services.

    The FY 10-11 budget leaves the department's funding in a vulnerable position. A
    significant amount of the department’s budget for services for mental health and
    substance abuse are not funded on a recurring basis. As the economy improves and
    a new administration comes into office, DMHDD must focus on restoring permanent
    recurring funding to these programs.

    The DMHDD Planning and Policy Council monitors the Department’s budget and
    makes recommendations as needed. There is great concern on the part of the


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    Planning and Policy Council on the shift of state dollars from recurring to non-
    recurring dollars.

   DMHDD’s ability to ensure availability of services and supports for uninsured and
    underinsured persons is limited due to lack of sufficient funding streams leaving
    many persons in the state with limited access to timely, appropriate care in the most
    appropriate environment. In response to these realities, the Department is exploring
    options to meet the mental health and substance abuse needs of those individuals
    who have been impacted by funding shifts, especially in TennCare. Since the “state
    only/judicial” categories were eliminated from TennCare some of those uninsured
    persons with SMI are now receiving services through the Behavioral Health Safety
    Net Program (BHSN).

    Historically, lack of insurance parity for mental health and substance abuse services
    and the disproportionate lack of allocation of health care dollars to fund services for
    persons with mental illness and substance use disorders limits access to services
    and supports. However, with the passage of parity legislation, access to services
    and supports should be increased. Since the Tennessee Department of Commerce
    and Insurance (TDCI) has insurance regulatory responsibility, DMHDD continues to
    meet with TDCI to assist them in understanding federal mental health and substance
    use disorders insurance parity regulations.

   DMHDD is challenged with building a data infrastructure to meet all federal and state
    mandates to gather data necessary to carry out duties related to planning, needs
    assessment, standard setting, evaluation, and development of services and supports
    for current and potential service recipients as well as completing an annual
    assessment of the public’s need for mental health and substance abuse treatment
    services and supports.

   Mental Health and Substance Use Crisis Services - DMHDD is working to decrease
    available outpatient services and supports for people with mental illness, serious
    emotional disturbance, substance use disorders, and co-occurring substance use.
    The addition of four crisis stabilization units in FY 2009 has greatly contributed to the
    success of the crisis service provider's ability to keep individuals out of the hospital.

    There are currently seven crisis stabilization units (CSU) with walk-in capabilities
    serving the state. These services have also contributed to decreased inpatient
    utilization, as well as ER and jail diversion through the walk-in center. This service
    was originally established based on a model that assumed 70% TennCare and 30%
    uninsured. However, due to TennCare cuts and the state of the economy, this model
    has proven to be just the opposite, serving close to 70% uninsured and 30%
    TennCare. This has created additional funding challenges for TDMHDD, particularly
    in light of the budget reductions occurring over the past several consecutive years.




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    During FY 09-10, the department, in conjunction with the Bureau of TennCare,
    established five Medically Monitored Crisis Detoxification Services to address the
    needs of individuals needing medical detox services on a twenty-four hours a day,
    seven days a week basis. This successful model, which reduces hospital
    admissions, emergency department services, and criminal justice involvement, is
    currently limited in its ability to fully serve the community due to reduced funding in
    FY 10-11.

    The availability of the MMCD services to the crisis delivery system has significantly
    improved access to care for uninsured individuals in need of detoxification services.
    Prior to establishment of MMCDs, most in need were only able to access services in
    a more costly, inpatient setting or did not receive treatment at all. Often, individuals
    with A&D addictions reach a point where they would rather end their lives than to
    continue using the intoxicant causing so much pain to themselves, family and
    friends. It is at this point that the crisis delivery system becomes involved and access
    to this service becomes invaluable.

    The reduction of funding for MMCD services for uninsured individuals has
    significantly reduced its benefits to the crisis services delivery system. The demand
    for the service far outweighs the supply, resulting in increased referrals to
    Tennessee's Emergency Departments and inpatient settings. The increased volume
    of uninsured individuals along with the corresponding decrease in uninsured MMCD
    funding, has made this service much less beneficial to the crisis services delivery
    system due to limited accessibility.

   Employment - A primary challenge for DMHDD is the lack of funding to establish an
    Employment Facilitator in each of the 7 mental health planning regions. Based on
    the significant success in the expansion and improvement of housing options for
    people with mental illness through the Creating Homes Initiative, DMHDD is
    committed to developing a similar model for Creating Jobs Initiative, anticipating
    similar outcomes. Research demonstrates that work is a key to recovery and that
    persons with mental illness are able to live more rewarding lives through this
    contribution to their communities. Studies show that 60% - 75% of the people with
    mental illness want to work. However, 85% - 95% are unemployed. The impact of
    the lack of employment opportunities for persons with mental illness and co-
    occurring disorders, includes increased homelessness, increased criminal justice
    involvement, and increased hospitalizations. Lack of funding severely limits the
    implementation of the Creating Jobs Initiative. DMHDD continues to seek alternative
    funding to develop and maintain this program.

   For the past two years, the State has not met its Maintenance of Effort (MOE)
    requirement for the Community Mental Health Services Block Grant. In order to
    meet the MOE, the State must maintain expenditures for community mental health
    services at a level that is not less than the average level of such expenditures
    maintained by the State for the 2- year period proceeding the fiscal year for which
    the State is applying for the grant. Since the MOE requirement for FY 2010 has not


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   been met, a waiver from the MOE requirement under condition 1, Extraordinary
   Economic Conditions has been requested from the Substance Abuse and Mental
   Health Services Administration. If approved, the waiver will enable DMHDD to
   continue mental health block grant funding allocations for the next state fiscal year
   contracting period beginning July 1, 2011. DMHDD has made every effort to find
   ways to both conserve and augment existing funding while working to ensure
   continuation of important mental health and substance abuse treatment services.


The Department and the DMHDD Planning and Policy Council recognizes the impact
the economy is having on the system of care, and as a result, sees its advocacy role as
critical in assuring that resources are optimized in a manner that does not compromise
the quality of care to those most in need. Mental Health and Substance Abuse services
are highly effective and are a bargain investment for individuals, families, communities,
and the state.




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