TRANSFORMING MENTAL HEALTH CARE IN AMERICA
The Federal Action Agenda: First Steps
Introduction
We envision a future when everyone with a mental illness can recover, a future when mental illnesses can be prevented or cured, a future when mental illnesses are detected early, and a future when everyone with a mental illness at any stage of life has access to effective treatment and supports-essentials for living, working, learning, and participating fully in the community.[2]
In April 2002, President George W. Bush issued Executive Order 13263 [see Appendix A] establishing the New Freedom Commission on Mental Health. He charged the Commission with conducting a comprehensive study of the public- and private-sector mental health service delivery systems and recommending improvements to enable adults with serious mental illnesses and children with serious emotional disturbances to live, work, learn, and participate fully in their communities. In response, the Commission called for nothing short of fundamental transformation of the mental health care delivery system in the United States, from one dictated by outmoded bureaucratic and financial incentives to one driven by consumer and family needs that focuses on building resilience and facilitating recovery. This Federal Mental Health Action Agenda follows the principles of the Executive Order to highlight specifics for the first year of a long-term strategy designed to move the Nation's public and private mental health service delivery systems toward this visionary goal.
Background on the New Freedom Initiative
New Freedom Commission on Mental Health
The work of the New Freedom Commission on Mental Health is a key component of President George W. Bush's New Freedom Initiative. Launched in February 2001, the New Freedom Initiative is designed to promote full access to community life for people with disabilities, including access to employment and educational opportunities and to assistive and universally designed technologies. The New Freedom Initiative builds on the 1990 Americans with Disabilities Act (ADA), the landmark legislation providing protections against discrimination, and on the U.S. Supreme Court's 1999 Olmstead v. L.C. decision, which affirmed the right of individuals to live in community settings.
In June 2001, President Bush issued Executive Order 13217 promoting community-based alternatives for all individuals with disabilities and directing key Federal agencies to work closely with States to ensure full compliance with the Olmstead decision and the ADA. Through comprehensive self-evaluations and extensive public input, a number of Federal agencies identified barriers to community integration in their policies, programs, regulations, and statutes and developed priorities and action steps to address these barriers.[3]
When the President appointed the New Freedom Commission on Mental Health in April 2002, he asked the group to study the problems and gaps in the mental health system and to make concrete recommendations for immediate improvements that the Federal government, State governments, local agencies, as well as public and private health care providers, can implement. The Commission met for 1 year to study the research literature and to receive comments from more than 2,300 mental health consumers, family members, providers, administrators, researchers, government officials, and other key stakeholders.
The Commission framed its work around the five principles set forth in Executive Order 13263, which seek to improve the outcomes of mental health care; promote collaborative, community-level models of care; maximize existing resources and reduce regulatory barriers; use mental health research fi ndings to influence service delivery; and promote innovation, flexibility, and accountability at the Federal, State, and local levels. In particular, the President's Executive Order directed the Commission to:
- Focus on the desired outcomes of mental health care, which are to attain each individual's maximum level of employment, self-care, interpersonal relationships, and community participation.
- Focus on community-level models of care that effectively coordinate the multiple health and human service providers and public and private payers involved in mental health treatment and delivery of services.
- Focus on those policies that maximize the utility of existing resources by increasing cost-effectiveness and reducing unnecessary and burdensome regulatory barriers.
- Consider how mental health research findings can be used most effectively to infl uence the delivery of services.
- Follow the principles of Federalism, and ensure that its recommendations promote innovation, flexibility, and accountability at all levels of government and respect the constitutional role of the States and Indian tribes.
A keystone of the transformation process will be the protection and respect of the rights of adults with serious mental illnesses, children with serious emotional disturbances, and their parents. With respect to children and adolescents, the New Freedom Commission on Mental Health and this Federal Mental Health Action Agenda clearly recognize that parents are the decision-makers in the care for their children and if any services, including screening, appear to be an appropriate action, parental consent must be obtained before it occurs. Therefore, in this document, whenever child or children is used, it is understood that parents or guardians are the decision-makers in the process of making choices and decisions for minor children. This same support and guidance can also include family members for individuals older than18 years of age.
Achieving the Promise: Transforming Mental Health Care in America
The Commission delivered its final report, Achieving the Promise: Transforming Mental Health Care in America, to the President in July 2003. Immediately following receipt of the report by the President, the Substance Abuse and Mental Health Services Administration (SAMHSA) and its Administrator, Charles G. Curie, MA, ACSW, was charged with the goal of implementing appropriate action steps to strengthen the Nation's mental health system. Signaling Congressional interest in mental health system transformation, in November 2003, Mr. Curie-along with representatives of the public and private sectors and a consumer family member-were called to testify about the Final Report before the Senate Subcommittee on Substance Abuse and Mental Health Services.
A Broad-Based Commitment
The New Freedom Commission on Mental Health called for immediate and profound changes, and the Federal government-in partnership with States, communities, consumers, families, and the private sector-is responding. The Federal Mental Health Action Agenda is a specific and affirmative plan for the initial Federal response to the charge for wholesale transformation.
Because children, adults, and older adults with mental disorders are seen in multiple systems and sectors, the Federal Mental Health Action Agenda represents a broad-based commitment for collaboration on the part of all Federal agencies whose programs can and do serve these individuals. In addition to the U.S. Department of Health and Human Services (HHS), these agencies include the U.S. Departments of Education (ED), Housing and Urban Development (HUD), Justice (DOJ), Labor (DOL), and Veterans' Affairs, and the Social Security Administration (SSA). Together, these agencies recognize that the action steps presented herein are ambitious and have substantial implications for coordination and sequencing of effort; they are prepared to meet the challenges that lie ahead.
Indeed, HHS is gratified by the caliber and degree of contribution to date from its Federal partners and expects more agencies and offices to join this landmark effort. Each agency brings value added to mental health system transformation, and the whole becomes greater than the sum of its parts. Together, the Federal partners are committed to working side-by-side, not to perpetuate the status quo, but to fundamentally alter for generations to come the way the Nation's mental health care system works. The synergy produced by this dynamic Federal partnership will be a guiding force for the work of mental health system transformation at the State and local levels.
Federal Leadership, Shared Responsibility
The Commission pointed out that no agency, individual, or organization can single-handedly transform the mental health service delivery system in this country. The Federal role is to act as a leader and a facilitator, promoting shared responsibility for change at the Federal, State, and local levels, and in the private sector, in such areas as education, research, service system capacity, and technology development. States, however, will be the very center of gravity for system transformation; many already have begun this critical work. Their leadership in planning, financing, service delivery, and evaluating consumer- and family-driven services will significantly advance the transformation agenda. Finally, an emphasis on individual recovery and resilience will transform not only service delivery systems but also hearts, minds, and lives for future generations.
The Need for a Transformed Mental Health System
In its October 29, 2002, Interim Report to the President, the Commission declared that the mental health service delivery system must be robust and responsive to consumers' needs because its failings may lead to "unnecessary and costly disability, homelessness, school failure, and incarceration." The Interim Report concluded that the system is not oriented to the single most important goal of the people it serves-the hope of recovery. State-of-the-art treatments, based on decades of research, are not being transferred to community settings. In many communities, access to quality care is poor, resulting in wasted resources and lost opportunities for recovery. This is particularly true in rural areas and among racial and ethnic minorities. More individuals would recover from even the most serious mental illnesses and emotional disturbances if they had earlier access in their communities to treatment and supports that are evidence-based and tailored to their needs.
Reform Is Not Enough
The Commission's findings make clear that simple reforms no longer are adequate to respond to the needs of children and their parents, adults, and older adults with mental disorders. Wholesale and fundamental transformation of the mental health service delivery system is required. The Commission articulated a vision of a transformed system as one in which Americans understand that mental health is essential to overall health; mental health care is consumer and family driven; disparities in mental health services are eliminated; in high-risk settings such as juvenile justice and child welfare, appropriate and early mental health screening, assessment, and referral to services occurs; excellent mental health care is delivered and research is accelerated; and technology is used to access mental health care and information.
This is a bold vision that points the Nation forward, to a future in which everyone, from public policy makers to consumers and family members, understands that mental health is a vital and integral part of overall health; a future in which every man, woman, and child in need-regardless of age, gender, race, ethnicity, or geography-receives the best research-based care available; a future that harnesses the tremendous power of technology to inform consumers, aid health care practitioners, and speed high-quality health care to underserved areas. This transformation will necessitate a shift in the beliefs of most Americans and will require the Nation to expand its paradigm of public and personal health care. It is nothing short of revolutionary.
Promoting Recovery
The Final Report points out that mental illnesses and emotional disturbances are treatable, and that recovery should be the expectation. Successfully transforming the mental health service delivery system to promote recovery rests on two key principles:
- First, services and treatments must be consumer- and family-driven-geared to give consumers real and meaningful choices about treatment options and providers-and not oriented to the requirements of bureaucracies.
- Second, care must focus on increasing individuals' ability to cope successfully with life's challenges, on facilitating recovery, and on building resilience, not just on managing symptoms.
Roadmap for Transformation
To transform the mental health service delivery system, the Commission challenged the Federal government, State governments, local agencies, and public and private health care providers to:
- Close the 15- to 20-year gap it takes for new research findings to become part of day-to-day services for people with mental illnesses. Waiting for the research to make its journey down an already clogged pipeline equates to generations lost in the process. Too many Americans already are underserved, and many more are done a disservice when they receive outmoded or unproven therapies that fail to improve their quality of life while they wait for the latest research to make its way into their communities.
- Harness the power of health information technology to improve the quality of care for people with mental illnesses, to improve access to services, and to promote sound decision-making by consumers, families, providers, administrators, and policy makers. The application of information technology to health care may well be the most important medical advance of the 21st century, and practitioners, consumers, and family members must have access to its unparalleled benefits and protection from its potential abuses.
- Identify better ways to work together at the Federal, State, and local levels to leverage human and economic resources to their best use for children, adults, and older adults living with-or identified at risk for-mental disorders. The time has come for agencies and individuals to step out of a silo mentality and learn to work across traditional administrative, philosophical, and funding boundaries.
- Expand access to quality mental health care that serves the needs of racial and ethnic minorities and people in rural areas. Disparities in access to and quality of mental health services must be eliminated.
- Promote quality employment opportunities for people with mental illnesses. People with mental illnesses want and need to work and employment can be both a goal of and a tool for recovery.
In response to the President's charge, the New Freedom Commission developed far more than a set of "might do" and "could try" activities. The group's recommendations are a roadmap for full-scale transformation of the mental health care delivery system in America. As such, the message of full community participation for children and their parents, adults, and older adults with mental disorders must be part of every strategy session, budget decision, and public debate concerning mental health service delivery and health care reforms.
The Focus on Recovery
Individual recovery is at the heart of the New Freedom Commission's vision to transform the mental health service delivery system in America. The good news at the heart of the Commission's Final Report is that adults with serious mental illnesses and children with serious emotional disturbances can and do recover. The Commission makes clear that success means a system grounded in recovery-one that reflects a belief in recovery, one that demonstrates a commitment to providing recovery-based services, and one that, through its actions, inspires in consumers and their families the hopefulness of recovery.
Recovery, as defined by the Commission, is the process by which people are able to live, work, learn, and participate fully in their communities. For some individuals, the Commission noted, recovery is the ability to live a fulfilling and productive life despite a disability. For others, recovery implies the reduction or remission of symptoms. For many people, recovery is a transformative process, one that is less about returning to a former self and more about discovering who one can become. [4] Science has shown that having hope plays an integral role in an individual's recovery.
Though the term is most frequently applied to adults with serious mental illnesses, recovery is for everyone-children and adolescents, adults, and older adults. No one is too young or too old to recover a valued social role[5] in his or her family and community. Recovery touches the adult or child who receives mental health services and the family members, friends, and supporters who play a vital role in the person's life. Building resilience (i.e., strengthening those factors that allow an individual to overcome adversity) to facilitate recovery is the goal of every individual and organization that is part of the mental health service delivery system in this country.
The Process of Transformation
The word "transformation" was chosen carefully by the Commission to reflect its belief that mere reforms to the existing mental health system are insufficient. Transformation is a powerful word with implications for policy, funding, and practice, as well as for attitudes and beliefs.[6] Indeed, transformation is not accomplished through changes at the margin but, instead, through profound changes in kind and in degree. These changes result in new behaviors and new competencies. Transformation is a continuous process, meant to create or anticipate the future. Once begun, the process of transformation leads to an organization that is profoundly different in structure, culture, policy, and programs.
Applied to the task at hand, transformation represents a bold vision to change the very form and function of the mental health service delivery system to better meet the needs of the individuals and families it is designed to serve. As with any large-scale organizational change, transformation of the mental health system will be a complex process that proceeds in a non-linear fashion and that requires collaboration, innovation, sustained commitment, and a willingness to learn from mistakes. In particular, transformation requires that:
- Consumers and family members are active partners in the transformation agenda. Their participation in transforming the system to meet their needs is not just a critical piece of the puzzle-it is the reason for doing the difficult, but necessary, work the Commission envisions.
- Federal agencies examine all funding, policies, and administrative vehicles (e.g., grants, contracts, technical assistance centers, etc.) and align them with the Commission's vision.
- The public and private sectors come together in partnerships designed to ensure that consumers are able to access the care they need through any door in any system.
The Action Agenda:
Transforming the Mental Health System
To develop this Federal Mental Health Action Agenda, SAMHSA invited key Federal agencies to compile inventories of current programs and activities that address the Commission's vision and to propose action steps to move the agenda forward. The pages that follow present the Federal response to the principles of the Executive Order and the Commission's work, with an emphasis on those first steps that will yield immediate results. The Introduction features highlights of the Action Agenda-the "big picture" items on which future action steps will build. Highlighted action steps are described in more detail in the body of the report, called the Federal Mental Health Action Agenda.
Preview of the Federal Mental Health Action Agenda
The elements of the Federal Mental Health Action Agenda include:
- The five principles in the Executive Order around which the New Freedom Commission on Mental Health framed its vision of a transformed mental health service system.
- The "State of Success" for each principle, which reflects the elements of a transformed mental health system over the long term.
- Action steps for each principle that will move the mental health service system toward transformation.
- A look at representative current activities that reflect each principle. These lists are illustrative but not exhaustive. An inventory of current, relevant Federal activities that respond to the Commission's vision has been completed by SAMHSA.
Moving Forward
Transformation is a long-term process. This Federal Mental Health Action Agenda outlines the initial steps in a multi-year effort to transform the form and function of the mental health service delivery system in America. Each step requires the full commitment of the agencies and individuals involved; all steps speak to the need for the public/private partnerships that will make the Commission's vision a reality. Ultimately, the Federal Mental Health Action Agenda is a living document that will move the Nation closer to the day when adults with serious mental illnesses and children with serious emotional disturbances will live, work, learn, and participate fully in their communities.
Highlights of the Action Agenda:
The Federal Response
Highlights of the Federal Action Agenda follow. These represent signature items that respond to the Commission's vision for mental health system transformation, organized under the fi ve principles of the Executive Order. These items will be addressed in the first of a multi-year effort to alter the form and function of mental health service delivery for children, adults, and older adults.
Principle A: Focus on the desired outcomes of mental health care, which are to attain each individual's maximum level of employment, self-care, interpersonal relationships, and community participation.
Every man, woman, and child with or at risk for mental disorders deserves a life in the community, with meaningful employment, interpersonal relationships, and community participation. They also need the tools of self-care that will make their recovery possible. In fact, a wide array of effective mental health services and treatments is available to allow children, adults, and older adults to be vital contributors to their communities. Yet, many people remain unserved, in part because of the stigma of seeking help. Racial and ethnic minorities and people living in rural areas are particularly ill served. This situation cannot be allowed to remain unchanged, especially when there is so much hope for recovery. Agencies, programs, and individuals must forge the interpersonal relationships that form the foundation for recovery from mental illnesses and emotional disturbances, and connect people with mental disorders to employment that provides both income and a measure of self worth. Highlights of the Federal response to this principle follow.
Initiate a National Public Education Campaign
SAMHSA will initiate a national public education campaign to improve the general understanding of mental illnesses and emotional disturbances, and to encourage help-seeking behaviors across the age span for people in need. It is expected that the public and private sectors will pool their resources and their expertise to plan, create, coordinate, and evaluate the campaign. Campaign materials will be customized to address gender-specific mental health issues for children and adolescents, adults, and older adults, and will be appropriate for racial and ethnic minorities and for urban and rural residents. The campaign also will address both private and public sector employers with a business case for hiring people with mental illnesses. Information and technical assistance will be readily available to support the campaign.
Launch the National Action Alliance for Suicide Prevention
In the United States, suicide claims approximately 30,000 lives each year. The vast majority of all people who die by suicide have mental disorders-often undiagnosed or untreated. HHS will launch the National Action Alliance for Suicide Prevention, a public-private partnership to oversee full implementation of the National Strategy for Suicide Prevention. A broad base of stakeholders in both the public and private sectors will support coordinated national efforts to prevent suicide, including ongoing support for the Suicide Prevention Resource Center and further nationwide development of suicide/crisis hotlines. The National Institutes of Health (NIH) in the HHS, through its National Institute of Mental Health (NIMH), will manage an aggressive suicide prevention research portfolio.
Educate the Public About Men and Depression
NIMH will continue its "Men and Depression" Campaign, a major HHS public information effort to encourage men and their families to recognize depression-the disease condition that causes the most disability in America-and seek treatment.
Develop Prototype Individualized Plans of Care That Promote Resilience and Recovery
The Commission recommended development of an individualized plan of care for every adult with a serious mental illness and every child with a serious emotional disturbance. These customized plans, developed in full partnership with consumers, parents of children and adolescents, and other family members as appropriate, must include evidence-based and promising practices in prevention and treatment, and must promote resilience and recovery. To this end, SAMHSA will convene a consensus development meeting to discuss the meaning and process of recovery for children, adults, and older adults. The agency will build on this meeting by reviewing current best practices and providing technical assistance to States and providers on the design and development of prototype individualized plans of care for children, adults, and older adults. These plans will describe the services and supports that must be coordinated from among multiple systems for an individual to achieve recovery and will be designed to be fl exible so they can be adapted to meet an individual's changing needs and preferences. When developed, these prototype plans will be shared with States, communities, providers, consumers, and family members to promote the use of customized plans of care in transformed mental health systems.
Promote Quality Services in the Workforce Development System for People With Mental Illnesses
DOL will work with its Federal partners to initiate the following strategies designed to increase employment opportunities for adults and youth with mental disorders:
- Develop an employer initiative to increase recruitment, employment, advancement, and retention of people with mental illnesses.
- Promote the use of customized employment strategies, including self-employment, micro-enterprise development, and small business options for people with mental illnesses.
- Help mental health support systems become Employment Networks under the Ticket to Work and Work Incentives Improvement Act.
- Disseminate information on mental health issues through DOL grant initiatives and programs such as: Work Incentive Grants, Customized Employment Grants, Homeless Veterans' Reintegration Program, Incarcerated Veterans' Reintegration Program, Veterans' Workforce Investment Program, Transition Program, Youth Offender Demonstration Program, Serious and Violent Re-entry Initiative, Ready4Work Grants, High School/High Tech Grants, and
- Chronically Homeless Grants.
- Assist youth with serious emotional disturbances involved with the juvenile justice system to transition into employment.
- Promote the employment of people with mental illnesses who are chronically homeless.
- Facilitate linkages between DOL/SSA's joint Disability Program Navigator Initiative, SAMHSA, and related State and local mental health service systems.
- Establish a DOL Work Group to promote quality employment of adults with serious mental illnesses and children with serious emotional disturbances.
Promote the Transition of Youth With Serious Emotional Disturbances From School to Post-Secondary Opportunities and/or Employment
Much concern was expressed by the Commission for youth with serious emotional disturbances dropping out of school with little prospects for meaningful employment. ED's Office of Special Education and Rehabilitation Services will work with DOL, SAMHSA, and SSA to assist older youth to transition from school to a post-secondary education program or employment.
Create a Comprehensive Action Agenda to Implement Throughout the Veterans Health Administration all Relevant Recommendations of the President's New Freedom Commission on Mental Health
As the largest provider of comprehensive health services in America, the Veterans Health Administration has created an action agenda to implement all relevant recommendations in the Final Report of the President's New Freedom Commission on Mental Health. An internal Steering Committee, along with participants from various Federal partners, already has embarked upon this challenging undertaking. The action agenda will drive a sustained effort over time to orient the Veterans Health Administration toward the expectation of recovery and veteran-centered care with a commitment to the provision of evidence-based services.
Initiate a National Effort Focused on Meeting the Mental Health Needs of Children as Part of Overall Health Care
The Commission highlighted the need for a national focus on the mental health needs of children and their parents/guardians that includes screening, assessment, early intervention, treatment, training, and financing services for children identified to be at risk for developing mental disorders. A Task Force of the Federal Executive Steering Committee (described below under Principle B) will develop a national public education initiative for parents, providers, and policy makers about the importance of the first years of life in developing a healthy foundation for social, emotional, and cognitive development. In addition, the Task Force will propose a comprehensive approach at the Federal and State levels for children identified to be at risk for mental disorders, assessment, and intervention in early childhood settings; educating and training professionals and families in effective treatment approaches and supports for young children identified to be at risk and their parents; and eliminating disincentives and barriers, particularly in financing systems, to serving this population.
Launch a User-Friendly, Consumer-Oriented Web Site
Personal health information systems can help consumers manage their own care while gaining computer literacy skills. To this end, SAMHSA's Center for Mental Health Services (CMHS) will explore investing in the development of a user-friendly, consumer-oriented web site-such as the San Diego Network of Care for Mental Health-in 25 geographically diverse locations around the country. The San Diego web site was featured as a model program in the Final Report of the President's New Freedom Commission. It provides information on mental illnesses and community resources and gives individuals and family members the ability to create personal health records on a secure server. Consumers can control personal health records, and the privacy of such records is protected according to regulations under the Health Insurance Portability and Accountability Act (HIPAA). The Federal funding will serve as seed money to the local jurisdictions, which will fund ongoing development and support of this vital resource that will put mental health information and services as close as the nearest Internet connection. Information technology accessibility for all individuals with disabilities is mandated by Section 508 of the Rehabilitation Act and is a cornerstone of the President's New Freedom Initiative.
Promote ADA Compliance, Support and Work to Eliminate Unnecessary Institutionalization, and Help Eliminate Discrimination
The Office of Civil Rights (OCR) in the HHS Office of the Secretary, together with the SAMHSA/ CMHS New Freedom Initiative technical assistance center, will continue Olmstead voluntary compliance initiatives, including providing technical assistance to States, disseminating information about Olmstead compliance, and promoting ADA compliance and community care. In keeping with its compliance responsibilities, OCR also will continue to investigate complaints and conduct compliance reviews to protect and enhance the rights of people with mental illnesses under Section 504 of the Rehabilitation Act and the ADA, with particular emphasis on Title II ADA most integrated setting complaints (i.e., Olmstead complaints) and will protect the rights of people with mental illnesses under the HIPAA Privacy Rule to prevent inappropriate disclosures of mental health information.
Principle B: Focus on community-level models of care that effectively coordinate the multiple health and human service providers and public and private payers involved in mental health treatment and delivery of services.
Consumers and families told the Commission that feeling hopeful and having the opportunity to regain control of their lives was vital to their recovery and to their children's recovery. However, understandably, consumers and family members feel overwhelmed and bewildered when they must access and integrate mental health care, support services, and disability benefi ts across multiple, disconnected programs that span Federal, State, and local agencies, as well as the private sector. This situation must be reversed so consumers of mental health services and family members stand at the center of the system of care. In particular relevant Federal programs must be aligned to improve access and accountability for mental health services at the Federal level and to serve as an example of such coordination at the State and local level. The Commissioners also urged that disparities in access to and quality of mental health services be eliminated. Highlights of the Federal response to this principle follow.
Launch the Federal Executive Steering Committee on Mental Health
The Federal government must take a leadership role to promote and model the type of collaborative efforts required for system transformation at the State and local levels. To this end, HHS will lead an intra- and inter-agency Federal Executive Steering Committee to guide the work of mental health system transformation. The Department will appoint as members high-level representatives from agencies within the HHS and from other Federal departments that serve children, adults, and older adults who have mental disorders.
The Department will charge this group with providing ongoing stewardship for the work that resulted from the New Freedom Initiative and the President's New Freedom Commission on Mental Health to promote access and effective services for adults with mental illnesses and children with emotional disturbances in all spheres of community life. The Department will require the entire Executive Steering Committee and selected Task Forces it appoints to meet regularly. These Task Forces will oversee vital elements of the transformation agenda and will include groups on workforce development, rural issues, children, eliminating disparities, and evidence-based practices, among others. In carrying out its specific charge, each Task Force will consider all elements key to community integration for children, adults, and older adults with mental disorders, including housing, employment, transportation, education, and assistive technology. Finally, the Department will require the Steering Committee to submit a progress report every 2 years, including a report on measurable benchmarks for success.
Include Eliminating Disparities in Mental Health Services as Part of the HHS "Close the Gap Initiative"
A Task Force of the Federal Executive Steering Committee on Mental Health will work closely with the Secretary's Health Disparities Council to ensure that eliminating disparities in mental health services is integral to the Department's overall "Close the Gap Initiative."
Create a National Strategic Workforce Development Plan to Reduce Mental Health Disparities
The mental health service delivery system can be only as good as the practitioners who staff it. Therefore, the Commission recommended making strong efforts to train, educate, recruit, retain, and enhance an ethnically, culturally, and linguistically competent mental health workforce throughout the country. In response, a Task Force of the Federal Executive Steering Committee will oversee creation of a national strategic plan to develop a mental health workforce better able to deliver culturally competent, evidence-based, 21st century health care. The strategic plan should address a wide range of providers, including psychiatrists, psychologists, nurses, social workers, consumers, and family members.
The Task Force will convene selected behavioral health care leaders from both the public and private sectors to create and manage a national strategic planning process. The goal of this effort will be to expand and improve the capacity of the mental health workforce to meet the needs of racial and ethnic minority consumers, children, and families; to address the concerns of rural mental health consumers and family members; to make consistent and appropriate use of evidence-based mental health prevention and treatment interventions; and to work at the interface of primary care and behavioral health care settings.
Initiate a Project to Examine Cultural Competence in Behavioral Health Care Education and Training Programs
The Commission recommended that all federally funded health and mental health training programs explicitly include cultural competence in their curricula and training experiences.
To this end, SAMHSA will initiate a project to examine all current behavioral health care education and training programs that receive Federal funds to help determine the extent to which they recruit and retain racial and ethnic minority and bilingual trainees; emphasize the development of cultural and linguistic competence in clinical practice; develop and include curricula that address the impact of culture, race, ethnicity, and geography on mental health and mental illnesses, on help-seeking behaviors, and on service use; engage minority consumers and families in workforce development and training; and educate trainees about evidence-based mental health interventions, among other areas.
Develop a National Rural Mental Health Plan
Despite the fact that rural America is home to approximately 25 percent of the U.S. population, rural issues are often misunderstood, minimized, and not considered in forming national mental health policy. A Task Force of the Federal Executive Steering Committee will work with the HHS Secretary's Rural Task Force to identify and convene key leaders in both the public and private behavioral health care sectors and will provide leadership and logistical support toward the development of a national rural mental health plan. At a minimum, this plan will address the integration of mental health and physical health care, financing incentives, alternative insurance mechanisms, workforce enhancement programs, and the effectiveness of mental health services delivered by distant providers using telehealth technologies.
Include Mental Health in Community Health Center Consumer Assessment Tools
Despite the fact that people with mental disorders are seen routinely in primary care settings, their mental health disorders may go undiagnosed, untreated, or undertreated in primary care. Based on findings of the U.S. Preventive Services Task Force and the Institute of Medicine report, From Neurons to Neighborhoods: The Science of Early Childhood Development (2000), SAMHSA, the Centers for Disease Control and Prevention (CDC), and the Health Resources and Services Administration (HRSA) will collaborate to facilitate serving adults and older adults identifi ed to be at risk for depression, and, with prior parental consent, children and adolescents identifi ed to be at risk for mental, emotional, and behavioral problems in federally funded Community Health Centers, and to coordinate followup treatment with community mental health agencies or other appropriate providers.
Promote Strategies to Appropriately Serve Children With Mental Health Problems in Relevant Service Systems
Serious emotional disturbance (SED) in childhood can be an important precursor to the development of serious mental illnesses as an adult. Supporting the mental health of children and adolescents with SED and their families is a strategic investment that will create long-term benefits for individuals, systems, and society. Children at risk for development of mental disorders and serious emotional disturbances are seen in numerous service systems, including schools, primary health care clinics, child care programs, the child welfare system, and the juvenile justice system. Neither Achieving the Promise nor this Action Agenda recommends mandatory and/or universal screening of children. The Commission recognized that parents are the decision-makers in the care for their children and if screening appears to be an appropriate action, parental consent must be obtained before it occurs. For these children, early detection through screening may help parents identify emotional or behavioral problems and assist them in getting appropriate services and supports before problems worsen and have longer-term consequences. Therefore, HHS agencies-including SAMHSA, Administration for Children and Families (ACF) and its Administration on Developmental Disabilities, the Agency for Healthcare Research and Quality (AHRQ), the Office on Disability, and HRSA-together with ED and DOJ, will gather and review current screening instruments to determine which are the most developmentally, culturally, and environmentally appropriate for children. Mental health consumers, parents/ guardians, and youth will participate in this review.
This Federal review group will make a commitment to assess the feasibility of implementing one or a combination of these instruments in specific service systems where children identifi ed to be at risk for mental disorders present for care and where providers can work with parents to link children to appropriate services and interventions, as needed. The goal is to recognize emotional and behavioral problems at an early stage so preventive interventions can help forestall future disease and disability and reduce the need for extensive treatment.
Principle C: Focus on those policies that maximize the utility of existing resources by increasing cost-effectiveness and reducing unnecessary and burdensome regulatory barriers.
Fragmented services often result from regulatory barriers that require a program or agency to use its funds to serve particular individuals with specific problems, even though people with mental illnesses have multiple and complex needs and require a broad array of services to address these needs. This narrow approach leads to increased costs, duplication of services, lack of services, and confusion for individuals and family members. Financial and regulatory barriers must be addressed to allow adults with serious mental illnesses and children with serious emotional disturbances to gain access to the type and level of care they need and to permit the most effective use of existing resources. Highlights of the Federal response to this principle follow.
Initiate Medicaid Demonstration Projects
Medicaid is the largest single funder of public mental health services in this Country, and Medicare is a significant payer, as well. As such, the Centers for Medicare and Medicaid Services (CMS) in the HHS is a critical player in the Federal response to mental health system transformation. Current Medicaid policies may act as disincentives to the development of community-based services for children, adults, and older adults with mental disorders. In response, CMS is committed to convening key stakeholders to discuss these barriers and to supporting demonstration projects to test the feasibility of alternative approaches, if authorized and funded by Congress. These may include demonstrations of:
- Supported employment, a mental health evidence-based practice;
- Respite care services for caregivers of adults or children with disabilities, including mental illnesses;
- Alternatives to psychiatric residential treatment for children with serious emotional disturbances;
- Efforts that promote self-determination and consumer direction in mental health systems, such as person-centered planning, vouchers, and consumer-operated services; and
- Systems of fl exible financing for long-term care that allow money to follow the individual.
In each case, these projects will demonstrate funding strategies that promote and support community-based treatment for children, adults, and older adults with mental disorders. CMS makes funding available through Systems Change Grants for feasibility studies for several of the demonstrations mentioned above. Additionally, CMS provides technical assistance for States pursuing these projects.
Help Parents Avoid Relinquishing Custody and Obtain Mental Health Services for Their Children
The Commission decried the fact that some parents have been forced to relinquish custody to obtain needed mental health services for their children. HHS will lead an effort among Federal agencies to initiate a multifaceted approach across systems with the goal of ending this tragic practice and increasing families' access to home- and community-based services and systems of care for their children with serious emotional disturbances. At a minimum, this effort will include the provision of technical assistance and dissemination of information to families and States on the State Children's Health Insurance Program (SCHIP) and on Medicaid options, such as the provision of home- and community-based services for children with mental or physical disabilities as authorized by the Tax Equity and Fiscal Responsibility Act (TEFRA); the Home- and Community-Based Services Waiver; the Rehabilitation Option; and proposed Medicaid demonstration projects, including respite services for caregivers and alternatives to psychiatric residential treatment for children with serious emotional disturbances. In addition, HHS and its Administration for Children and Families (ACF) will clarify Federal law, Title IV-E, and develop model legislation clarifying the responsibility of State Child Welfare Agencies and prohibiting custody relinquishment to access mental health services.
Support the Ticket to Work Program
As part of its overall support for the Ticket to Work and Work Incentives Improvement Act of 1999, CMS will release a solicitation to provide health care and other support services to individuals, including those with serious mental illnesses, who may be at risk of losing employment and independence. This solicitation will be for the Demonstration to Maintain Independence and Employment.
Additionally, under the Ticket to Work and Work Incentives Improvement Act, CMS will provide assistance to States through a Medicaid Infrastructure Grant Program. The Ticket to Work Act addresses many of the work disincentives faced by people receiving Supplemental Security Income (SSI) and Social Security Disability Insurance (SSDI), such as loss of cash benefi ts and medical coverage. The Medicaid Infrastructure Grant program for 2004 includes a provision that will allow States to propose the use of funding to lessen or remove the primary barriers to employment for adults with disabilities through a comprehensive, coordinated approach between Medicaid and non-Medicaid programs.
The major objectives of this program, called Comprehensive Employment Opportunities Infrastructure Development, are (1) protection of health care coverage, (2) availability of key supportive services, and (3) increased coordination of programs and policies. While the proposals submitted by States will vary, CMS expects that States participating in this program will use the funds to remove barriers to work for people with disabilities, including people with mental disorders, by creating health systems change through the Medicaid program or by bridging Medicaid and other programs to further remove barriers.
Educate Employers and Benefits Managers on the Practicability of Paying for Mental Health Services
A multidisciplinary group of mental health consumers, corporate benefit managers, health care consultants, pharmacy benefit managers, and Employee Assistance professionals will be invited to form an Employer Toolkit Workgroup to review the recommendations of the New Freedom Commission on Mental Health and to suggest a comprehensive approach for employers in selecting and purchasing mental health services. A toolkit for employers to use will contain several items, including a Solution Brief outlining the issues, guidelines for selecting a mental health vendor, recommendations for evaluating performance of mental health vendors, disability programs, and pharmacy vendors. The toolkit will provide guidance for the structure and operations of these various programs, including sample policies and procedures.
Develop a Strategy to Implement Innovative Technology in the Mental Health Field
SAMHSA will convene a consensus development workgroup, including HHS Office of the National Coordinator for Health Information Technology (ONCHIT), HRSA's Offi ce for the Advancement of Telehealth, public mental health and private-sector experts, consumers, and family members, to:
- Review the current status of telemedicine, information technology, Internet technology, and electronic decision support tools in health care;
- Examine the current status of implementation of these tools in mental health; and
- Prepare key recommendations for immediate next steps in technology support for mental health services.
Explore Creation of a Capital Investment Fund for Technology
Studies show that technology can be used to improve the quality, accountability, and cost-effectiveness of health care services. To help harness the tremendous power of technology for mental health care, SAMHSA will explore the creation of a Capital Investment Fund for Technology. The Capital Investment Fund will be used to work with States to design and initiate an electronic health record and information system that is consistent with the Institute of Medicine Report, Patient Safety: Achieving a New Standard of Care (2004). The electronic health record and information system will incorporate an individualized plan of care and will be consistent with the proposed Comprehensive State Mental Health Plan. It will provide decision support to service providers as they order tests, diagnose illness, and devise treatment plans. The system also will provide the capacity for an unprecedented, real-time disease surveillance and management system.
Principle D: Consider how mental health research findings can be used most effectively to influence the delivery of services.
Effective, state-of-the-art treatments vital for quality care and recovery are now available for most serious mental illnesses and serious emotional disturbances. Yet these new, effective practices often are not being used to benefit countless people with mental disorders. There is a significant lag time between discovering effective forms of treatment and incorporating them into routine patient care. Further, even when new discoveries become available routinely at the community level, clinical practice may be inconsistent with the original treatment model, especially when staff are not adequately trained to provide evidence-based care. The lag time between research and practice must be shortened, and evidence-based practices must become a part of routine mental health care for all children, adults, and older adults with mental disorders. In addition, more research is needed in the critical areas of mental health disparities, the long-term effects of medications, trauma, and acute care.
Accelerate Research to Reduce the Burden of Mental Illnesses
Building on the discoveries rapidly emerging from the decoding of the human genome and from new, more powerful imaging techniques, NIMH will reorganize and streamline research to produce new interventions. The ultimate goal will be to prevent or cure mental illnesses.
Expand the National Registry of Evidence-Based Programs and Practices to Include Mental Health
The Nation must have a more effective system to identify, disseminate, and apply proven treatments and evidence-based practices to mental health care, the Commission noted. In response, SAMHSA will expand its National Registry of Evidence-based Programs and Practices (NREPP) to include the best evidence-based mental health promotion and treatment interventions for mental disorders. The Agency will:
- Identify a procedure through which the status of evidence-based practices can be reviewed and summarized for the public and private mental health service delivery fi elds;
- Summarize action steps currently being taken in parallel fields, such as primary care, to implement evidence-based practices;
- Review the activities of the Practice Guideline Coalition and NREPP, and make recommendations for how they might be integrated and implemented in the mental health services; and
- Recommend a procedure through which consensus can be developed across key mental health groups, consumers, and family members regarding implementation of evidence-based practices.
Develop New Toolkits on Specific Evidence-Based Mental Health Practices
To disseminate more broadly known evidence-based practices to the field, SAMHSA will expand its National Evidence-Based Practices Project with the addition of toolkits in areas that may include children's services, supportive housing, older adults, trauma and violence, collaborative models in primary care, consumer-operated service approaches, and supported education. The toolkits, developed in collaboration with private partners, will include materials for administrators, clinicians, consumers, and family members on the implementation of evidence-based practices and will be tested in pilot States.
Expand the "Science-to-Services" Agenda
The 15- to 20-year gap it takes for new research findings in mental health prevention and treatment to become part of everyday services for children, adults, and older adults is simply unacceptable. SAMHSA and NIH have begun a formal "Science-to-Services" agenda to further develop and expand evidence-based practices in the field. This is an ongoing, reciprocal relationship in which science informs services, and the experiences of service providers identify priority areas for further research. SAMHSA's CMHS and NIMH are spearheading this effort for the area of mental health. To expand these efforts, a Task Force of the Federal Executive Steering Committee will work with SAMHSA, NIH, AHRQ, and CMS to identify those evidence-based and promising practices that warrant further research, those that are ready for fi eld implementation, and those that can and should be funded at the State and local level. The Task Force will consider all three legs of the research-to-practice stool-science, services, and funding-and will establish guidance to the field about the practical application of research findings.
Conduct Research to Reduce Mental Health Disparities
NIMH is expanding its support for programs that conduct research to reduce health disparities by issuing a new program announcement (2004) for the development of Advanced Centers for Mental Health Disparities Research. The purpose of this initiative is to promote the enhancement of established research core infrastructures and investigator-initiated research aimed at understanding and ameliorating mental health disparities. Research projects may include, but are not limited to, studies of mental health disparities among American Indians, Alaska Natives, Asian Americans, African Americans, Hispanics, and Native Hawaiians and Pacifi c Islanders. Studies of ethnic subpopulations within these broad categories are also encouraged. The Institute will also continue its support for the Disparities in Mental Health Services Research Program, the Socio-Cultural Research Program, the Office of Special Populations, and the Offi ce of Rural Mental Health (NIH).
Principle E: Follow the principles of Federalism, and ensure that [the Commission's] recommendations promote innovation, flexibility, and accountability at all levels of government and respect the constitutional role of the States and Indian tribes.
The Commission made clear that much of the work of system transformation will take place at the State and local levels, as well as in the private sector. The Federal government, in turn, can facilitate innovation and flexibility by promoting the development of transformed systems of care for adults with serious mental illnesses and children with serious emotional disturbances. State Incentive Grants and similar vehicles encourage innovation and require accountability; however, funding for such grants is necessary but not sufficient. Federal agencies and programs have a key role to play in providing the types and range of technical assistance and training that will move the field forward, from one in which individual agencies treat specific clients to one in which a comprehensive system of care is accessible to adults and children with mental disorders and their family members. Highlights of the Federal response to this principle follow.
Award State Mental Health Transformation Grants
The Commission vested States with one of the most critical elements of system transformation: creation of Comprehensive State Mental Health Plans. Development of the State plans requires that all key stakeholders be at the table, including consumers and family members, and those who work in systems that serve children, adults, and older adults with mental disorders, such as criminal and juvenile justice, child welfare, health, housing, homelessness, employment, education, and transportation.
President Bush's Fiscal Year 2005 proposed budget contained $44 million and Congress appropriated $20 million to help States develop comprehensive plans. CMHS will design, implement, and evaluate a 3-year State Mental Health Transformation Grant program to support State efforts to develop a Comprehensive Mental Health Plan. These grants are expected to support State mental health services infrastructures and to promote implementation of science-based mental health interventions. SAMHSA will help grantees identify prototype State plans and provide technical assistance to customize these plans for specific State needs.
Award Child and Adolescent State Infrastructure Grants
SAMHSA will continue to support the Child and Adolescent State Infrastructure Grant program. These grants help States increase their system infrastructures to support mental health and/or substance abuse services and programs for children and adolescents with mental, substance use, and/or co-occurring disorders. These 5-year grants will focus on strengthening State capacity to transform the service delivery system to meet the needs of this population of youth and their parents/guardians, including cross-system coordination and collaboration, fi nancing, increased access to services, workforce development, data management and accountability, implementation of evidence-based interventions, individualized care planning, service integration, family and youth involvement, and sustainability of system reforms. These grants will complement and help prepare States for SAMHSA's State Mental Health Transformation Grants and the development of their Comprehensive State Mental Health Plans, which include cross-system planning for children who have serious emotional disturbances.
Develop Statewide Systems of Care for Children With Mental Disorders
HRSA's State Maternal and Child Health Early Childhood Comprehensive Systems Grants will bring in other Federal partners to plan for and develop statewide systems of care to support the healthy social and emotional development of children. These grants enable States to plan, develop, and implement comprehensive, collaborative systems to improve childhood outcomes. In particular, grants support the development of a State plan that addresses access to health insurance and regular primary care services, mental health and social-emotional development interventions, early child care and educational supports, and parent education and family support. These are 2-year planning grants followed by multi-year implementation grants.
Establish a Foundation for the Samaritan Initiative
Based on experience with the $35 million Collaborative Initiative to Help End Chronic Homelessness, the President proposed the Samaritan Initiative at $200 million in his Fiscal Year 2005 budget. This initiative would provide funding for permanent supportive housing for people who experience chronic homelessness.
Establish the Reentry Initiative for Ex-Prisoners With Psychiatric Disabilities
HUD's 2006 budget request includes $25 million as a part of a prevention initiative for prisoners returning to the community, many of whom are struggling with serious mental illnesses. HUD will collaborate with DOL and DOJ in this effort.
In addition, DOL will compile data on people served and types of services provided to people with psychiatric disabilities who are incarcerated. Information will be solicited from SAMHSA and DOJ's Bureau of Prisons, National Bureau of Corrections, and relevant foundations and associations. DOL's Employment and Training Administration, VETS, and the Faith-Based Offi ce will support One-Stop Centers to identify resources and effective practices. Policy recommendations will be developed to address service gaps systematically and strategically.
Award Seclusion and Restraint State Incentive Grants
SAMHSA will continue to support grants designed to enhance State capacity to provide staff training to implement alternatives to seclusion and restraint in mental health care settings. This program also supports a Resource Center, which is a central repository on effective practices to reduce and eliminate seclusion and restraint and provides technical assistance to the grantees.
Click here to view the Highlighted Action Steps to Transform the Mental Health System
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