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Mental Health Commission Examines Service Fragmentation

By Meredith Hogan Pond

With its Interim Report complete, the President's New Freedom Commission on Mental Health has shifted its attention to critical improvements needed in the Nation's mental health services delivery system. At the December meeting in Arlington, VA, the Commission focused on the issue of fragmentation in the service delivery system.

Charged with conducting a comprehensive study of America's mental health service delivery system and advising President George W. Bush on ways to improve it, the Commission comprises 22 members appointed by the President, including SAMHSA Administrator Charles G. Curie, M.A., A.C.S.W.

Nancy Domenici, Charles G. Curie. and U.S. Senator Peter Domenici (R-NM) at a recent meeting of the President's New Freedom Commission on Mental Health.

In welcoming Commission members and guests, Commission Chair Michael F. Hogan, Ph.D., described the fragmented services system as "a huge challenge." Mental health experts and business leaders addressed the Commission about personal experiences, possible solutions, and repercussions of service system fragmentation as one of the continuing barriers to care faced by consumers of mental health services and their families nationwide.

The Commission also listened to three business executives who shared their own experiences with depression and the fear of losing their employment because of this very common mental illness.

As described in its Interim Report, published last fall (See SAMHSA News, Fall 2002), the Commission acknowledged that "the reasons for fragmentation of the mental health system are complex and driven by historical forces." According to the report, the system itself is actually a loose collection of diverse programs that deliver or pay for treatments, services, or other supports such as disability, housing, or employment. The programs are funded by myriad sources, such as Medicaid, Medicare, state agencies, local agencies, foundations, or private insurance. Within this array of programs and funding streams, there are great differences in mission, setting, and funding that contribute to inconsistency, complexity, and a lack of coordination.

Dr. Steve Sharfstein presents his recommendations to the Commission on possible solutions to fragmentation of care.

A panel of three experts spoke on "Dealing with Fragmentation in the Service Delivery System." The Commission heard from Steve Sharfstein, M.D., President and CEO of the Sheppard Pratt Health System, in Baltimore, MD; Timothy A. Kelly, Ph.D., who served as Commissioner of the Virginia Department of Mental Health from 1994 to 1997; and Laurie Flynn, Director, Carmel Hill Center for Early Diagnosis and Treatment at Columbia University in New York City. The following day, Ron Diamond, M.D., described "A Model To Reduce Fragmentation." Dr. Diamond is Medical Director of the Mental Health Center of Dane County in Madison, WI, an innovative model for integrated consumer services.

Seeking Solutions

In his presentation to the Commission, Dr. Sharfstein described himself as a "community psychiatrist and leader of the largest not-for-profit mental health system in Maryland." He reported, "Fragmenting of funding has led to fragmenting of care. The fee-for-service system, which has replaced grants in Maryland in terms of public services, has led to less coordination of care." Dr. Sharfstein described Sheppard Pratt's paperwork for consumers as an "administrative nightmare."

Theorizing that things may be getting worse because states are in deficit due to the economic downturn, Dr. Sharfstein said that increasing numbers of people find that their mental health care is not funded. From his unique perspective, he outlined some fundamental principles upon which reform of the mental health system should be based, including:

Interpreting "costs" broadly to include budgets of criminal justice, general health care, and welfare and disability systems
Integrating care for treatment of substance abuse and mental illness, developmental disabilities and mental illness, and medication management with psychotherapy support
Creating "continuous healing relationships" in community-based settings
Ensuring parity in payments for mental health services, including payments through Medicare and Medicaid.

In his recommendations to the Commission, Dr. Kelly pinpointed three related areas that "would go a long way towards reforming the fragmented system of care." These three areas are quality of care, cost effectiveness, and agency accountability. To improve quality of care, Dr. Kelly emphasized the critical need for standardized, reliable, clinical outcome data made available for wide use. Data showing positive results from specific consumer services help keep those services from being cut by policymakers. For that reason, he said, "data are an important way of increasing the voice of consumers in the service system."

To maximize cost effectiveness, Dr. Kelly suggested that valuable mental health resources need to be redirected to innovative community care, and ineffective programs need to be ended. And, he said, by making agencies take responsibility at the Federal, state, and local levels, agency accountability will inevitably "lead to innovation, flexibility, and true reform." According to Dr. Kelly, current mental health policy tends to support the status quo, funding services regardless of effectiveness.

Laurie Flynn and Timothy Kelly address the Commission.

After working for 16 years with the National Alliance for the Mentally Ill (NAMI), Laurie Flynn said that current service system fragmentation comes in part from "our not knowing what to do, and from doing a lot of things poorly." Ms. Flynn recommended that the Commission support mental health screenings in schools, clinics, shelters, youth clubs, residential treatment centers, juvenile justice settings, and work with PTAs, NAMI chapters, substance abuse communities, and others.

"Early intervention and treatment can reduce disability and save lives," she said.

Destigmatizing Depression

The Commission also heard testimony on workplace issues that are affected by mental health. In the presentation, "Business Executives Share Personal Experiences with Depression," Tom Johnson, Retired Chair and CEO, CNN News Group, and Larry Gellerstedt, III, President and COO, the Integral Group, both from Atlanta, described their ongoing commitment to the destigmatization of mental health issues in the workplace based on their own struggles with depression.

"Each of us kept the secret about depression," Mr. Johnson said. He addressed the need to make employees who may be fearful of losing their job or status feel that it is "ok to go for treatment."

A third VIP panelist, philanthropist J. B. Fuqua, Chairman, The Fuqua Companies, answered questions from Commission members. Mr. Fuqua offered matching seed funding of $1 million to start a pilot project, "Defeating the Stigma of Depression," which would help people perceive depression as an illness like any other disease.

Together, the three men proposed to the Commission the launch of a "national awareness campaign to promote the understanding of, treatment for, and elimination of the stigma associated with depression." They also recommended the creation of a National Depression Information Center similar to existing Federal information centers on diseases such as cancer, heart disease, and stroke.

One Program's Experience

With more than 20 years of service as Director of the Dane County Mental Health Center's community treatment program in Madison, WI, Dr. Ron Diamond has strong opinions on the positive results that come from an integrated community treatment program, which is a key element of the center's system of care.

Dr. Diamond distinguished between a system and a set of programs. Traditional systems have clinical programs that decide what services they want to offer, and the person is expected to fit into the available services. If the person needs a service not offered by the program, it is the person's problem, not the system's problem. For example, a system may offer a program for psychotherapy, but a client may need housing assistance, which is not offered.

In contrast, an effective mental health system does whatever is required to meet the needs of its clients, and individual program components support one another as part of a larger, integrated system.

Emphasizing the idea of responsibility, he said, "If you are schizophrenic and you're in Dane County, you are my problem. I don't care if you are in jail, in the hospital, homeless, at a university hospital, or a state hospital-you are my problem."

Dr. Diamond also recommended local control of both Federal and state funding, saying, "If you could have true managed care-that is if a local organization or entity had access to all the resources and all the responsibilities for the public good . . . I think you could have more efficiencies than the current hodge-podge of what you have now." In short, we need to "reduce the conflict we have between different funding sources," he said, by considering the notion of wrapping disparate Federal and state resources together under local control.

For a copy of the Interim Report to the President, contact SAMHSA's National Mental Health Information Center, P.O. Box 42490, Washington, DC 20015. Telephone: 1 (800) 789-2647 or 1 (866) 889-2647 (TTY). For information about the Commission and an electronic copy of the report, visit www.MentalHealthCommission.gov.

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