NAMI report card 2009

NAMI report card 2009:
New England improves but nation’s scores stall
(May 2009 Issue)

By Nan Shnitzler

When the National Alliance on Mental Illness gave report cards on mental health care in 2006, the nation got a discouraging D. Three years later, two New England states show improvement, Massachusetts from C to B and New Hampshire from D to C, but the nation remains stalled at D. In all, 14 states bettered their grades; 12 states lost ground; six failed.

"Grading the States 2009: A Report on America's Health Care System for Adults with Serious Mental Illness" urges states not to lose sight of the New Freedom Commission's vision of a transformative mental health care system - consumer-driven, evidence-based and integrated into overall health care - despite the economic crisis that is decimating state budgets and threatening gains in care.

"On one hand, this robust report provides a template for change and for states to review their progress," says NAMI Executive Director Michael Fitzpatrick, MSW. "On the other, because of the terrible economic environment, some grades could easily be wiped out in the next six months. That's a challenge."

The 2009 methodology scored 65 criteria in four sub-categories: health promotion and measurement; financing and core services; consumer and family empowerment; and community integration. Data sources included state mental health agencies, federal agencies, health care associations and academic research. The Stanley Family Foundation funded the report.

New England fared well, says Fitzpatrick, a former Maine state legislator. He thinks the region's consumers, advocates, providers and state governments work relatively well together and have built momentum since some model systems were dismantled a decade ago.

"Looking back 10 to 15 years, systems in New Hampshire, Vermont and Rhode Island were considered best-in-country," Fitzpatrick says. "What we saw in 2006 and now in 2009 are systems in recovery from mismanagement and bad decisions by state legislatures and governors."

Tobias Fisher, MBA, MSW, policy director for NAMI-Massachusetts, was gratified the state made good on its 2006 pledge to do better. Massachusetts earned high marks for comprehensive health insurance reform, parity law expansion, the Medicaid carve-out (Massachusetts Behavioral Health Partnership) and alternatives to restraint and seclusion.

But the Department of Mental Health suffered deep mid-year budget cuts. A one-time cash infusion from a revolving fund softened the blow, but Commissioner Barbara Leadholm, M.S., MBA, faces difficult choices and consolidations in the coming fiscal year.

"The issue is to continue the transformation the department is engaged in to support as many consumers as possible and help them achieve success in the community," Leadholm says.

The report recommends Massachusetts expand jail diversion programs to help stem the rate of prison suicides, one of the highest in the nation. Leadholm says jail diversion is practiced at some courts, jails and houses of correction to link consumers with mental health resources. In addition, DMH is working closely with the Department of Corrections to ensure DOC personnel are serving the "mental health needs of consumers in segregated units," she says.

New Hampshire was praised for its "In Shape" physical wellness program, the broad-based Mental Health Commission, peer supports and telemedicine. But NAMI-New Hampshire Executive Director Michael Cohen, M.A., CAGS, cautions against complacency. "A 'C' doesn't mean we've succeed," Cohen says. "It's critically important to recognize there's room for improvement."

Cohen says that the state still needs to better understand that mental health is part of overall health. Urgent needs cited in the report, such as more inpatient beds, housing and jail diversion programs, can help problems get addressed within the mental health service system where they belong rather than seeping into high-cost systems, such as schools, prisons and nursing homes.

Erik Riera, Bureau of Behavioral Health administrator, says the NAMI report delivered a fair assessment of New Hampshire's community mental health system, but funding constraints will hinder not only NAMI's recommendations, but also New Hampshire's own 10-year plan.

"We will likely consider changes in our service systems as we look for ways to improve efficiency and increase effectiveness," Riera says. "We will continue to make every effort to ensure services are available for our most vulnerable population."

In Rhode Island, which retained a C grade, advocates are keeping an eye on a five-year global Medicaid waiver, which caps total Medicaid funding in exchange for freedom to reallocate resources. Fitzpatrick says Rhode Island's waiver changes Medicaid from an entitlement to a limited, defined benefit that no longer guarantees access to care.

"Waivers are a way states squeeze the Medicaid program to bring in more uninsured," Fitzpatrick says. "You have to watch that the most valuable services don't become those services 'lite.'"

Charles "Chaz" Gross, CAGS, executive director of NAMI-Rhode Island, says the waiver "trumpets" creativity in service delivery, but the bottom line is that the money has to be managed over five years.

"We're talking about a state system that can't seem to manage its own budget. It's scary," Gross says.

Gross praised Rhode Island's innovative information delivery systems, via a Web-based information network and a "211" telephone line, which enable access to mental health resources. He's discouraged by constant complaints that personnel in hospitals, community mental health centers and law enforcement demonstrate insensitivity to people with mental illness.

Going forward, Fitzpatrick says these are dangerous times with the potential for governments to make decisions that could create harm.

"The challenge is for mental health advocacy and provider groups, which are working better than any other time in our history, to be organized and focused on protecting what works," Fitzpatrick says. "Unless you have a constant drumbeat on the ground, you will see systems go off the tracks."