Georgia’s Imperative: Implementing the Final Report of the … · 2019. 5. 1. · Georgia’s Imperative: Implementing the Final Report of the President’s New Freedom Commission

Implementing the Final Report of the President’s New Freedom Commission on Mental Health

Ninth Annual Rosalynn Carter Georgia Mental Health Forum

Georgia’s Imperative:

Georgia’s Imperative:Implementing the Final Report of

the President’s New Freedom Commissionon Mental Health

Ninth Annual Rosalynn Carter Georgia Mental Health Forum

May 12, 2004

Atlanta, Georgia

4 Ninth Annual Rosalynn Carter Georgia Mental Health Forum

Table of Contents

Welcome .......................................................................................................................................................................... 4Thomas H. Bornemann, Ed.D., Director, The Carter Center Mental Health Program

Opening Remarks ............................................................................................................................................................5Rosalynn Carter, Chair, The Carter Center Mental Health Task Force

Keynote Address ..............................................................................................................................................................7James Stone, M.S.W., C.S.W., Deputy Administrator, Substance Abuse and Mental Health Services Administration

Questions and Answers ................................................................................................................................................13

Panel: Laying the Foundation ......................................................................................................................................15Cynthia Wainscott, Moderator, Chair-elect, National Mental Health Association

Goal One: Americans Understand That Mental Health Is Essential to Overall Health ......................................17Benjamin Druss, M.D., M.P.H. Rosalynn Carter Chair in Mental Health, Rollins School of Public Health, Emory University

Goal Two: Mental Health Care Is Consumer- and Family-Driven ........................................................................20Larry Fricks, Director, Office of Consumer Relations, Georgia Division of Mental Health, Developmental Disabilities and Addictive Diseases

Goal Three: Disparities in Mental Health Services Are Eliminated ......................................................................22Gail Mattox, M.D., Chair, Department of Psychiatry and Behavioral Sciences, Morehouse School of Medicine

Goal Four: Early Mental Health Screening, Assessment, and Referral Are Common Practice ..........................26Tricia Hernandez, M.S., Chair, Mental Health Services Coalition

Goal Five: Excellent Mental Health Care Is Delivered and Research Is Accelerated ..........................................29Peter Buckley, M.D., Professor and Chair, Department of Psychiatry and Health Behavior,Medical College of Georgia

Goal Six: Technology Is Used to Access Mental Health Care and Information ..................................................32Rick Dunn, Director of Evaluation, Decision Support Section, Georgia Division of Mental Health, Developmental Disabilities and Addictive Diseases

Questions and Answers ..............................................................................................................................................36

Work Groups – Charge and Recommendations ..........................................................................................................37

Closing Remarks ............................................................................................................................................................41Rosalynn Carter, Chair, The Carter Center Mental Health Task Force

Biographies......................................................................................................................................................................42

Georgia’s Imperative: Implementing the Final Report of the President’s New Freedom Commission on Mental Health 5

The Forum receives major support from AstraZeneca and GlaxoSmithKline.

Special thanks to the Planning Committee:

Thomas Bornemann, Ed.D., The Carter Center Mental Health Program

Lei Ellingson, The Carter Center Mental Health Program

Cherry Finn, Georgia Department of Human Resources

Cheryl Josephson, National Mental Health Association of Georgia

Pierluigi Mancini, Ph.D., Clinic for Education, Treatment and Prevention of Addiction

Delois Scott, Georgia Mental Health Consumer Network

Sue Smith, Ed.D., Georgia Parent Support Network, Inc.

Pat Strode, National Alliance for the Mentally Ill – Georgia

Sharon Jenkins Tucker, Georgia Mental Health Consumer Network

Publication Design: Madison Graphics, Inc.

Editor: Randi Rossman

Event Photographer: Annemarie Poyo

Thomas H. Bornemann, Ed.D.Director, Mental Health Program, The Carter Center

elcome to the ninth annual Rosalynn Carter Georgia Mental Health Forum. This is achance for those of us in Georgia to take a look at issues of compelling concern to our state.Like most states in the union, Georgia is challenged tremendously right now: challengedfiscally, challenged from a public policy perspective, and challenged to improve services andservice delivery. That challenge is even tougher due to the economy and other factors. It isimportant for us to pull together as a total community and look at what we can do to movean agenda forward and overcome these challenges.

Today we are going to look at the President’s New Freedom Commission on Mental Healthas a framework from which to begin our work. As you read the report, you will see that itdoes not get into specifics. The details of how to implement the report’s recommendationsare for us to determine. Real change associated with the commission’s report is going tohappen here – at the state and local level. We have been looking forward to this forum andto rolling up our sleeves and seeing what can be done to improve mental health serviceshere in Georgia.


Welcome

W


Rosalynn Carter Chair, The Carter Center Mental Health Task Force

elcome to The Carter Center and to our Georgia Mental Health Forum. I am partialto Georgia. I got started here with my mental health work. That was a long time ago, and everything has changed since then. When Jimmy was governor, nobody talked aboutmental illnesses. No one would admit that there was a mentally ill person in the family.

I remember going to Central State Hospital in Milledgeville and seeing people tied inchairs, rocking. It was terrible. Back then, we began moving people out into the communityinto temporary centers until we could establish better facilities. I remember visiting one in Thomasville, Ga., on what had been an old Army post. What a change – it was such a wonderful contrast. People were able to walk outside. They had a store where they could choose their clothes, something they had not done in years. They went through aline in the cafeteria and chose their own food. Compared to what we are doing today, itdoesn’t seem like very much. Back then it was an amazing step forward from being shut upin an institution.

That day in Thomasville, I walked out onto the porch and saw two men who had been at Central State for years. They had recently been transferred to this facility. One man wassmoking a cigarette. The other one wanted it and finally got up the courage to nudge thesmoker and point to the cigarette. While the owner of the cigarette did not share then, thenext time I went to Thomasville, I saw the two walking outside together, talking with eachother. It was wonderful to see the change – from isolation to community.

Changes in mental health care are still going on. I recently received a survey reportshowing a reduction in stigma and an increase in people accessing the mental health systemand obtaining treatment. That is improvement! Yet, the New Freedom Commission reportsthat in Georgia and states across the country, the mental health system is in shambles andneeds to be transformed, not just reformed. It is sad that with all of the great advances inknowledge of the brain and in diagnosis and treatment of the illnesses, our system has notkept up with the progress and something this dramatic has to be done. We have tried manytimes in the past to improve the mental health system, sometimes by trial and error. We allknow that there are programs that work. One of our forums focused on some of these herein our own state.

Over the past few years, there has been increased attention on mental health with thesurgeon general’s report and now with the President’s New Freedom Commission report.What struck me when reading the report of the current commission was how many of theissues are the same as those of our commission 25 years ago. This is frustrating news. Thereis one striking exception, though, and that is recovery. With all the improvements in theability to diagnose and treat mental illnesses effectively, we now know that recovery ispossible. It is absolutely wonderful to see recovery as a focus of the report.

Opening Remarks

W

The commission has done its work. Now it’s up to us, the mental health community andthe general public, to complete the task of transforming our system of care and implementingthe report’s recommendations. And, if the general public is going to be of any help in ourefforts, we have to educate them and get them involved.

Implementing these recommendations is going to be a huge task, and we must worktogether. No one group can do it alone. It will take all of us, everyone in the mental healthfield – policy-makers, advocates, professionals, researchers, consumers, and family members.

Today is an important time for us to come together. The mental health system in ourstate is struggling, as it is in states across the country. Programs are being cut. As a result,instead of moving forward with all our new knowledge and evidence-based practices, we are in danger of losing what we have. This is frightening.

Today we will look at the recommendations of the New Freedom Commission and seehow we can best leverage and implementthem. My hope is that we can agree on atleast one recommendation from each of thesix goal areas that can be incorporated intoGeorgia’s mental health system. If we can dothat, we will consider this day a success.



he concept of mental health system trans-formation has been with us for years. Whilewe all know that the delivery of services inthe mental health system must change, weare still experiencing the very sameproblems that we had in the 1978 Cartercommission report. That is the bad news.

The good news is that things really arechanging now. We are focusing more on ascience base, including research in brainfunctioning, understanding of trauma, andother factors in mental illness. The result isan understanding that mental illness is

not a function of weak character or poorupbringing, but morecomplicated issues. Wecan only hope that soonthe general public willequate mental healthwith physical health,

and as a consequence, we will see the stigmaattached to people with mental illness gothe way of the stigma that attended cancerin years gone by. In the past 25 years, therehas been a tremendous change in the waymental health professions regard mentalillness. At the time of the Carter commissionreport, we did not regard serious mentalillness as treatable, and so we relied on institutional care. The word “recovery” was not in our vocabulary.

Our message to the public has to be thatmental health is fundamental to physicalhealth. That mental illness is real and is aphysical illness with physical and chemicalmanifestations. That mental illness istreatable and recovery is possible. It is time,

therefore, to end the blame-and-shameattitude that people have and eradicate the stigma related to mental illness.

Good mental health needs to be part ofour nation’s effort to promote good healthin general. This concept is reflected in thesurgeon general’s report on mental health.Just as a person can do much to promoteand maintain overall health regardless of age, each person also can do much to promote and strengthen mental health at every stage. Therefore, it is importantthat we understand mental health care atevery stage in the context of the publichealth model.

The public health model takes acommunity approach to preventing andtreating illness. Its premise is that caring for the health of an individual protects thecommunity, while caring for the health ofthe community protects the individual, withan overall benefit to society at large. Mentalhealth is a public health issue because itaffects the overall health of the communityand our nation as well as that of anindividual. The surgeon general’s report on mental health states that “from earlychildhood until death, mental health is aspringboard of thinking and communicationskills: learning, emotional growth,resilience, and self-esteem.” These are theingredients of each individual’s successfulcontribution to community and society.Thus, not caring for the mental health of anindividual denies that person a full life inthe community and denies the communitythe benefits it could receive from thatperson’s sound mental health.

Keynote Address

James Stone, M.S.W., C.S.W.Deputy Administrator, Substance Abuse and Mental Health Services Administration

T

Mental health is a public health issue because it affects the

overall health of the communityand our nation as well as

that of an individual.

We can see the truth of thisstatement across thegenerations. Fiftypercent of studentswith serious emotionaldisturbances drop outof high school. Onlyabout one in threepeople with a mentalillness is employed.The costs of mentalillness in terms ofhealth and lostproductivity arestaggering. The WorldHealth Organizationhas identified mentalillnesses as theleading cause ofdisability worldwide,

accounting for 25 percent of all disability in industrial countries. How we care for themental health of the current child and adultgenerations will determine if mental healthcare will become a public health crisis forthe next generation. About 5 to 9 percentof American children have a seriousemotional disturbance that, left untreated,can lead to serious emotional illnesses andphysical complications in adulthood.

By the year 2010, approximately 40million Americans will be age 65 and older. More than one-fourth of older adultshave mental health issues, including mentalillnesses, alcohol use, depression, anxietydisorders, dementia (including Alzheimer’sdisease), and suicidal ideation. Their mentalillnesses will significantly affect their healthand functioning, with a compounding effect on the care they will need and itsassociated cost.

We have evidence that poor mentalhealth can undermine physical well-being.We know that patients who experience amajor depressive episode following a heartattack have an increased risk of early cardiacdeath. We know that emotions such as fear,anxiety, and depression can worsen the painof cancer and other severe illnesses. Mentalhealth and physical health are inseparable.

Scientific studies demonstrate thattreating the mental health needs of adultsbenefits them both mentally and physically,even when they have a chronic illness.Treating the mental illnesses of dual-diagnosed patients can improve theirinterest and ability to care for themselves. It can engage them in following theirprimary care provider’s directions andadvice, particularly about taking medica-tions. It can transform their hope inrecovery or bolster their ability to cope with illnesses from which there is littlechance of recovery. Science has substan-tially broadened our knowledge about thecritical link between mental and physicalhealth. Unfortunately, our society as awhole and our national health care systemhave been slow in making the benefits ofthis knowledge available to consumers atthe clinical level.

Our current mental health system is characterized by services that arefragmented, disconnected, and often inade-quate. Too often, today’s system focuses only on managing the symptoms of mentalillness and accepts long-term disability as a foregone conclusion. Recovery, notdisability, should be the expected outcomefor everybody. A recovery-focused systemsees each individual as a unique humanbeing and not just as a person with acategorical disability. A recovery-focusedsystem focuses the dialogue about care torevolve around the comprehensive needs of



a person living in a community, such as finding a job and home and buildingfulfilling relationships with others.

Individuals with mental health disordersundergo unique experiences while being in recovery. They grow to accept having a chronic incurable disease that is apermanent part of them without guilt orshame, fault or blame. After time andfocused help, they can avoid complicationsof the condition. They can participate inongoing support systems as both recipientand provider. They can change manyaspects of their lives, including theiremotions, interpersonal relationships, andspirituality. They learn to accommodatetheir illness and grow through overcomingit. The most compelling element of recoveryis the belief that people with mentalillnesses can take charge of their own lifeand make choices.

However, our current mental healthsystem is not focused on recovery. Wecannot have a mental health care systemthat is driven by the needs of the consumersand their families without transforming theway we do business. What does it mean totransform a system? Let’s look at a definitionof transformation by retired Vice AdmiralCebrowski, special assistant for transfor-mation in the Department of Defense, whostudied this concept in depth. He viewstransformation as an ongoing process thatdemands profound changes at the core of asystem, not at its margins. Transformationinvolves new ways of thinking, doing, andworking together. Once the process of trans-formation begins, a profoundly differentsystem will emerge, with changes in itsstructure, culture, policy, and programs.

In the final report by the President’s NewFreedom Commission on Mental Health,Achieving the Promise: Transforming MentalHealth Care in America, the commission

asks that we undergo a complete upheavalof what we know, what we do, and how we go about delivering mental health care from the federal to the clinical level. Thecommission envisions a national mentalhealth system in which everyone with amental illness at any stage of life will haveaccess to effective treatment and supports.This system will actively facilitate recoveryand helps those with mental illnesses buildresilience to life’s challenges. These wordshave particular meaning when we considerdual-diagnosis as one of life’s greaterchallenges.

Achieving the Promise outlines six goals fora transformed mental health care system:

1. Americans will understand thatmental health is essential to overall health.

The commission’s two recommendationsfor achieving this goal are: (1) that wereduce the stigma of seeking care and (2)that we address mental health with thesame urgency as we address physical health.

The stigma of seeking mental health careis so strong that nearly half of the nearly 15million American adults who have seriousmental illnesses will not seek treatment.Their failure to seek treatment has seriousimplications for long-term health. As manyas half of the adults who have a diagnosablemental illness also will have a substanceabuse disorder at some point in their lives.Research demonstrates that if only onedisorder is treated, both usually get worse. In addition, failure to seek treatment forserious mental illnesses places adults at risk of other adverse affects, such as patientdistress, impaired functioning, or heightenedrisk of death, pain, disability, and a loss of freedom.

As part of our efforts to eliminate stigma,SAMHSA has created the Center forAddressing Discrimination in Stigma (ADS

Center). The ADS Center is making information about recognizing and eliminating stigma available. This infor-mation is available at our Web address.

One manifestation of stigma is reflected inthe disparity between insurance paymentsfor primary care and mental health services.

Mental health care serviceshave traditionally been morelimited than other medicalbenefits. This situation affectsstate mental health care servicesin particular, since the states areincreasingly relying on Medicaid

programs to support their mental healthcare system. Medicaid is now the largestpayer of mental health services in thiscountry. SAMHSA is working with theCenters for Medicare and Medicaid Services(CMS) to investigate alternative financingmodels to align payment with what weknow works in mental health care services.At the state level, you can advocate forbetter cooperation and collaborationbetween your state Medicaid office and state or local service providers.

The surgeon general’s report on mentalhealth found that the mental health fieldcan help eliminate stigma by finding causesand effective treatments for mentaldisorders. This report states that, “Whenpeople understand that mental disorders arenot the result of moral failings or limitedwillpower, but are legitimate illnesses thatare responsive to specific treatment, muchof the negative stereotyping may dissipate.”

As mental health professionals, you can help eliminate stigma by focusing onthe use of evidence-based practices anddocumenting their effectiveness by demon-strating to consumers and nonconsumersalike that recovery is a real possibility.Stigma is something that mental healthprofessionals must fight aggressively. Stigma

is an antiquated byproduct of fear andignorance that has no place in the 21stcentury. It is preventing people fromreceiving the treatment they need, denyingadults their path to recovery, and under-mining effective, integrated services forthose with illnesses that are often disablingwhen left untreated.

2. Mental health care will be consumer-and family-driven.

A transformed mental health system will respond to an individual’s diagnosis ofserious mental illness with a highly individ-ualized plan of care. This plan will recognizethe individual in his or her entirety and willintegrate the full range of an individual’sneeds to support recovery, such as housingand supported employment. To ensure thatthe needed resources are available, statesshould develop a comprehensive mentalhealth plan outlining responsibility forcoordinating and integrating programs.

I am pleased to say that these comprehensivestate mental health plans are alreadymoving from the commission’s vision toreality. President Bush’s 2005 fiscal yearproposed budget contains $44 million tohelp states begin to develop plans that can transform mental health care at thelocal level. When your state is debating thebest elements of its comprehensive plan,make certain that representatives of yourorganization speak to what you believe willbenefit the needs, desires, and demands ofyour consumers.

3. Disparities in mental health care areeliminated.

One disparity is the care available in ruralareas. Another is racial and ethnic disparities.Minorities in the United States face manysocial and economic barriers to health care,including racism and discrimination,


Stigma is an antiquatedbyproduct of fear and

ignorance that has no place in the 21st century.


violence, and poverty. Each of these conditions adversely affects both physicaland mental health.

4. Early mental health screening,assessment, and referral to services arecommon practice.

In this goal, the commission emphasizesthe need to treat dual-diagnosed disorders as primary illnesses. Integrated treatmentscan improve patient engagement, reducesubstance abuse, improve mental health,and reduce relapses for all age groups. These

benefits apply not only to mental illnessescombined with substance abuse disordersbut also to mental illnesses and otherphysical disorders.

One of the many factors that can affectthe emotional health of young children isthe mental health status of their parents.Therefore, treating the mental illness of adults becomes preventive treatmentfor children’s disorders. The commissionrecommends that we initiate mentalhealth screenings in all settings in whicha high occurrence of behavioral disordersexists. Given the high incidence ofsubstance use disorders among parents ofchildren in the child welfare system, thecommission suggests that these parents arescreened for co-occurring disorders andlinked as needed with appropriatetreatment and supports.

Transformation of our mental healthsystem requires that we change how weprovide care, including building strongerpartnerships among those with a stake inthe mental health care of the community.The screenings recommended by thecommission involve not only primary andmental health care providers but also theeducation, judicial, and child welfaresystems, among others.

5. Excellent mental health care isdelivered, and research is accelerated.

Accelerating research, and in particularshortening the lag between discovery of aneffective form of treatment and the timewhen it becomes part of routine patientcare, is essential for mental health systemtransformation.

SAMHSA is taking steps to more rapidlyidentify and disseminate evidence-basedpractices. One important and recentadvance is the expansion of the NationalRegistry of Effective Programs (NREP).

NREP conducts expert evaluations ofprograms to determine model evidence-based interventions and places theseprograms in a national registry. Weexpanded NREP last year by adapting itscriteria to mental health and co-occurringdisorder treatment programs. Now we aredoing the same thing with mental healthpromotion and prevention programs.

This goal highlights another critical issueof mental health care in America: workforce adequacy, both in terms of sufficientnumbers and skills. Not only is there ashortage of providers, but many of thesystem’s most experienced providers are nottrained in cutting-edge, evidence-basedpractices.

For example, there is a serious need tocrosstrain primary care providers to becomeknowledgeable participants in providingmental health care. Primary care providersnow prescribe the majority of psychotropicdrugs for both children and adults.Approximately 70 percent of the care forcommon mental disorders is delivered ingeneral medical settings. I do not think that most people in primary care realize how much mental health service they

actually provide.

Another example is that the schools ofsocial work in New York City are trainingstudents for jobs that nolonger exist. They arestill training people forthe 50-minute clinical

hour. Yet, social work does not happen inclinics anymore. We need to be workingwith people in their own environment.Therefore, we are working very hard totransform the way students are taught inschools of social work and psychology andin the psychiatric field. I would advise all of

you to look at how people are being trainedas you look at your state system. Are theybeing trained for jobs that exist?

6. Technology is used to access mentalhealth care and information.

The last goal states that we should use thetechnology that is available to us to accessmental health care and information. Forexample, nearly 60 million people live inrural and frontier areas, each facing a rangeof life challenges, and deserve the samequality of mental health care as our urbancitizens. But in areas without an adequatesupply of mental health professionals,primary care physicians deliver most mentalhealth care. Telehealth, for example, israpidly emerging as our opportunity to cross-train and support primary care physicians tooffer specialized care long distance and tointegrate evidence-based practices at thelocal level.

I have just given you a brief overview of the New Freedom Commission’s reportand its vision of a transformed system.SAMHSA and other federal agencies arenow taking the first tangible steps towardturning the commission’s vision into areality. We have created a TransformationWork Group, an executive team of 18federal partners that have been meeting the past several months to analyze thecommission’s recommendations anddetermine how federal agencies can respond.The team has just recently completed anational mental health action agenda. Thisagenda is based on the conviction thatmental health illnesses are treatable andrecovery should be the expectation. Theaction agenda sets time-limited, realisticpriorities for the first year of a planned five-year transformation. It defines the first stepsof the federal role in the transformation.Federal agencies can act as leaders,


State-level leadership andplanning, financing, service

delivery, and evaluation ofconsumer- and family-driven

services will significantly advancethe transformation agenda.


facilitating and promoting shared responsibility for change at the federal,state, and local levels.

However, the states will be at the verycenter of system transformation. State-levelleadership and planning, financing, service

delivery, and evaluation of consumer- andfamily-driven services will significantlyadvance the transformation agenda.

When we create a mental health caresystem that supports every American inbecoming all they can be, our nation willbecome all that it can be.

Q & AQ Please talk about the response from your federal partners at CMS regarding financing. I think a

lot of people are willing to implement some of the creative solutions presented in the report but are unable to do so because of financing. For example, I know my primary care colleagues have a lot of trouble with reimbursement when they give a psychiatric diagnosis.

A Mr. Stone: I think that CMS is a lot more flexible than we give it credit for. Very often it does comedown to a question of finance. I would suggest that you work very closely with your state Medicaidagency. Get to know those people, and I think that you will find a lot of opportunity for flexibility thatyou did not know existed. Part of the reason that it is not widely known that CMS is more flexible isthat flexibility costs money, and frankly, there is no real advantage financially to the state to display thatkind of flexibility. My underlying message is this is not about the lack of flexibility but about how muchthings cost. If you can showcase the value, you will find that CMS is a lot more flexible than you realize.

Q While it has taken awhile, we are beginning to see some trickling of funding to address co-occurringdisorders. Can you share with us an overall picture of the agencies – including addiction treatment,mental health treatment, and prevention – to serve the complete client?

A Mr. Stone: I think the whole concept of co-occurring disorders is fairly recent. While consumers mergedmental illness and substance abuse a long, long time ago, the field was very slow to pick up on it, and thebureaucracy was even slower.

We are the problem. The problem surrounding co-occurring disorders probably persists because we arecomfortable working with our own little funding streams and our own little silos. This is doing a lot ofdamage to people in need of service. This is an idea whose time has come.

Coordination of care occurs at the local level, not at the state or federal level. Localities – counties and cities – have to figure out how to blend funds and how to encourage providers to provide thoseintegrated services. The field is already there, and our consumer base is already aware. We have to figureit out.

Q What are you doing to get the parity bill that has been sitting at the federal government out ofcommittee so it can be heard?

A Mr. Stone: It is very difficult for people in political life to take a position on mental health. Those inpolitical life would like to pretend that mental illnesses do not exist. There is no real benefit for them.They are willing to get involved in substance abuse issues because that is visible and it gets them some

Questions and Answers


press. But mental illness and mental disability are generally scary to people in political life. I am not surewhy. I think the continual education of those in political life by advocates is very important.

As for the parity bill, both the president and Secretary Thompson have expressed support for parity.Beyond that, the issue is languishing in Congress, probably because of other priorities. I think we canonly continue to pressure our representatives to move it along. There has to be a will to do it, and I amnot really seeing that will right now.

A Mrs. Carter: I want to add something to that. In the House, we have 268 representatives who aresponsors of the bill, more than half. In the Senate, we have 65 senators who are sponsors of the bill. We cannot get it out of committee because of the committee leadership. Since we have the votes in both the House and the Senate to pass it, we need to put pressure on the Republican leadership of thosecommittees. Insurance companies are very powerful, so it is up to all of us and to everybody that we caninfluence to keep the pressure on, write local congress people or those who are running for office, to besure that they support parity in insurance.

Q My question is related to housing. We often see people of all ages in long-term care settings who havemental health issues and who are in these settings solely because Medicaid will pay for the housing.Without affordable housing, we cannot transition them out of the nursing homes. Therefore, people endup in personal care home settings or boarding care settings because there is not affordable housing. I amwondering if you have any comments on what hope there might be for affordable housing.

A Mr. Stone: I think people do forget that housing is such an important issue. The Department of Housingand Urban Development (HUD) has essentially gone out of the business of providing subsidized housingfor those with disabilities gradually over the past 10 years – all disabilities, not just mental health. It isbecoming an increasing problem. What exacerbates it is that many of the programs that started out along time ago with special funding from the federal government are decreasing their commitments to the housing providers. As a result, these providers are turning their housing into other kinds of housing.

Part of the issue is that we have to raise the amount of money that people obtain for disabilities – theincome from Social Security, for example. People cannot reasonably afford decent housing on the SSIamount. Just raising SSI to a more reasonable level would do a lot to alleviate the housing problem.That is something else for which we should advocate.


r. Stone talked about transformation. Weare a little overtransformed in Georgia rightnow, and we are leery of change because ofwhat has happened here over the last 10years. House bill 100 created 19 regions,which then became 13, which then becameseven. Each one of those regional changescame with huge management upheavals. We now have geographic areas so large it isdifficult to conduct local planning. In fact,much of the decision-making has been re-centralized. These changes were imposedupon us from outside the system, and it isinteresting that consumers, families, andadvocates opposed each of these changes.The uncovering of long-standing irregular-ities has damaged the public confidence inour system. Our internal strife – what mygrandmother called “squabbling” – becamevery public sometimes.

As power shifts, people feel uncomfortable.Change is difficult. What we desperatelyneed in Georgia is a coordinated voice. I think the New Freedom Commission’sreport gives us an opportunity to do that.

One of the outcomes of what we havegone through is that our system is seriouslyunderfunded. In fiscal year 1991, MentalHealth, Developmental Disabilities, andAddictive Diseases (MHDDAD) servicesaccounted for 5 percent of the state budget.In fiscal year 2002, it was 3 percent. Ourpopulation has increased by 31 percentduring that same period, and the ConsumerPrice Index has gone up 36 percent. Peoplewho are a lot smarter with numbers than I am tell me that if the Department ofHuman Resources (DHR) had gotten its fair

share as the population and the ConsumerPrice Index went up, we would have anadditional $275 million.

As grim as those numbers are, they do not showcase the total problem, becausesignificant Department of CommunityHealth (DCH) dollars went into DHR and are administered now by DHR. Thisadministrative change made DHR’s budgetbigger but did not produce any servicecapacity enhancement. If you figure thatadministrative budget shift in the picture,we are even farther behind in our fundingthan the numbers indicate.

Another really serious problem we have isthat our fiscal incentives absolutely do notencourage – in fact, they often discourage –planning between agencies. Our depart-ments of Community Health, JuvenileJustice, Corrections, and Education operateindependently of one another. There arehuge mental health dollars spent by all ofthose other agencies.

We continue to miss an opportunity forearly intervention in the schools. We needto expand, not contract, our understandingof and vision for prevention. We have gonefrom 13 prevention specialists to seven, and I currently believe we only have three.We are heading in the wrong direction on prevention.

Data is another serious deficit. We do nothave a statewide data system with commondata criteria to exchange information. Wedo not have a common definition for thepopulation served. When you think aboutattempting to plan in a system that does nothave a common language, you can begin to

Panel: Laying the Foundation

Cynthia WainscottChair-elect, National Mental Health Association

M

see the handicap. The good news is that we are contracting for a gap analysis. Withleadership by the Georgia Mental HealthPlanning and Advisory Council, a contractand request for information is on the street.

We have some real strengths, however. I think our major strength is the people here in this room today. I look around and see many colleagues who havecommitted untold hours of energy. We have an unrecognized power. We have

not held hands and marched together oncommon agendas very often. However, if wedo unite in a common agenda, we can reallytransform our system, not just change it.Another strength we have is our nationalleadership position with recovery.

I am going to close by saying we havesome deficits, we have some real strengths,and I think this is a remarkable opportunityfor Georgia.



“Mental health is essential to overallhealth” is the first goal of the President’sNew Freedom Commission on MentalHealth. I think the statement is self-evidentfor many of us here. It is like saying that youcannot make a coin with only one side. Sowhy would the President’s New FreedomCommission make this their very first goal,and why should we be taking the time totalk about it today?

The reason is that too often mental healthis not treated as essential to overall health,in the United States or here in Georgia.Mental health care in both the private and

public sector is increas-ingly carved out orseparated from otherhealth services. Healthand mental healthbenefits also are notequal. The difference in benefits packagesreinforces the divisionsbetween the treatment

systems, endangers quality of care, andperpetuates the belief that mental health isnot really a part of overall health. Finally,stigma is alive and well and drives thischasm wider, for just as stigma perpetuatesinequalities in mental health benefits andmental health care, the failure to recognizemental health as a part of overall healthperpetuates stigma.

The President’s New Freedom Commissiondescribed a fragmented and broken systemand called for a major transformation. Intoday’s political environment, the states arethe ones who need to take a lead in thisprocess. We need to “think globally and actlocally,” or think nationally and act in the

states. That is why this conference is soimportant. Within our state are a number of key constituencies, each of which has an important role to play in bringing aboutsuch a transformation in Georgia. Most ofthe stakeholder groups are represented heretoday: providers, purchasers, academicians,policy-makers, and consumers.

Providers

I know there are a number of providers inthe room here today, both general medicaland mental health. Primary care providersare the front line in the recognition andtreatment of mental health in the UnitedStates. As we heard earlier, about 50 to 70percent of mental health is delivered inprimary care settings. You also heard thestatistic that only half of mental disorders in primary care are correctly diagnosed andthat only half of those that are diagnosedare appropriately treated. Primary careproviders should know that these statisticsare, for the most part, not their fault. Wehave a medical system that is ill-suited to provide population-based care and thefollow-up required to improve thesenumbers. We must work together toimprove that system.

Mental health providers must rememberthat our clients have bodies. We need to be aware of clients’ ongoing medical issues,keep a problem list, and make sure theyhave and are seeing a primary care providerregularly. We need to consider lifestyleissues such as tobacco use, diet, andexercise. Improving basic physical health is important for emotional and mental well-being.

Goal One: Americans Understand That Mental Health Is Essential to Overall Health

Benjamin Druss, M.D., M.P.H., Rosalynn Carter Chair in Mental Health, Rollins School of Public Health, Emory University

Just as stigma perpetuatesinequalities in mental health

benefits and mental health care,the failure to recognize mental

health as a part of overall healthperpetuates stigma.

Purchasers

Providers cannot do this alone. We needhelp from those of you who are purchasers,both in the private and public sectors.These efforts need to be conducted locally,using personal connections with employersas well as research evidence on cost andtreatment efficacy. Currently, an Atlantainitiative is beginning to represent a joint effort of advocacy groups, providers,and corporate leaders to make Atlanta a national model for the provision of high-quality mental health care through the workplace.

We have heard about Medicaid. As thelargest purchaser of public-health mentalhealth benefits, Medicaid must be a criticalpartner in any efforts to transform mentalhealth care, either nationally or in Georgia.

I know that these are not easy times forstate Medicaid agencies. Costs and rolls arerising, states are strapped for cash, providersare frustrated, and constantly changingfederal regulations are making it necessaryto build new information systems. However,the very issues that make this such achallenging environment also make this a critical time to work on improving andstreamlining the delivery of public healthsector mental health services.

I am proud to say that Georgia has aforward-thinking Medicaid department,which has supported the first Medicaid-funded peer-to-peer counseling program inthe United States. But just as we cannottransform Georgia’s mental health carewithout the help of Medicaid, Medicaidneeds our help in navigating through today’sshark-infested political and economic watersin Georgia and other states.

Policy-makers

If mental health is part of overall health,what notion could be simpler and morelogical than the idea of parity: that benefitsshould be the same for medical and mentalhealth care? This legislation has beennotoriously difficult to enact on a federallevel. A limited federal parity law wasenacted in 1996. It is set to expire at theend of this year, and it seems to be stuck in congressional committee. Most of thebattles since 1996 for mental health parityhave been fought and won in states. A totalof 34 states now have some degree of mentalhealth parity, with bills pending in manyother state legislatures.

Many of you were probably involved inenacting Georgia’s parity bill in April 1998,and it is one of the stronger state paritymandates. It is a considerable improvementon the federal legislation, but it also shows



how any parity bill, even a good one, has limits in ensuring equal treatment for mental disorders. For example, the lawonly applies to employers who carry mentalhealth insurance. It does not preclude themfrom simply dropping mental health benefitsaltogether. Like most laws that focus onbenefits, it does not ensure that clients areable to obtain access to the services listedon a benefits sheet. It also has only limitedapplicability to Medicaid and Medicare,which provide benefits to those individualswith the greatest disability. None of this ismeant to undercut the great importance of parity; it is just to say that parity will be only one step – not an end point – in achieving true equality of mental health treatment.

Academicians

In Georgia, we have two psychiatryresidency programs, four medical schools,four clinical psychology programs, sevenschools of social work, and 34 nursingschools. These academic institutions havean enormous reach geographically, politi-cally, and, of course, academically. We whobelong to them need to work with front-lineclinicians and policy-makers to make surewe are asking the sorts of questions andanswers that are relevant to care in Georgiaand that we share our results with those end users.

Academicians need not be afraid to climbdown from the ivory tower, roll up oursleeves, and work as partners with othergroups to improve day-to-day care. Forexample, the Medical College of Georgia is currently working with local consumerleaders to develop a recovery-basedcurriculum for medical students.

Finally, we have an obligation to developa next generation of clinicians who under-stand that mental health is central tooverall health. This includes not onlymental health trainees but also other physi-cians and health care workers, encompassingthe broader Georgia health care community.

Consumers

Consumers are the most importantconstituency of all, because they are thereason that the mental health system existsin the first place. This gives consumers andtheir families both a unique expertise and amoral legitimacy in arguing for improvingand transforming care in Georgia.

The main lesson consumers must considerfrom goal one of the President’s NewFreedom Commission is that mental healthadvocacy is part of overall health advocacy.Most of what is currently broken in themental health system is a microcosm ofwhat is broken in the broader health system.Like the mental health system, the healthsystem is not really a system at all but rathera hodgepodge of services poorly organized toserve the needs of consumers. Like mentalhealth care, health care as a whole isgradually shearing into two systems – onefor “haves” who benefit from new andexciting advances in medicine and one for “have-nots” treated in public settingswhose caseloads are rising and resources are shrinking.

Given these parallels, it is important formental health advocates to align with otherhealth consumer advocacy groups to ensurethat we are fixing the entire health systemand that mental health is front and centerin any broader efforts to fix that ailinghealth system.

While I have divided these stakeholdersinto providers, purchasers, policy-makers,academic leaders, and consumers, thisdivision, like that between mental healthand general medical care, is artificial. Nearlyall of us are likely to fall into more than oneof these groups. We should acknowledge andbe at peace with the fact that we are likelyto be wearing multiple hats and thus bearmultiple responsibilities in improvingmental health care in Georgia.

Finally, we must recognize that becausemental health is part of overall health,mental health transformation must be a part of overall health transformation. We

are never going to be able to have anexcellent mental health system if it isembedded in a dysfunctional health system.We are never going to be able to have anexcellent health system if the mental healthsystem remains broken. The two are inextri-cably intertwined. The prospect is at oncedaunting and liberating. It is dauntingbecause transforming the health system is such an enormous task, and no one canaccomplish it alone. It is liberating becauseit means that we, the mental healthcommunity, are part of a much larger group seeking to transform health care, and so we are not alone in our battle.


Goal Two: Mental Health Care Is Consumer- and Family-Driven

Larry Fricks, Director, Office of Consumer Relations, Georgia Division of Mental Health, Developmental Disabilities and Addictive Diseases

Goal two of the New Freedom Commission’sreport states, “Mental health care is consumer-and family-driven.” I had an interestingwindow into the status of this the last twodays while I was in Annapolis at a meetingof the Annapolis Coalition, a group workingto develop a workforce in this country for behavioral health care. In the past,consumers have not been at these meetings.For this meeting, the coalition recognizedthat certified peer specialists were now partof this country’s workforce. They officiallyrecognized us and had us there. There was a lot of discussion about the report. Many of the presenters frequently used the wordrecovery during their presentations, but theyquickly slipped back into the doctors andscientists being in charge and that the futureof the system depended on their knowledgeand expertise.

Finally, some of the groups representedthere said, “Stop, remember goal numbertwo? Going back to the old way of doingbusiness will not promote recovery, becauseyou cannot build a recovery system withoutthe dramatic and powerful influence ofpeople who have experienced recovery. You cannot build that system of recovery ifyou are allowing people to base what theyare doing simply on what they are learningin academic settings.”

These doctors and scientists were prettyhonest about the disconnect between whatis learned in school and what you do whenyou get out in the field. I am very excitedabout working with the Medical College of Georgia to design training for residentsthat helps them understand strength-basedrecovery.


An outgrowth of the 1999 surgeongeneral's report on mental health has beenthe realization of the value of peer-to-peersupport in the acquisition of real recovery.Certified peer specialists (CPSs) providehope and model the possibility of recoveryto every consumer they serve. The role of the CPS is to transition ownership ofrecovery into the hands of the consumers.Our CPSs train other consumers to managetheir illnesses and to promote their ownrecovery. This is one of the six evidence-based practices reported in the surgeongeneral’s report.

Dr. Jim Saben, in his article aboutstrengthening the consumer voice inmanaged care, published in the April 2003 edition of Psychiatric Services, says,“The primary responsibility of the certifiedpeer specialist is to provide direct servicesdesigned to assist consumers in regainingcontrol over their own lives and controlover their recovery processes. Peer specialists

are expected to model competence in the possibility of recovery and to assistconsumers in developing the perspectiveand skills that facilitate recovery.” He goeson to say, “The aim of peer support is toprovide an opportunity for consumers todirect their own recovery and advocacyprocess and to teach and support each otherin the acquisition and exercise of skillsneeded for management of symptoms andthe utilization of natural resources withinthe community.”

The foundation of getting our CPSprogram off the ground in Georgia startedwith consumer-recovery values. Theleadership came from the consumermovement, when the Georgia MentalHealth Consumer Network wrote a grant to design the training and certification.

Next, we obtained the Medicaid rehabili-tation option to finance certified peerspecialists. There is a lot of flexibility in therehabilitation option. When Substance

Abuse and Mental Health ServiceAdministration (SAMHSA) administratorCharles Curie was at the 2003 RosalynnCarter Symposium on Mental Health Policy,he said, “Folks, it is about relationships.”Historically, in this country, the folks delivering the services – the state Office of

Mental Health, DevelopmentalDisabilities and AddictiveDiseases – and the Medicaidagency did not get along. There was a disconnect betweenthose two agencies. If those two agencies, one funding the

services and the other one delivering theservices, cannot work together and are atodds, you cannot build a recovery system.

We developed a peer support institute sothat consumers can know exactly what goodpeer support looks like. This givesconsumers the power to tell the providerswhat they need.

We use technology to support our efforts.The certified peer specialists have their ownWeb site where they can go online andsupport each other, sharing information andbest practices across the state.

We recently completed mediationrecovery training by the University of SouthFlorida. Peer specialists were trained on how to mediate toward recovery to helptraditional staff understand the concept ofrecovery and how they can work togetherwith consumers toward recovery. We offercontinuing education every three months.

Peer support is 55 percent cheaper thanother forms of day support services and moreeffective. Currently, we have 200 certifiedpeer specialists who serve 2,500 consumerswith this new Medicaid service. The billingthis year for peer support will be $5.5million, and we have been doing this forthree years. Preliminary outcome data of500 patients, age 18 to 55 with schizo-phrenia and bipolar illness, found a 5percent greater improvement for thoseserviced by peer supports than other dayservices in three areas: skills, functioning,and resources. South Carolina and Hawaiinow have certified peer specialists. Thisrepresents goal two in action. It works.

Consumer leaders from New Zealand and the United Kingdom will be looking at three model consumer programs in thiscountry, and ours is one of them. We arevery honored by that.


Goal Three: Disparities in Mental Health Services Are Eliminated

Gail Mattox, M.D., Chair, Department of Psychiatry and Behavioral Sciences, Morehouse School of Medicine

It is a privilege to be part of this transfor-mation team here in Georgia. What exactlydo we mean by mental health disparities?There are three major areas in which wemust focus: (1) Minorities have less access to and are less likely to receive care; (2)minorities in treatment typically receivepoorer quality of care; and (3) minorities areunderrepresented in mental health research.

There were two recommendations for goalthree in the New Freedom Commission’sreport, which include improving access toculturally competent quality care and toquality care in rural areas.

I would like to step back for a moment toreview some of the findings from the surgeongeneral’s report specific to various ethnic

Peer support is 55 percentcheaper than other forms of

day support services and more effective.


groups. We know from the available limiteddata that African-Americans receive mentalhealth care at about half the rate of non-Hispanic whites. Sixty percent of olderAfrican-American adults are not receivingneeded services: They are more likely to useemergency rooms and are more likely to tryalternative therapies first. Older African-American adults are overrepresented ininpatient treatment and underrepresented in outpatient treatment. As for our African-American youth, we definitely do not see them very often in private psychiatrichospitals. They are more likely to be inlong-term residential facilities or in theDepartment of Juvenile Justice.

African-Americans only make up about 2 percent of psychiatrists, 2 percent ofpsychologists, and 4 percent of socialworkers in the United States. For a varietyof reasons, incorrect diagnosis is common,with schizophrenia overdiagnosed andaffective disorders underdiagnosed. Whensomebody presents acute and psychotic, it is difficult to get a good history at that time.So frequently, the psychosis is determined to be possible schizophrenia versus a manicepisode with psychotic features. Data alsosuggests that African-Americans may bereceiving fewer SSRIs and less utilization ofatypical antipsychotics, which means theyare more likely to have severe side effects.

We know from the surgeon general’sreport that similar issues exist for theLatino-Hispanic population. For example,37 percent are uninsured compared to 16percent for all Americans. There are manybarriers to care for the Hispanic population,such as language issues.

As for the American Indian and Alaskanative populations, even though they onlymake up 1.5 percent of the population, they have the highest suicide rate, aresuffering disproportionately from depression,and are overrepresented in inpatient care.They are only 25 percent as likely as whitesto seek outpatient care, and when they do seek care, they may be diagnosed as“problem free.”

When we look at mental healthincidences over the past 30 days, the datasuggests that the prevalence of mentalhealth concerns was not that differentamong ethnic groups, according to theKaiser Family Foundation. When surveysasked, “How often did you feel that yourmental health was not good in the past 30 days,” you see the percentages amongdifferent ethnic groups and averages for theentire U.S. population are very close. So

what does that mean if people are stating in answer to survey questions over thetelephone that they have poor mentalhealth, but they are not receiving services?This points out the disparities.

One in 10 children has some type ofmental health issue, but fewer than one in five receives services. This is more pronounced with ethnic groups. Forexample, in the Kaiser Family Foundationsurvey, about 31 percent of white childrenwere receiving needed mental healthservices compared to 22 percent of African-Americans and 14 percent of Hispanics.

Let’s turn to the disparities in rural areas.Some of the major issues for rural consumersand residents are that they tend to be older and poorer, with more chronic healthconditions. Rural residents under 65 aredisproportionately uninsured, transportationis a major problem, isolation is a challenge,and there is limited access to mental health

specialists. If they are able to seektreatment, there are limited psychosocialrehabilitation services available in the ruralareas once they have discharged.

Some of the recommendations specificallyoutlined in the president’s commissionreport are:

• Tailor services for a diverse population

• Provide accessible and available care

• Provide culturally competent care

• Improve access to care, especially forrural areas

• Use technology such as telemedicineand video conferencing to reach remote areas

• Train general health care providersbecause they are often the front line for mental health services

• Train law enforcement

• Train emergency room staff



Some of Georgia’s initiatives addressingthe problem of disparities are:

• After-school and summer camp programfor Latino youth

• Conversational English classes

• Bilingual staff

• Gender-specific treatment services

• Enhancement of the 24-hour help line

• Outreach to shelters and the homeless

• Wraparound services systems of care

• The five-year cultural competenceinitiative

• Improving transportation in rural areas

The National Alliance for the MentallyIll (NAMI) has played a major role inGeorgia with outreach initiatives todifferent ethnic groups, particularly theFamily-to-Family program targeting theLatino and African-American communities.The National Mental Health Association ofGeorgia has played a major role with ProjectHope, as one example. Over the last year ortwo, CHADD has been reaching out to lookat the disparities in diagnosing ADHD inthe African-American and other minoritypopulations. I also would like to mentionthe Center of Excellence on HealthDisparities, which is here in Atlanta at the National Center for Primary Care underthe leadership of former Surgeon GeneralDr. David Satcher.

But with all of these initiatives andefforts, there are still major challengesfacing us in Georgia. First of all, we knowthat there is still a high percentage ofminority youth in the juvenile justicesystem. I served as a consultant to theDepartment of Juvenile Justice and had achance to travel around the state. It wasdisheartening on intake day to see the large

number of minority youth and know that a high percentage of them have unmetmental health needs. We still have limitedresearch around best practices for minoritypopulations. We have a shortage ofproviders, particularly in the rural areas.The percentage of homeless and uninsuredin Georgia is still a major issue, and the lackof availability of multiethnic staff is a problem.

Let me share some statistics. When welook at race and ethnicity in terms ofpoverty, poverty is higher among ethnicgroups. More minorities are uninsured. Thepercentage of physicians who are African-American or Hispanic is small. Looking atGeorgia’s distribution of medical schoolgraduates in 2002 and 2003, 263 werewhite, 52 black, and six were Hispanic.

I would like to conclude with Dr.Satcher’s approach in the National Centerfor Primary Care. When looking at how toapproach eliminating health disparities, hehas always emphasized that it has to be amultidimensional effort. You have to look atenvironment, lifestyle, access to care, andbiological genetic factors. You also have toaccount for basic science research, clinicalresearch, and health sciences research, butmost importantly, at community-basedinterventions and how can we work inpartnership to address health disparitiesfrom a multidimensional perspective.

The New Freedom Commission reportstates, “In a transformed mental healthsystem, all Americans will share equally in the best available services and outcomesregardless of race, gender, ethnicity, orgeographic location.” I am very encouragedand optimistic that together we can try to accomplish a transformed system here in Georgia.

Goal four is related to early mental healthscreening, assessment, and referral. Weknow clearly that screening is a preventivemeasure that can result in healthieroutcomes. However, screening as apreventive measure generally falls to thebottom of the list when we talk aboutsaving money or cutting funds in humanservices. That happened most recently inour budget cuts here in Georgia. For thecurrent and next fiscal year, the majority ofbudget cuts came from prevention services.

I want to start with early screening. Wewere lucky enough at the Mental HealthServices Coalition earlier this year to haveDr. Patrice Harris speak to us about her

perspectives on earlyscreening. She sharedwith us a resource fromthe American PsychiatricAssociation called QualityIndicators: Defining andMeasuring Quality inPsychiatric Care for Adultsand Children. I stronglyrecommend that as youare reviewing the New

Freedom Commission report recommenda-tions on screening and assessment, you lookat this book concurrently, because many ofthe recommendations are similar.

In 1999, the American PsychiatricAssociation established a task force forquality indicators for children. That taskforce looked at many recommendations that are similar to those outlined by theNew Freedom Commission. The QualityIndicators Task Force recommended thatthe mental health status of children andadolescents should be assessed yearly,utilizing a method or measure appropriate

for the child’s age and development. Therewas also a recommendation that children inhigher risk groups, for example, those withparents having affective, anxiety, substanceabuse disorders, or schizophrenia, beregularly assessed for evidence of impairedfunctioning. Children enrolled in specialeducation programs, those in child welfare custody, and those with ongoinginvolvement in the juvenile justice system present a higher risk and should be monitored for earliest assessment of anydeveloping problem. Recent studies showthat children in the juvenile justice systemexperience mental illness and severeemotional disturbance at a rate of 85percent or more.

In an effort to expand our acronym vocabulary here in Georgia, I come with along string of letters called EPSDT. EPSDTis early and periodic screening, diagnosis,and treatment. The Mental Health ServicesCoalition brought this to the table as apotential platform to look at advocacyaround early screening for children andadolescents. Congress passed EPSDT in1967, so it has been around a long time. It requires any state providing Medicaidservices to offer early and periodicscreening, diagnosis, and treatment servicesto eligible individuals under the age of 21.EPSDT is a lengthy law, so I am only goingto give some highlights.

There are two major components ofEPSDT. One is assuring that health careresources are available and accessible tothose in need and who are eligible throughMedicaid. In addition, it requires that thoseMedicaid recipients receive assistance toeffectively use these services. Toward thisend, there needs to be a way for eligible


Goal Four: Early Mental Health Screening, Assessment, and Referral Are Common PracticeTricia Hernandez, M.S., Chair, Mental Health Services Coalition

The Quality Indicators TaskForce recommended that the

mental health status of childrenand adolescents should be

assessed yearly, utilizing a method or measure

appropriate for the child’s ageand development.


recipients to be informed that this is anavailable service to them and then be given help accessing the services. This isfrequently done through case management.

Screening through EPSDT requires both a screening of general health – includingmental health – and a developmentalassessment. If an issue is identified duringscreening, there is a mandate under EPSDTthat there be an immediate referral forfurther assessment. If further assessmentindicates the need for treatment, there is amandate that treatment be put into placeimmediately. Unfortunately, the first versionof EPSDT in 1967 did not require states to pay for the treatment services requiredunder the federal law. It was not untilCongress passed an additional law in 1989that Medicaid was then required to pay forthe treatment services.

EPSDT covers both newly identifieddisorders through screening and assessmentas well as those disorders that existed priorto the individual being eligible for Medicaid

benefits. Diagnosis andtreatment services must includetreatment for mental illnessesand conditions discoveredthrough screening. The servicesthat are found necessarythrough this screening,assessment, and treatmentprocess must be provided, evenif they are not already a part ofthe state’s service provisioningthrough Medicaid. WhileEPSDT providers are notrequired to provide all EPSDTservices, they are required torefer to other professionals whocan provide those services. Andfinally, the state is required toreport to the Department ofHealth and Human Services on a regular basis about how

many children, adolescents, and families areenrolled in the program and how many aregetting screened, diagnosed, and treated.

Unfortunately, the Health Care FinancingAdministration does not aggressivelyenforce EPSDT, and the result has been lowparticipation rates. In Georgia, EPSDT ismanaged in the Department of CommunityHealth under the Office of Child andMaternal Health and is called HealthCheck. Each state, when implementingEPSDT, was expected to report to Health and Human Services their projectedparticipation rate. Georgia’s projectedparticipation rate in 1995 was 80 percent.Georgia’s actual participation rate has neverexceeded 46 to 47 percent. Billing rates forEPSDT remain substantially low and havenot been reassessed in the last 10 years. Thereimbursement rate through Medicaid is $55for the entire screening.

This federal mandate does present aplatform for us to start talking about how to put into place what already is requiredbut is not being done. We could use 10- to15-minute long general behavior checkliststhat are not difficult or challenging tocomplete and yet can make a tremendousdifference in knowing how to take the next step if a child or adolescent needsfurther assessment. Many checklists exist for children, teens, and adults, such asdepression symptom inventories andsymptom indexes for depression, anxiety,and psychotic illnesses. The Connors Rating

Scales have both rating scales for parentsand teachers so behaviors can be assessedacross contexts.

While I have been talking primarily about assessments for children, it would bevery dangerous to say that the screeningassessment process stops at age 21. All of usare very familiar with the fact that illnessesand symptoms of mental illnesses becomeevident for many individuals in adulthoodand often are misdiagnosed as otherillnesses. These illnesses include schizo-phrenia, whose symptoms do not generallyappear until adulthood, other psychotic

disorders, mooddisorders such as majordepression, and anxietydisorders. It also is important toconsider theimpact of environ-mental factors.There may besymptoms underlying manymental illnessesthat do notbecome evidentuntil environ-mental stressorsmake them moreevident. Under therecommendationsof the NewFreedomCommission, andcertainly by manyother organiza-tions, earlydetection leads toearly interventionat any age.



Where does screening need to happen?Screening needs to happen whereindividuals are, particularly for children and adolescents. School settings are key, as are community living arrangements and primary health care settings.

Why have early screening? The NewFreedom Commission report states thatpreventive interventions will keep problemsfrom escalating. The American PsychiatricAssociation recommends indicated preven-tions that are targeted interventions forthose individuals in high-risk groups alreadymentioned who currently display minimalsymptoms. If we can catch people at theminimal symptom stage and provide appro-priate and competent treatment, then weknow that in later life, the individual will live a longer time in recovery. Earlyscreening results that indicate somesymptoms of mental illness should lead to more comprehensive mental healthassessment. These assessments include intelligence testing, achievement testing,and personality testing to give a holisticreview of where the individual is to ensure that the selected treatment is most appropriate for the individual.

How does referral to treatment play a rolewith early screening and assessment? If youhave no early screening assessment, it wouldbe impossible to figure out what kind oftreatment setting an individual would need.

In Georgia, we have single points of entryacross the state that can provide access toservice delivery systems and to appropriatetreatment for those who need mental healthservices, substance abuse services, co-occurringservices, and culturally competent services.

As we look into creating some actionsteps here in Georgia, we must address theissue of parity – a healthy brain is part of ahealthy body. It is already fundamentallyevident across the nation that we give otherillnesses the attention of early screening andassessment. We find this frequently indiabetes, in coronary disorders, and, mostrecently, in obesity. You see huge nationalcampaigns about screening and early inter-vention and a lot of funding that goes intothese campaigns. We do not see this asfrequently with mental illness, and why not?From an advocacy perspective, we shouldcertainly see that more.

A final important note is the importanceof using a holistic approach, as those withother illnesses may present higher risk forthe development of mental illnesses.

What is our role as advocates in earlyscreening, assessment, and treatment? Usingour voice to ensure federal law like EPSDTis followed, ensuring that laws in Georgia donot violate this federal law, and promotingparity among mental illnesses and otherillnesses.

Goal Five: Excellent Mental Health Care Is Delivered and Research Is Accelerated

Peter Buckley, M.D., Professor and Chair, Department of Psychiatry and Health Behavior, Medical College of Georgia

Goal five is “excellent mental health careis delivered and research is accelerated.”This one sentence intertwines both care and

research. We first need to appreciate thecontext of goal five. Why were excellentcare and research chosen as a goal for the

report? The report says, “Far too often,treatment and services based on rigorousclinical trials languish for years rather thanbeing used effectively at the earliest oppor-tunity.” The key point is that research doesnot get out into the field fast enough. Evenwhen these discoveries become routinely

available at thecommunity level,clinical practice toooften is highly unevenand inconsistent, with deviations fromthe original treatmentmodel.

As an example, wehave some very good

data specific to Georgia regarding schizo-phrenia with the schizophrenia PatientOutcomes Research Team (PORT) guide-lines, rudimentary recommendations on how to treat people with schizophrenia. A survey published a couple of years ago byDr. Anthony F. Lehman, director of theCenter for Mental Health Services Researchat the University of Maryland School ofMedicine, and colleagues shows that while90 percent of inpatients receive the properamount of medication in conformance withthe guidelines, only 40 percent of outpa-tients are receiving correct medicationdosages. So even in the face of compellingdata about medication protocols, there is agap in service delivery.

Why are there such barriers in deliveringscience to service? We have already heardsome of the issues that promote gaps, suchas issues around reimbursement that do notfully support the services that we believe weshould be able to give. We have heard aboutassessment issues, about disparities, and howour work force is not focused upon or givenup-to-date training on best practices.

The recommendations for goal five are:

• Accelerate research to promote recoveryand resilience

• Advance evidence-based practices usingdissemination and demonstrationprojects and promoting public/privatepartnerships

• Improve and expand the work force,providing evidence-based mental healthservices and supports

• Develop the knowledge base in fourunderstudied areas: mental healthdisparities, long-term effects of medications, trauma, and acute care

Just what is evidence-based practice?Evidence-based practice is defined as theintegration of best research evidence andclinical experience with patient values.Emerging best practices are practices ortreatments that are promising but do notquite yet have the evidence base needed todocument and move into the full realm ofevidence-based practices. Unfortunately,these evidence-based and emerging bestpractices are patchy in their implemen-tation, typically implemented in aninconsistent or watered-down fashion,which will adversely affect the outcome.Data suggests that if you implement anevidence-based practice in a “quasi-fidelity,”or partial, manner, you lose the benefit ofthat practice.

Some examples of evidence-basedpractices include:

The Texas Medication Algorithm Project(TMAP). This was a true public/privatepartnership developed several years ago for best practices in medication treatmentfor both schizophrenia and mood disorders.TMAP started in Texas and has spreadacross several states, including Florida,Georgia, South Carolina, New York, and Pennsylvania.


Unfortunately, these evidence-based and emerging best practices

are patchy in their implemen-tation, typically implemented in

an inconsistent or watered-downfashion, which will adversely

affect the outcome.


One impact of TMAP is on cognitiveimprovements in people with schizophrenia.We know that if people with schizophreniacan improve their cognition, they will do far better in their recovery and in theircapacity for employment than if we simplyimprove other symptoms like delusions or hallucinations. The individuals who got algorithm-based care as opposed totreatment-as-usual had significant improve-ments in their mental cognitive functioning.Not only do people experience cognitiveimprovements, but those people withalgorithm-based care had lower overall use of mental health services as well asgeneral medical and rehabilitation services.This effort demonstrated that this practice is feasible, delivering not only symptomaticimprovements but also demonstrable service improvements.

Family Solutions Program. TheUniversity of Georgia implemented a family

solutions jail diversionprogram for first-timejuvenile offenders. In this 10-week program, childrenand their families commit totherapy. The children in thisprogram had a re-offenderrate of only 13 percent, ascompared to a 21 percent

re-offender rate for those who did notcomplete the program.

Recovery model in Ohio’s state hospital.A study in the Ohio inpatient systemcompared treatment-as-usual to a recovery-based model. The recovery-based model wasfound to deliver hope, focusing on people’sabilities rather than their disabilities.Individuals with recovery-based treatmentplanning did statistically better in terms of their overall functioning on globalassessment of function.

Our future is in our current and futureclinicians. We are concerned with how the academic environment will deliver corecompetencies in recovery-based practices.We simply cannot aspire to system transfor-mation if we do not train our providers inrecovery-based values and content. Therecurrently is a large disconnect between whatpeople are taught in colleges and univer-sities and what they need to know whenthey get out into the field. We are hoping toengage in a planning process to look at thisdisconnect and shift the focus with ourmedical students early on. Medical studentstypically spend electives in laboratories orwith researchers. Instead, it would be ahelpful and relevant opportunity for ourmedical students to spend their electiveswith people in recovery and with peersupport specialists. We also are interested in implementing recovery-based modules aspart of residencies.

Available evidence-based resourcesinclude tool kits created by the SAMHSAfor six topic areas:

• Illness management and recovery

• Medication management

• Assertive community treatment

• Family psychoeducation

• Supported employment

• Integrated dual-diagnosis treatment

These kits include information sheets for all stakeholders, introductory videos,practice demonstration videos, workbookmanuals for practitioners, evaluation, andfidelity measurement.

What are some of the future opportunitiesfor us? The New Freedom Commissionreport provides a fantastic opportunity for new alliances in advocacy to promoteevidence-based practices. We have the

We simply cannot aspireto system transformation if we

do not train our providers in recovery-based values

and content.

opportunity to provide services and researchefforts to integrate care. We havetremendous opportunities in early interven-tions, research, bridging science to clinicalcare, genetics, and other aspects of cognitiveremediation. We have opportunities not

only for research and recovery but also fordissemination, promotion, and training onbest practices. And finally, we have anopportunity to develop the knowledge baserequired for evidence-based practices.


Goal Six: Technology Is Used to Access Mental Health Care and Information

Rick Dunn, Director of Evaluation, Decision Support Section, Georgia Division of Mental Health, Developmental Disabilitiesand Addictive Diseases

I appreciate the opportunity to speakabout the report by the President’s NewFreedom Commission on Mental Health and particularly how goal six can beachieved in Georgia. Some of the statementsmade by the president when he announcedthe formation of the New FreedomCommission helped me think about ways we can achieve the goals outlined by the

commission. The statement that struck me was, “Our fragmented mental healthservice delivery system is an obstacle toquality mental health care. Many years and lives are lost before help, if it is given atall, is given.” I think the fragmented natureof the mental health service delivery systemis an important framework for thinkingabout data.


The motivating principle behind theserecommendations is to enable adults andchildren with serious mental illnesses oremotional disturbance to live, work, learn,and participate fully in their communities. It is important to remember this in thecontext of data and information, because we often think of data and information asprimarily paperwork or busy work. The veryfact that the commission identified a goalrelated to data and information forces us tokeep in mind that ultimately, informationand data are related to the concepts of recovery. If we are going to achieverecovery, community integration, and a high quality of life, information and data are critical.

Goal six states that our mental healthsystem should capitalize on communicationsand information technology to improve the quality and effectiveness of care. I wantto give a caveat: I am not an informationtechnology person or a computer systemsperson. I am a data person. There are somespecific recommendations in the report,such as the idea of an electronic medicalrecord and telemedicine, that I unfortu-nately know very little about. Therefore, I am going to focus on the broader point,which is that quality information and dataare important for achieving quality care.

The larger point thecommission was tryingto make with goal six is that mental healthsystems need to makemore decisions based ondata and must developthe systems that will

allow this type of decision-making to occur.The commission report stated that mentalhealth systems should use information and knowledge to promote structures andinfluence processes in the most appropriate

way to produce positive outcomes. Again,quality care relies upon quality information.Additionally, we must improve access toinformation by consumers and their families.Informed choice by family and consumersrequires quality information.

Achieving these information and datagoals is certainly not going to be easy.Mental health has a long reputation fordramatically underinvesting in moderninformation systems. There also is adeserved reputation for lack of applicationof modern technology to mental healthproblems. That certainly makes things verydifficult. Compounding these challenges is the fragmented nature of mental healthservice delivery systems. If we are going toget the information needed, some of thisfragmentation of care will have to becoordinated and consolidated.

While we certainly have some barriers,there is good news. There has been a lot of work in recent years, sponsored by theCenter for Mental Health Services, indeveloping common data standards. Therehas been a lot of work in developingcommon instruments that states could use as well as common ways to analyze andreport results. These efforts lay an excellentfoundation going forward to build upon thecommission’s recommendations.

I think it is fair to say that Georgia sharesthe commission’s vision that quality carerequires quality information. I wanted to share with you at least the goals andprinciples that guide our effort to build aninformation system that a mental healthservice delivery system deserves.

1. Data and information should be used toimprove decisions. Clinical and admin-istrative decisions made by consumersand family members, providers, payers,and managers will be enhanced by an

Mental health systems shoulduse information and knowledge topromote structures and influenceprocesses in the most appropriateway to produce positive outcomes.

information system that provides all the data needed quickly, accurately, and efficiently.

2. Data and information should be used to improve services. An informationsystem that makes available to stake-holders reliable information on acommunity’s mental health needs,services, service users, costs, revenues,performance, and outcomes is critical to improving care.

3. Data and information should be used toimprove accountability. To be the mostbeneficial, information on accounta-bility needs to be readily availablewithin the framework of continuousquality improvement.

4. Systems must improve communications.By communications, I do not neces-sarily mean communication betweenindividuals or organizations, althoughthat would be a nice principle to adoptas well. I am talking about communi-cation between information systems.There is no single information system,and information cannot be sharedacross information systems or acrossservice delivery systems. While wecollect a wide variety of information –financial, serious incidence, encounter,enrollment, performance – the infor-mation cannot deliver value if it isisolated.

Based on these four principles, we need to develop what ideal or model informationwould look like. This is not somethingunique to Georgia. There has been a lot offoundation work done with SAMHSA andother states in terms of developing datastandards, what type of information isneeded to effectively manage a mental

health system, what type of information isneeded by consumers and family members tomake informed choices, etc.

The model information system would startwith population characteristics and track all the way through outcomes. Some of thedata components that the ideal informationsystem would contain are:

• Population data is the demographiccharacteristics of our service area so we canunderstand the need for services withinthese areas.

• Encounter data is the information thatcharacterizes the users of services, such asdiagnostic information, functional status,symptoms, types of services used, andfrequency of use.

• Financial data includes cost per unit ofservices, administrative costs, and revenues.

• Human resource data includes thecharacteristics of the providers of care andsupport staff.

• Organizational data includes infor-mation about the organizational structureand processes of providers.

Once that data is there, we must transformthe data. The vision is a single informationsystem that links together all of thesedifferent data components. Therefore, information about the population,enrollment, and outcomes must be linked toone another so you can view the results byconsumer, provider, service area, or region –so the information is easy to understand and use and is relevant. Information systemsshould also be able to produce qualityoutput, including performance indicators,report cards, and consumer outcomes. All ofthese elements are critical for managementfunctions, quality improvement, andaccountability. The system must be able to answer four key questions:



• What are we doing?

• What should we be doing?

• How well are we doing?

• How do we improve?

If we are able to answer those fourquestions, consumers, family members,providers, payers, and programs can betterdirect and manage mental health systems. It will have a large impact on the quality of care.

It is important to remember that thisvision is the ideal. The problem with thesetypes of visions is that they are pie in thesky. There are too many obstacles to imple-mentation. What is important to note isthat in Georgia we do not have to build a new information system from scratch.Many of the data elements described in the ideal information system are alreadybeing collected. We already have a lot ofinformation now.

However, we certainly have some flaws.We do not have encounter data for non-Medicaid consumers, centralized financial

data, human resource data, or organizationaldata that we can readily utilize. We do nothave the linkage between mental healthand other service systems that may serveconsumers, such as correction, labor, vitalrecords, DFACS, education, etc.

While we do collect a lot of data, thevalue of that information is limited due to the fact that these databases or modulesare not integrated. What information wehave sits in silos. Each silo has its owngatekeeper, data definition, and identifiers.That is problematic when one wants to lookat information to improve the quality ofcare. While we have outcome informationand financial information, the two are not linked; therefore, we can’t evaluate and improve.

A first real opportunity in Georgia tomeeting goal six is to consolidate ourexisting data sets. We need to think of waysof using the information we already havemore efficiently and more affordably.


Q & AQ When we talk to legislators about not cutting funding for medication, transportation, or mental

health community services, we cannot show that Georgia spent more money as a result of makingthose cuts. If a legislator says we cannot afford to provide all these medications, then we need to beable to show that the outcome is a higher cost to the state: emergency room visitations, hospital-ization, or unemployment. Without that data, we are challenged in our advocacy efforts and willcontinue to be challenged with very serious cuts to the mental health system.

A Mr. Dunn: We have a lot of information. That information is weak because we have a difficult timeintegrating it. If we were able to integrate a lot of our information, we would be able to provide the typeof information that you need in your advocacy efforts. That is what is frustrating: The information exists,but it is limited in terms of its utility because we cannot associate it.

Questions and Answers


he President’s New Freedom Commissionon Mental Health was chartered to addressthe problems in the current mental healthservice delivery system. It comes 25 yearsafter the Carter commission on mentalhealth. Both were formed to assess thecondition of the public mental healthsystem and address the needs of people whohave mental illnesses. This comprehensivereview brought to light many problemsfacing our nation, including the availabilityand quality of services for people withmental illnesses as well as the lack offunding for mental health services. Thefindings were troubling, but a thoroughappraisal was much needed. The report’sfindings and recommendations are useful for guiding the future of the public mentalhealth system.

The Carter Center Mental HealthProgram was pleased to focus on the report

for the Ninth AnnualRosalynn CarterGeorgia Mental HealthForum. It is extremelyimportant that theentire Georgia mentalhealth community take action on thesefindings. Panelists have reviewed theopportunities andchallenges facing

Georgia in implementing these recommen-dations. After hearing from the experts intheir respective fields, the participants atthe forum broke into work groups to identify action steps that can be imple-mented to meet the goals outlined in theNew Freedom Commission report. Theforum concluded with participants offering

recommendations for implementing andtaking action to start the transformation of the mental health system in Georgia.

Goal One

Goal one of the report is: Americansunderstand that mental health is essential to overall health. Specific recommendationsto begin to meet this goal are:

1. Implement a school education pilotprogram. The pilots would engage a fewschools across the state. Measures wouldlook at how mental health educationaffects suicide rate, high school dropoutrate, and delinquency rates.

2. Implement EPSDT training across statein school systems. It is not acceptablethat EPSDT training is only 47 percentin this state. We must raise it to thenational level by utilizing advocacyorganizations to raise the issue withintheir own local school systems andfollow through with implementation. Abarrier we face is appropriate linkagesfor treatment. If a child is determinedto be at risk for mental illness, we needto ensure the schools have a clear linkto proper service delivery to that childand family.

3. Leverage the Atlanta Business Leaders’Initiative (ABLI). This group is thebrainchild of three prominent CEOswho have come public with theirmental illnesses – Tom Johnson, J.B.Fuqua, and Larry Gellerstedt. Byeducating other CEOs about the preva-lence and cost of mental illnesses intheir organizations, we can help driveparity in large organizations. If we cansuccessfully implement this program

Work Groups – Charge and Recommendations

T

This comprehensive reviewbrought to light many problems

facing our nation, includingthe availability and quality of services for people with

mental illnesses as well as the lack of funding for

mental health services.

within the large employers in Georgia,it could become a model program forthe country.

4. Statewide educational campaign.Implement an educational campaign,“Health Starts With the Head.” The campaign would target variouspopulations – professionals, consumers,general public, and others. Allianceswill be formed with mental healthassociations and DHR to create a task force to look at the possibility forimplementing and funding a statewidecampaign. To gauge effectiveness, wewould conduct pre- and post-campaignsurveys to assess attitudes andknowledge surrounding mental health issues.

5. Engage the media. Convene a smallgroup of media leaders to brainstorm onthe types of stories that would engagethe media surrounding mental healthissues and how mental health permeatesother issues. Discuss with the mediahow the mental health community

could assist and the types of infor-mation that media require to craftstories that will address this goal.

Goal Two

Goal two of the report is: Mental healthcare is consumer- and family-driven.Recommendations of the work group tomeet this goal are:

1. Fund existing mental healthombudsman bill. We need to work withlegislators to move this bill forwardwith funding so the law goes into effect.The effectiveness of this legislation canbe measured by looking at how manycomplaints came in, were received, andwere resolved.

2. Allow consumers the ability to set theirown recovery and treatment goals. Atypical problem is that the consumerand their provider may both havecompletely different goals. For example,the consumer’s top priority may be toobtain gainful employment, while theprovider’s priority might be to takemedications and go to therapy. The

consumer must be involved insetting goals.

3. Develop a unified languagefor recovery. We must use thesame terminology so we havea common language acrossservice delivery systems.

Goal Three

Goal three of the report is:Disparities in mental healthservices are eliminated.Recommendations of the workgroup to meet this goal are:



1. Address how we categorize clients.Sometimes when working with diversepopulations, we force people to check abox and categorize themselves in waysthat may not reflect their culture orbeliefs. We should allow for flexibilityin how clients identify themselves.While the goal of checking boxes for identifying racial and ethnicbackground is to capture informationfor data analysis, we want to make surewe capture the right information.

2. Address cultural competence. Culturalcompetence must be addressed at all levels. In order to improve access to quality care that is culturallycompetent, the state of Georgia muststandardize, coordinate, and fullyimplement mental health culturalcompetence training for interpreters,providers, and all staff in accordancewith federal laws and guidelines.

3. Expand the mental health system inGeorgia to encompass nontraditionalservices. The movement to decentralizethe system in Georgia should continueand provide support for faith-based,community, and nontraditionalservices. Also affecting access are thehours of operation. Most intake andservices are provided during traditionalbusiness hours only. We need after-hourand weekend services.

4. Revitalize the “No Wrong Door”Project. The concept of the “No WrongDoor” Project was that no matter wheresomeone shows up in the mental healthsystem, that would never be a wrongdoor: Someone in that agency will beable to guide and provide something tothis client. Providing a single point ofentry so that clients are not forced tonavigate a complex system alone iscritical. A challenge is that sometimes

there is not a service to which to referthe client. However, we need to trainpeople who are not working in themental health field, such as primarycare physicians, law enforcement, andemergency room personnel, to directconsumers appropriately. Some of thisintelligent referral is going on, but it is fragmented and needs to bestandardized. In order to accomplishthis recommendation, there must becollaboration among all agencies.

5. Understand barriers preventingconsumers from seeking services andtreatment. We still do not fully under-stand how to address the consumerswho are not seeking services andtreatment. Are they showing up in their faith organizations or going tonontraditional sources? If so, we mustprovide education for those sources.

Goal Four

Goal four of the report is: Early mentalhealth screening, assessment, and referral to services are common practice. The keyrecommendation of the work group to meetthis goal was to link existing services toschools with an effective screening method-ology. The first action step was to identify ascreening methodology that is developmen-tally appropriate across the lifespan for use statewide by all agencies, as well asindependent insurance agencies, to ensureconsistency in information. We need theright tool with the right questions. We needa tool that is culturally competent, ageappropriate, developmentally appropriate,valid, and reliable.

To get this first step accomplished wewould need to:

• Build consensus for the idea.

• Identify what this screening tool wouldlook like across the entire lifespan.

• Identify key points where this toolwould be used.

• Identify how this screening tool wouldbe developed.

• Identify how this screening tool wouldbe disseminated across various systemsto capture individuals at key points intheir lifespan.

• Identify accountability for the use of the instrument.

• Identify service gaps so that whenassessments uncover a problem, the individuals can be referred to appropriate services.

The responsible parties for implementingthis recommendation would be a collabo-ration of different stakeholders, includinginsurance companies, medical associations,state agencies, university systems, licensingagencies, and advocacy agencies across thelifespan. Difficulties with how they wouldall talk to each other need to be addressed.

Goal Five

Goal five of the report is: Excellentmental health care is delivered and researchis accelerated. The work group acknowledged

that we would like to see furtherwork force development, the useof prevention strategies, a pushtoward more research, and moretraining on recovery principles. A key recommendation, however,is to conduct a gap analysis anduse that information to planfurther. We must first understandwhat level of implementation wereally do have for best practicesfor adult mental health inGeorgia. Using that information,we could then work in each of ourregions with providers to identifya percentage of improvement we

want to see. This would not mandate whichevidence-based practice the provider mustimplement but help ensure responsibility forincreasing the amount of evidence-basedpractice service provided. In this way,quality improvements can be made in amanner that best supports the needs of thelocal regions.

Goal Six

Goal six of the report is: Technology is used to access mental health care and information. The work group had two keyrecommendations. First, Georgia must facilitate a process that will result in a set of common data elements that will answerthe questions: What are we doing, how wellare we doing, what should we be doing, andhow can we improve that? Second, a datawarehouse needs to be established thatwould link multiple state agencies.

Both these action steps are massive areasthat will improve mental health servicestremendously by allowing the entire systemto come together and speak the samelanguage so that we can communicate andevaluate our efforts.



Rosalynn Carter Chair, The Carter Center Mental Health Task Force

t is unfortunate that presidential commissions are not provided the means for implementingtheir recommendations. The commissions do so much good work, and then it is left to others to act on their findings, and so often this does not happen. After the Cartercommission, we formed a nongovernmental organization to work on this, and we did get the Mental Health Systems Act passed. The act didn’t do much because it didn’t lastvery long. But the recommendations did. They became a model for good programs aroundthe country.

One of the striking differences in the 25 years since the Carter commission was that, back then, we never dreamed that people could recover from a mental illness. We wereattempting to focus attention and efforts on what we could do at the federal level. Todaywe realize that the real responsibility and authority for service delivery rests at the state and local level. If real change and progress are going to occur, it will occur here. I am soimpressed with the expertise and the innovative programs we have in our own state thatcan serve as models for the rest of the country. We can teach others a lot by what we aredoing right here in Georgia.

It is our responsibility now to ensure that the issues identified as important to advancethe recommendations of the New Freedom report stay in the forefront of policy-makers’ andthe general public’s minds. It is up to all of us to make sure they are not forgotten but areacted on and integrated into all our organizations’ activities. Government at all levels willbe charged with the mechanics of transforming the system. Our responsibility is to helpthem where we can and make it happen.

We’ve explored today how we can contribute to this effort. And now, since we’ve comeup with things we can do, we have another challenge: to follow through and get themdone. We have to work together to accomplish our goals and improve the quality of care for all Georgians who have mental illnesses.

Closing Remarks

I

Peter Buckley, M.D.

Dr. Peter Buckley is professor and chairman of the department of psychiatry and healthbehavior at Medical College of Georgia in Augusta. Prior to that, he was professor ofpsychiatry and vice chair in the department of psychiatry at Case Western Reserve UniversitySchool of Medicine and medical director at Northcoast Behavioral Healthcare System. Dr. Buckley conducts research on the neurobiology and treatment of schizophrenia. He isauthor of a textbook on psychiatry and has authored/edited six other specialist books onschizophrenia. Dr. Buckley has published widely in major psychiatric journals, with over 200

publications as original articles, abstracts, and book chapters. He is a reviewer for federal and international grantagencies, is a reviewer for more than 25 medical and psychiatric journals, and serves on the editorial board of threejournals. Dr. Buckley is a board member of several professional organizations. He is the recipient of several awards forhis work, including an Exemplary Psychiatrist Award from the National Alliance for the Mentally Ill and the 2004Administrative Psychiatry Award from the American Psychiatric Association.

Benjamin Druss, M.D., M.P.H.

As the first Rosalynn Carter Chair in Mental Health at Emory University’s Rollins Schoolof Public Health, Dr. Druss is working to build links between the mental health and broaderpublic health and health policy communities. Prior to this position, he was on faculty in thedepartments of psychiatry and public health at Yale, where he was the director of MentalHealth Policy Studies. Dr. Druss has published more than 50 peer-reviewed articles in medicaland psychiatric journals largely focusing on the policy and systems issues on the interfacebetween primary care and mental health. He has received several national awards for his

work, including the 2000 American Psychiatric Association Early Career Health Services Research Award, the 2000Academy Health Article-of-the-Year Award, and the Academy Health 2003 Alice S. Hersh New Investigator Award,presented to the top junior health services researcher in the country.

Rick Dunn

Rick Dunn is the director of the evaluation unit in the Georgia Division of Mental Health, Developmental Disabilities and Addictive Diseases. He has extensive experience instatistical analysis, the techniques of policy analysis, and program evaluation. Prior to joiningthe state of Georgia, he taught public policy and research methods at the University ofGeorgia, Dickinson College, and the College of Charleston. Currently, he directs Georgia'sPerformance Measurement and Evaluation System (PERMES), data collection for numerousfederal grants, and ongoing evaluations of particular services. He also currently serves as theco-principal investigator for Georgia's State Data Infrastructure Grant funded by the

Substance Abuse and Mental Health Services Administration.


Biographies


Larry Fricks

Larry Fricks currently serves as the director of the Office of Consumer Relations for theGeorgia Division of Mental Health, Developmental Disabilities and Addictive Diseases. He is a founder of the Georgia Mental Health Consumer Network, Inc. that now has some 3,000members, a founder of the Georgia Consumer Council, a founder of Georgia’s Peer SpecialistTraining and Certification, and a founder of the Georgia Peer Support Institute. He also is onthe national advisory council for the Center for Mental Health Services and the advisoryboard for The Carter Center Mental Health Journalism Fellowships.

Tricia Hernandez, M.S.

Tricia Hernandez has worked in both publicly funded and private, not-for-profit settingswith adults and children diagnosed with mental illnesses and severe emotional disturbances as well as with juvenile sexual offenders. Her clinical experience includes completing comprehensive psychological assessments and providing individual and group therapy undersupervision in community mental health centers, juvenile justice facilities, and in privatepractice. Most recently, she has worked as an operations manager in nonprofit organizationsas well as co-developed a private, not-for-profit agency providing services related to foster

care. She previously served as chair of the Juvenile Justice Committee of the Mental Health Services Coalition andcurrently serves as chair of the Mental Health Services Coalition, a collaboration of public and private individualsand organizations focused on advocating for meeting the mental health needs of Georgians.

Gail Mattox, M.D.

Dr. Gail Mattox currently serves as chairperson of the department of psychiatry and behavioral sciences at the Morehouse School of Medicine, where she also holds the rank of professor of clinical psychiatry. Dr. Mattox has more than 18 years of clinical experience as a community psychiatrist and served as the medical director for Fulton County Departmentof Mental Health, Developmental Disabilities and Addictive Diseases and as an associatemedical director for Laurel Heights Hospital Residential Treatment Facility. She played amajor role in the development of The CHAMPS Program in Fulton County, a system of

care for youth with severe psychiatric disorders, and served as its first medical director. Dr. Mattox serves on theMental Health Planning and Advisory Council for the state of Georgia and is active in numerous professional and community-based organizations.

James Stone, M.S.W., C.S.W.

James Stone is deputy administrator of the Substance Abuse and Mental Health ServicesAdministration, a division of the U.S. Department of Health and Human Services. He serves as chief operating officer for the agency, overseeing three centers: Center for MentalHealth Services, Center for Substance Abuse Prevention, and Center for Substance AbuseTreatment, plus the Office of Applied Studies. His early career was spent in the juvenilejustice field. He was deputy director of Detention Care for Onondaga County and then joinedthe New York State Division for Youth, where he served in a variety of positions, including

director of Youth Homes in Rochester and superintendent of the Agricultural and Industrial School of Industry. Hewas appointed by Governor Patakas as commissioner of the New York State Office of Mental Health, overseeing stateoperations serving 6,000 inpatients in 27 hospitals and 20,000 outpatients.

Cynthia Wainscott

Cynthia Wainscott is chair-elect of the National Mental Health Association's board ofdirectors and serves as the World Federation for Mental Health's vice president for NorthAmerica and the Caribbean. From 1990-2002, she was executive director of the NationalMental Health Association of Georgia. In the 1980s, she directed a National Institute forMental Health pilot site for D/ART (Depression: Awareness, Recognition and Treatment), a groundbreaking public education campaign, and developed and trained model outreachprograms nationwide. In Georgia, Ms. Wainscott is a member of the governor's Mental

Health, Mental Retardation, and Substance Abuse Advisory Council, the state Medicaid agency's Drug UtilizationReview Board, and the Mental Health Planning and Advisory Council. She is chair of the Georgia Parent SupportNetwork and the Advisory Committee for Emory University’s Fuqua Center for Late Life Depression as well as co-chair of the Governance Committee of the Mental Health Services Coalition. In 1995, she was named the mosteffective mental health association executive director in the United States.


Biographies

Sponsored by:The Carter Center Mental Health ProgramGeorgia Mental Health Consumer Network

Georgia Parent Support Network, Inc.National Mental Health Association of GeorgiaNational Alliance for the Mentally Ill – Georgia

Documents

Georgia’s Imperative: Implementing the Final Report of the … · 2019. 5. 1. · Georgia’s Imperative: Implementing the Final Report of the President’s New Freedom Commission