Role of County Psychiatric Leaders

Role of County
Psychiatric Leaders
Roger Peele, MD, DLFAPA
RogerPeele.com
RogerPeele@aol.com

1

History of Counties - 1
Pre-1066, England divided into shires.

Post-1066, “county.”

First county in US, James City County, 1636

[NACo]

3

History - 2
Since the 1770s, Americans have not
wanted a king, have wanted authority
close to the people.

In 1800s, concept that county seats should
be within a day’s buggy ride.
[NACO]

4

History - 3
Two roles of counties:

1. Administrative arm of the state or
national government.

2. Local government.

5

History - 4
Over the years, there has been an increase
in:
1. Greater autonomy from the state
government.
2. Rising revenue.
3. Stronger political accountability.
4. Widening range of services.
[NACo]
6

Counties - Number
48 states
Alaska uses “borough”
Louisiana uses “parish”
Total number: 3028
Most: Texas: 254
Least: Delaware: 3

7

Counties – Size and
Population
Arlington County, Virginia: 26 sq miles
North Slope Borough, Alaska: 87,860 sq miles

Loving County, Texas, 45 folks
Los Angeles County, 9,848,011 folks

More than 2/3 counties have <50,000.
[NACo]

8

County Roles
Huge variance in priority of expenditures:

In Virginia counties: 55% on education

In New Hampshire: 67% on public welfare

In Maine: 56% on public safety

[NACo]
9

Source of Revenues
3% from Feds [e.g., Payment in Lieu of
Taxes (PILT)]
33% from states
Rest: from county sources, but states limit
types of taxes counties can use. For
example, a state might prohibit a sales tax
or prohibit income tax.

[NACo]
10

Range of Income
Household income, Median, [2009]:
Loudon County, Virginia: $110,643.
McKinley County, NM: $30,366

[NACo]

11

County Debt:
Most urbanized counties: $500/resident

Most rural counties: $172/resident

[NACo]

12

County Employees
About 4 of every 100 residents.

[NACo]

13

Governance - 1
Authority limited to what was granted by the
state [“Dillon’s Rule” – 1868]
“Home Rule,” [California – 1911] in which
the counties have broad range of power to
determine their organizational structure,
what they can tax, and how they spend
their money.
[NACo]
14

Governance - 2
As for counties part of urban areas, John F.
Kennedy, about 1959, while still a Senator
declared:
“city governments cannot always assume sole
responsibility for the solution to these pressing
urban problems. I repeat, they cannot – our
state governments will not – the federal
government should not – and therefore you on
the county level must.”
[NACo]

15

Governance - 3
In addition to the states pushing responsibility
down to the counties, there has been a tendency
to push responsibilities upward from cities and
towns. Examples in increased responsibility:
-- police protection
-- jails and prisons
-- public welfare

16

Governance - 4
Consolidation of counties. NYC, 1898, has
not been a common trend, less that 40.

[NACo]

17

State Authorized
County Boards
Some states have established county
boards and given the county board
considerable authority. For example in
Virginia, Community Service Boards. In
Maryland, County Service Agency.

18

Governance - 5
In many states, a level has been created
between the state and the county,
“Regional” authorities. (E.G., East
Carolina [NC] has nine counties reporting
to it)

[NACo]

19

Governance - 6
Also, especially in urban areas, “Council of
Governments,” at least 600, have been
formed over the years, having specific
authorities, e.g., transportation, housing.

[NACo]

Governance - 7
Community Mental Health Act of 1960s
called for federal grants to go to “local”
boards, specifically excluding any
governments – so counties left out.

21

Governance - 8
Revenue sharing between Federal
Government and Counties initiated under
Nixon and killed under Reagan.

22

Forms of Government - 1
Commissioner form.

Voters elect a multi-member board – sheriff,
coroner - each member of which wield
both legislative and executive authority.

[NACo]

23

Forms of Government - 2
County Administrator form has two styles:

3. County Council selects the
Administrator.
4. County Administrator is elected by the
county voters.

[NACo]
24

Governance Tension
state v county
While counties were assuming more
responsibilities, they were not always
given more authorities.

[NACo]

25

Governance Tension
rural v. urban

Partially resolved by Supreme Court,
Reynolds v. Sims, 1964, “legislators
represent people, not trees or acres.
Legislators are selected by voters, not
farms or cities or economic interests.”

[NACo]
26

Economic Development
A more recent interest of county
governments has been economic
development, e.g., approve hospitals to
bring more Medicare money into a county.

[NACo]

27

Health Authority

• Thirty two states give
counties Public Health
Authority.
[NACo]
28

Federal-State-County
In comparison to the federal government
and state government, counties tend to be
most flexible, the most locally responsive,
and most creative.

[NACo]

29

Advice to Counties
Think globally, act locally.

[NACo]

30

Three Rights - General
In conceptualizing the goals of those of us
working in the public sector, useful to
think of “rights.”
• Freedom or Independence from the
Disorder
• Nondiscrimination
• Access to their community

31

Rights and County Role
1. Facilitate access to treatment
2. Assure nondiscrimination
3. Remove barriers and provide support to
live in their community

32

Independence - 1
Right of people with psychiatric illnesses to
receive the most current treatments so
that each person has the maximum
independence from their illness that can
be achieved with modern treatments.

33

Independence - 2
Not the same as “least restrictive,” which is
a negative goal. Medicine needs positive
goals, such as being able to function
independently.

Test: Receiving treatment as defined by
most authoritative standard of care and
treatment.
34

Achieving Independence - 3
-- Costs: medications, transportation, time a
way from work.

-- Lack of connection between primary care
and psychiatric care.

35

Patient acceptance of treatment:
-- Language barriers
-- Address lack of awareness as to “mental
illness” [as opposed to “bad”]
-- Address stigma of patient, family and
community
-- Address misgivings about psychiatric
treatments
36

Achieving independence - 5
-- Addressing machismo that might include
conceptualizing mental-health-related
violence or conceptualizing alcoholism as
manly, not an illness.

37

-- Apply techniques, such as motivational
interviewing.

-- Enhancing health literacy.

-- Provide community-based educational
programs, such as “fotonovelas.”

38

Achieving independence - 6
Commitment to freedom.

Terms used:

Customer/consumer/recipient

Provider

Nondiscrimination - 1
have the same availability to care and
treatment as is available for other
illnesses.

41

There are no exceptions.

There are no added burdens for the patient
or for their clinicians.

Test: Is “mental illness” mentioned in a
policy or regulation? If so, probably a
discrimination.
42

Vigilance

Examples:

Carve out of mental health.

Multiaxial burden.

43

American Psychiatric Association has taken
position that insurance carve outs are
inherently discriminatory.
Issue now being addressed, does “parity”
reach services, such as residential
programs that do not have an equivalence
in the rest of medicine.

A mental health service carve out might not
be discriminatory, might bring services
beyond what is regarded as “medical” that
are very important.

Access to their community - 1
live in their community.

46

Access to their community - 2
1. No barriers to access.
2. Provided supports – education, job
support, housing, etc. – that enhance
ability to live in their community

47

Rights - Summary
Counties have the major role in assuring
that people with psychiatric illnesses to
live in their communities. This is especially
true of those whose illness is disabling.

48

“Silo”
County four-letter word.

Integration - 1
“Integration” has many meanings”
2. Integrate as to community.
3. Integrate as to ethnic/culture
4. Integrate as to family
5. Integrate as to age [youth commonly
integrated into family services]
6. Integrate as to school or occupation, e.g.,
school-based, veteran-based

Integration - 2
6. Integrate as to institution, e.g., jail-based
program.
7. Integrate as to service, e.g., all clinics
under one authority, all inpt units under
one authority
8. Integrate as to problem, e.g., substance-
abuse program, eating-disorder program,
juvenile-delinquent program. ID program.

Integrate - 3
9. Specialty based, e.g., psychiatric,
psychological

Any view on integration can be another
view’s fragmentation.

Integration - 4
Major integrative initiatives at this time:

1. Integration of psychiatry into primary care.
2. Dual-dx focused on two diagnoses:
substance-abuse into the rest of mental
health services.

Integration
with Primary Care
APA website has identified some substantial
programs, both focusing on depression:
1. Institute for Clinical Systems
Improvement [ICSI] developed DIAMOND
with 9,000 in 62 medical groups in MN and
WI,

Impact
2. IMPACT uses Problem-Solving Treatment
in Primary Care, a 6-8 sessions,
counseling provided by staff with little or
no prior mental health training.

Montgomery County, MD
Introduction
Suburb of Washington, DC
About a million people.
Many ethic groups and recent immigrants
[147 different languages found in survey of
students in public schools.]
The County’s Behavioral Health and Crisis
Services serves between 8,000 –
9,000/year.

24 Hour Crisis Services - 1
24 hour crisis services.
Triage and evaluations beds [6].
Residential Alternative to hospitalization [8
beds]
Outreach team to evaluate and, if
necessary, begin the process to attain
emergency hospitalization.
24-Hour hotline [local NAMI program]

24-Hour Crisis Services - 2
Provides support for major untoward events,
e.g., homicide in a school.
Lethal Assessment Program [LAP] by all of
the police departments and sheriffs.
Some years recently, no domestic
homicides in the County

Montgomery County
Access Program
Assesses 2,000 individuals to mental health
services.
Has safety net program for those between
referral and date of appointment.
Referrals to settings with more
independence, e.g., state hospital to
residential, residential to independent
housing.

Community Support Programs
Community Support Programs:
1. Monitoring need for level of care to ascertain if the person is ready
for more independent living. Monitors residential programs, more
than one/day.
2. Project for assistance in Transition from Homelessness, e.g., case
management, screening, diagnostic treatment services, housing
assistance.
3. SSI/SSDI Outreach, Access, and Recovery {SOAR} program.
Program to help SSI/SSDI people who are homeless [e.g.,
coming out of hospital; living is shelter attain desirable supports.
4. For seniors, about 100 consultations to the County’s Aging and
Disability Department

Child & adolescent services
1. Clinics in multiple sites provide treatment
for children and adolescents.
2. Evaluate students referred by the public
schools. [96% are stabilized without
referring to ERs]

Adult Service
Assertive Community Treatment [ACT] program.
{Madison County model}
Collaborates with local NAMI to increase their work
with families and peers.
Collaborates with community agency to counsel
African immigrants seeking mental health
services.
Collaborates with veterans program to train
clinicians as to PTSD, TBI, military culture, and
other veteran issues. [Considering implementing
telemental services.]

Forensic Services
1. Screen 9,000 individuals who are
arrested, 200 assessments for suicidality.

For Addictions
Programs for people with addictions [about 800/year]:
Outpatient clinic
Treatment program includes treating the dual diagnosed.
Methadone maintenance program
Mental health court [100/year]
Detox
Residential
Dual Dxed residential

[Of those completing treatment, 87% have a decrease in their use of
substances]

Victim and Abuser Programs
1. Programs for victims, provides clinical,
legal, and police protection [2,000 year]

Core Service Agency - 1
County coordinates services among
potential resources for people with
psychiatric illnesses:
Transitional sheltered housing [2]
ERs [6]
Hospital Inpt units [4]
Partial Hospitalization programs [3]
Senior program [1]

MR/DD/ID program [1]
Program for hearing impaired and mentally
ill [1]
Psychiatric Rehabilitation Programs [11]
Vocational/Supportive Programs [5]
Drop in center [2]
Language capacity is stressed, most have
Spanish-speaking capacity. One has
capacity to speak 24 languages.

For children, many of the same as adults
are in the County. Also, a therapeutic
nursery is available.

with Local NAMI
1. 24-hour line.
2. Family educational programs
3. Care-giver educational programs
4. Peer programs for those who have a
psychiatric disorder

Advisory Boards
Alcohol and Other Drug Abuse Advisory
Committee
Mental Health Advisory Committee.

LA County - 1

The Los Angeles County
Department of Mental Health
(DMH), the largest county
mental health department in
the country, directly operates
more than 80 programs

71

LA County - 2
and contracts with more than 700
providers, including non-governmental
agencies and individual practitioners
who provide a spectrum of mental
health services to people of all ages to
support hope, wellness and recovery.

72

LA County -3
Mental health services provided
include assessments, case
management, crisis
intervention, medication
support, peer support and
other rehabilitative services.

73

LA County - 4
• Services are provided in multiple
settings including:
2.residential facilities,
3.clinics,
4.schools,
5.Hospitals,
74

LA County - 5
5.county jails,
6. juvenile halls and camps,
7. mental health courts,
8. board and care homes,
9. in the field and
10. in people’s homes.
75

LA County - 6

• Special emphasis is
placed on addressing co-
occurring mental health
disorders and other
health problems such as
addiction. 76

LA County - 7
The Department also
provides counseling to
victims of natural or
manmade disasters, their
families and emergency first
responders.
77

LA County – Service
Recipients - 1
Service Recipients

DMH’s services to adults and older adults
are focused on those who are functionally
disabled by severe and persistent mental
illness, including those who are low-
income.

78

LA County
Service Recipients - 2
Services to children and youth are focused
on those who are uninsured, temporarily
impaired, or in situational crises, seriously
emotionally disturbed, and diagnosed with
a mental disorder.

79

LA County – Service Recipients
3
They include wards or dependents of the
juvenile court, children in psychiatric
inpatient facilities, seriously emotionally
disturbed youth in the community, and
special education students referred by
local schools and educational institutions.

LA County – Recovery - 1
• A Commitment to Recovery and
Wellness

• Recovery refers to the process in which
people who are diagnosed with a mental
illness are able to live, work, learn, and
participate fully in their communities.

81

• We are committed to providing education
about mental health issues and how they
affect individuals and families; and teach
and promote self-advocacy.

82

The Recovery Model is the framework for all
adult services and is based on the belief
that adults diagnosed with a mental illness
can lead productive lives by seeking and
maintaining meaningful relationships
through employment, education, or
volunteer work, and participating fully in
their community.

83

• We are also committed to encouraging
individuals, families, and communities to
share responsibility to support one
another.

84

• Wellness and Recovery Outcomes

Our aim is to help our clients and families
to:
• Achieve their recovery goals;
• Find a safe place for them to live;

85

LA County Recovery - 5
• Use their time in a meaningful way;
• Have healthy relationships;
• Access public assistance when
necessary;
• Weather crises successfully; and
• Have the best possible physical health.

LA County – Children
-1
Child Mental Health Services
in Los Angeles County are
targeted for children from
birth to 15 who are seriously
emotionally disturbed (SED)
and have been diagnosed
with a mental disorder.
87

-2
• Our goal is to enable
children with behavioral
disorders to remain at
home, succeed in school
and avoid involvement with
the juvenile justice system.
88

-3
• A wide range of services are provided to
these children and their families through a
network of County-operated and
contracted agencies across all eight
service areas of Los Angeles County as
well as several programs and services that
are delivered Countywide.

89

LA County – Transition Age
Youth - 1
• DMH Services for Transition Age Youth
• The Transition Age Youth (TAY) Division
seeks to provide an array of mental health
and supportive services for Seriously
Emotionally Disturbed (SED) and Severe
and Persistently Mentally Ill (SPMI) youth
ages 16-25.

90

TAY - 2
The TAY Division has identified a number of
priority TAY populations to receive these
services; along with a specific emphasis
on outreaching and engaging TAY who
are currently unserved and underserved.

TAY - 3
These priority populations include the
following:
1. TAY struggling with substance abuse disorders;
2. TAY who are homeless or at-risk of
homelessness
3. TAY aging out of the children's mental health,
child welfare, or juvenile justice systems;
4. TAY leaving long-term institutional care; or
5. TAY experiencing their first episode of major
mental illness

TAY - 4
• TAY Programs

Full-Service Partnerships (FSP)

Drop-in Center

Enhanced Emergency Shelters for TAY

Project-Based Operating Subsidies for Permanent
Housing

93

TAY - 5
Probation Camp Services
Housing Specialist Services
TAY System Navigators
Co-located Staff at Transition Resource Cente

Field Capable Clinical Services (FCCS)

LA County – Adults - 1
Los Angeles County Department of Mental Health
provides an array of mental health and
supportive services for clients, between the ages
of 19 and 59, who live with serious mental illness
and co-occurring substance use disorders.
Mental health services are available through
directly operated and contract agencies
throughout the County.

95

LA County Adults - 2
Services typically provided in these
agencies are: assessment, therapy,
medication, case management/brokerage,
crisis intervention, and other supportive
services related to housing, prevocational
and employment.

96

LA County Adults - 3
These services are intended to reduce
psychiatric symptoms, increase
independent functioning and self-reliance
so that individuals can achieve the fullest
and most productive life possible.

LA County
Director - 1
• The Director also serves as the
public guardian for individuals
gravely disabled by mental
illness, and is the conservatorship
investigation officer for the
County.
• [NACo]
98

LA County
Director - 2
• The Director of Mental Health is
responsible for protecting patients’
rights in all public and private
hospitals and programs providing
voluntary mental health care and
treatment, and all contracted
community-based programs.
• [NACo]
99

San Francisco County - 1
San Francisco County, as part of its
Coverage Initiative Healthy San Francisco,
has expanded its network of contracted
community clinics and health centers and
is seeking to build a seamless system of
health, mental health and substance
abuse services.

• Stationing health workers at mental health
clinic sites –– the flip side of employing
behavioral workers in primary care
settings –––is being successfully
implemented at San Francisco’s Progress
House where UCSF nursing students tend
to the health needs of mental health
residents.

Click onto:

http://networkofcare.org/home_text.cfm

• [Networks of Care :]
• [
Network of Care For Seniors/People with Disa
]
• [Network of Care For Mental Health]
• [Network of Care For Kids]
• [Network of Care For Children & Families]

• [
Network of Care For Developmental Disabilitie
]
• [Network of Care For Domestic Violence]
• [Network of Care For Public Health]
• [Network of Care For Probation Services]
• [
Network of Care For Veterans and Service Me
]

Housing - 1
1. Institutional care.
2. Hospital
3. Halfway/residential/transitional facilities.
4. Emergency Housing
5. Supportive housing/special needs
housing

105

Housing - 2
6. Affordable Housing [rental]
a. subsidized
b. unsubsidized
7. Market rate rental
8. Home Owenership

106

What is Housing First?
• A mental health and housing
services program based on the
philosophy of consumer choice that
offers people who are homeless and
who have psychiatric disabilities
immediate access to an apartment
of their own, without “readiness
requirements”.

Current System: To enter Housing and
service programs you must climb the
steps

Permanent
Housing
Transitional
Housing
Drop-in,
Shelter
Outreach

108

Housing First…levels the steps

Outreach Permanent Housing
and Support
Services
109

(NYC Survey of housing providers in
2005)
• Clean time –92.5% of Providers require
• Methadone – 11 % exclude
• Insight into mental illness
• Compliance with treatment
• Criminal background
– Sex offenders – 82% exclude
– History of arson – 80% exclude
• Credit checks
110

Essential Elements of
Housing First

1. Consumer Choice
2. Separation of Housing and Services
3. Recovery Orientation
4. Community Integration

111

Responsibilities in Leased Based
Housing
• Expectations of tenancy
• Rent payment
• Quiet enjoyment (both tenant and their neighbors)
• Maintaining apartment (HQS)

• Financial Realities- planning/budgeting
• Application process and timelines

112

Disturbing statistic…

Adults with serious mental illness who are
treated in public systems die, on average,
20-25 years earlier than the general
population (average age of 58 compared
to 78 for the general population).

Joseph Parks, et al. (2007) “Morbidity and Mortality in People with Serious
Mental Illness." National Association of State Mental Health Program
Directors (NASMHPD) Report.

7 % hepatitis
6 % cancer
5 % asthma/COPD
•80% have substance use disorders
•
3 %are smokers
75% and more
hyperlipidemia
• 24% hypertension
• 9.2% diabetes
• 9 % HIV positive

• 8 % seizure disorders
• 7 % hepatitis
• 6 % cancer
• 5 % asthma/COPD
• 3 % hyperlipidemia

Research Evidence
• New York Housing Study

• Comparing Pathways to Housing
with Continuum of Care Programs
in NYC

• 36 month longitudinal outcomes

Participants
Inclusion Criteria
2. 15 days of the past
month literally
homeless
3. 6 months of housing
instability
4. Major Psychiatric
Diagnosis

Study Design
- Longitudinal Random Assignment
- N=225

- Experimental (Pathways) 99
- Control (Continuum) 126

Proportion of Time Stably
Housed:

1

0.8
Proportion

0.6 Experimental
Control
0.4

0.2
0
th

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on
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-M

-M

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as

6-

12

18

24

30

36
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Time

Note. Significant at 6-, 12-, 18-, 24-, 30-, and 36-month.

Percentage

0
5
10
15
20
25
B
as
el
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e
6-
M
on
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12
-M
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18
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24

Time
-M
on
th
30
-M
on
th
36
-M
on
th
Percentage Heavy Substance Use

Control
Experimental

Substance Treatment Utilization
in the Past 2 Weeks
Substance Treatment Service
Utilization
Proportion of Services

0.3
0.25
0.2 Pathways to Housing
0.15 Continuum of Care
0.1
0.05
0-M h
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30 n t h

36 nt h

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12 nt h

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-M

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6-

Time

Note. Significant at 6-, 12-, 18-, 24-, 30-, 36-, 48-month.

Washington DC Cost Estimates
Washington DC Cost Estimates
Cost per Day per Person
$3,500.00
$3,085.72
$3,000.00

$2,500.00

$2,000.00

$1,500.00

$1,000.00
$435.37
$500.00
$67.12 $105.62 $80.62 $17.04
$0.00

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* Shelter amount does not include the increased use in services associated
with shelter/street stay, including jail, emergency room services, and

Program Philosophy
• Consumer Choice
• Housing is a basic human right
• Recovery is possible

Separation of Housing and
Support Services

 Housing: Scattered site independent
apartments rented from community landlords

 Treatment: Treatment and support services
provided using Assertive Community
Treatment (ACT) Teams, Housing Support
Teams, Case Management, or other off-site
services

124

Community Integration

• Housing that is normal housing- not
a program

• Housing where the services can
walk away from the person who no
longer needs them (or return if
necessary)
125

Consumer choice as a continuous
process in Housing First programs

• People continue to choose the type and
sequence of services once housed.

• Choices include the right to risk; people
make mistakes and learn from that
experience, dignity of failure

• Continued practice in making choices leads
to making the right choices and the
126 experience of success

Integration with
Correction
Some counties have mental health
[including substance-related disorders] with
jails, prisons, community re-entry programs,
and parole offices. Not just mental health
clinicians, but also case management.

[e.g., Macomb County, MI]

127

Prevention - 1
Focus tends to be on preventing addictions:
In schools:
Alcohol curriculum
Tobacco curriculum
Other drug curriculum
Social skills building
“Choices” graduation ceremonies with
certificates
128

Prevention - 2
Libraries: Resource centers
Local media. Example: SOS: Something of
Substance, ½ hour program x 10
[Suffolk County]
Speakers bureau.
County Guides. Example: Heroin Education
Leads to Prevention (HELP)[Suffolk
County]
129

Advocacy Organizations - 1
1. Those the County creates.
A. Specific for mental health. Sometimes a
subpart of mental illness
1] specific for addictions,
2] specific for intellectual disabilities
3] specific victims of trauma

130

• NAMI
• Mental Health Associations
• Parent-teachers Associations

131

Two roles:

3.Inward directed: Advocate for directions
they want the County to take.
4.Outward directed: Advocate for County’s
programs.

132

Preference:
Only one Advisory Board and refer all
advocates to that body, “as I have to
assume they represent the community.”
[Function of relationship with rest of
governance]

133

Professional Organizations
County Medical Society, common
County Psychiatric Society, chapter of state
district branch, uncommon
County psychological association,
uncommon
County social work association, uncommon

134

Standards - 1
• Feds:
– Medicare regulations
– Medicaid regulations

State regulations, common

County regulations, uncommon

135

Standards - 2
JCAHO:
Hospitals
Clinics

American Psychiatric Association Practice
Guidelines. The word “Standards” avoided.

136

Medical Director Role - 1
1. Speaks to the psychiatric needs of
patients with:
a. the County’s clinicians,
b. with County administration,
c. with other relevant County agencies,
e.g., police.

137

Medical Director Role - 2
– D. Any external board/commissions that
impact the work of the County’s mental health
work.
– E. With the state mental health authorities.
– F. With regulatory bodies and accreditation
bodies.

138

Medical Director’s Role - 3
– G. With other bodies that may need to know
the County’s psychiatric views and needs,
such as professional society, lay
organizations, educational institutions, and so
forth.
– H. With any organization or individual who
believes the County’s clinical work is
inadequate.

139

Roles of Medical
Director - 4
2. Conduit for new developments,
sometimes adding interpretations.
3. Participation in policy development.
4. Participate in non-clinical meetings, and
keep clinicians informed of the results to
where they will often not need to attend non-
clinical meetings.

140

Medical Director’s Role - 5
5. Participation in program and in individual
evaluations.
6. Supervision of psychiatrists. May be a
qualitative supervision as to their clinical
work, not necessarily administrative
supervision of needs like scheduling.
7. Recruitment of psychiatrists

141

Role of Medical Director - 6
8. Final say on clinical issues [should be
rare that such are taken out of hands of the
front-line psychiatrist.]
9. Addressing legal issues, trying to obtain
legal assistance in how to reach clinical
goals. [Usually best to ask attorneys “how,”
not “whether.”]

142

10. Establishes the clinical values [hopefully
by hammering out a consensus].
a. Evidenced based?
b. Recovery goal for all?
c. Coercion has a role in providing
clinical care?
d. Costs are to be a determining factor
in deciding on treatment?
143

Role of the Medical Director - 9
11. Use the physician-to-physician network
to resolve issues that would otherwise not
be well settled. Thus, the medical director
needs to evolve a first-name-basis informal
system with local clinicians, who can resolve
an issue that seemed block by bureaucratic
rules, an “old-boys network” of more than
boys.

144

12. Assist the private sector through keeping
that sector informed as to clinical
developments and informed as to resources
that help those clinics, hospitals and
practitioners be more effective in their work
with their patients.

145

Roles of Medical
Director - style
Manage on one’s feet.
Create a sense of omnipresence in the
organization.
Be seen.
Be heard from.

146

Nursing Homes
Nursing homes, once a “de-institution”
option, is now being seen as an institution.

[NY Times, 12Sep2011]

147

Needs - 1
1. Greater recognition of the county’s role in
serving the mentally ill.

148

Needs - 2
2. Very broad, automatic access to services.
– Probably need standards of automatic
access. Regulations that increase access.
– Standards need empirical basis – should not
depend on establishing standards on only a
rational basis.

149

Needs - 3
1. A way to measure a county’s adequacy
as to access of the mentally ill to that
county’s communities. [Wheelchair
analogy].

150

Needs - 4

Adults with serious mental illness who are
treated in public systems die, on average,
20-25 years earlier than the general
population (average age of 58 compared
to 78 for the general population).

Joseph Parks, et al. (2007) “Morbidity and Mortality in People with Serious
Mental Illness." National Association of State Mental Health Program
Directors (NASMHPD) Report.

Needs - 4
5. A climate of innovation. There are many
people with mental illness whose access to
their community is far less than ideal.
Clinical and administrative innovations
should be encouraged.

152

What Should the APA do?
Establish an organization within the APA, a
bottom-up, democratic organization, to
facilitate communication of ideas,
experiences, and bases for advocacy.

153

NY
Lawsuits;
2. 1980s: To have pts moved from state
hospitals to least restrictive: many to
nursing homes.
3. 2009: Against warehousing in adult
homes.
4. 2011: Against warehousing in nursing
homes

Integration with
Primary Care - 1
• Psychiatry & Primary Care Integration
Across the Lifespan
POSITION STATEMENT
• Approved by the Board of
Trustees, September 2010
Approved by the Assembly, May 2010

Integration with
Primary Care - 2
1. Access to and payment for clinically
appropriate services provided by
psychiatrists should be included as an
essential feature in medical/health home
initiatives.

Integration with
Primary Care - 3
2. Parity of benefits design for beneficiaries
as well as parity in payment for all
physicians, particularly psychiatric that
does not discriminate by location of
service or diagnosis should be provided.

Integration with
Primary Care - 4
3. Psychiatrists should have choices of
participation in a new health system, such
as fully integrated clinicians and/or
managers of the system, as collaborative
care partners, and as consultants to it.

Integration with
Primary Care - 5
4. The exact financial formula for these
choices should be negotiated such
that it is compatible with parity and
nondiscrimination regarding both
psychiatric patients and psychiatric
physicians.

A. Psychiatric Ass. policy statement [Eliot Sorel, M.D., Anita Everett, M.D. Roger Peele,
M.D., Catherine May., M.D., Michael Houston, M.D., Hind Benjelloun, M.D., Kayla
Pope, M.D.; and consultant, Jack McIntyre, M.D.]

Integration with
Primary Care - 6
American Psychiatric Association Ad
Hoc Work Group Report on the
Integration of Psychiatry and Primary
Care
Thirty-two page document outlining potential
resources, past models and the need to
pursue this goal.

[Authors: Anita Everett, M.D., Roger Kathol, M.D., Wayne Katon, M.D., Eliot Sorel, M.D. APA Staff
Irvin Muszynski, J.D., and Mary Ward

Integration with
Primary Care – 7
Resource document [A Psychiatric Ass.,
2009]:
Integrated Care of Older Adults with Mental
Disorders

Integration with
Primary Care - 8
Addressing Mental Health Concerns in Primary
Care: A Clinician’s Toolkit

American Academy of Pediatrics

This toolkit is a resource designed to help primary
care clinicians in implementing algorithms to
help guidance in enhancing mental health care.
CD-ROM. 2010. $199.95.

NC
County Resources [a website]:
http://www.icarenc.org/index.php?
option=com_content&view=article&id=201&Itemid=126
Orange County:
Part of Orange-Person-Chatham Authority.
Phone numbers of resources, e.g.:
clinics, hospitals, programs
How to get Medicaid or Medicaid waiver.

•

Outpatient Commitment – 1
AACP Position
The AACP recommends that states and
counties add features to their quality
assurance monitors for providers to
measure the effectiveness of IOC on
adherence to treatment and on IOC’s
reduction of dangerous behavior.. IOC
must be shown to improve both measures
beyond that which can be achieved by
less coercive means.

Outpatient Commitment - 2
The AACP cautions states and counties
against implementing IOC where
resources for services are insufficient to
afford the committed outpatient the
highest quality mental health care, as well
as access to the basic resources of
income support, housing, and physical
health care. These localities risk providers’
utilizing IOC inappropriately.
[http://www.communitypsychiatry.org/publications/position_statements/ioc.aspx]

Evidenced-based Practice - 1
AACP Position Statement on
Implementation of Evidence-Based
Practice, December, 2005

http://www.communitypsychiatry.org/publicat
ions/position_statements/evidence.aspx

NACo on ACA - 1
• Resolution in Support of Provisions of the
Affordable Care Act that Help County Safety
• Net and Behavioral Health Programs
• Issue: Essential need to implement key features
of the Patient Protection and Affordable Care
• Act of 2010 (ACA).
• Adopted Policy: The National Association of
Counties supports full funding for, and
• implementation of, the provisions of the ACA
that help counties meet the service needs of low
• income and disabled populations.

NACo on ACA - 2
• Specifically, NACo supports maintaining and
expanding
• affordable health coverage and benefits to
uninsured and underinsured residents who rely
on
• county health care delivery systems – including
the Medicaid maintenance of effort (MOE)
• requirements and the scheduled Medicaid
expansion. NACo also supports the ACA’s
provisions

NACo on ACA - 3
• American County Platform and Resolutions 2011‐
2012
• to improve care coordination to ensure that everyone
has a medical/health home for efficient,
• accessible and cost-effective care; to improve access to
preventive care and health promotion, for
• underserved populations; and to promote the use of peer
supports and counselors, together with
• effective care coordination that spans health and social
support services.

NACo – SSDI
1
• Resolution in Support of Reducing the 24-Month Waiting Period for
Participants in Social
• Security Disability Insurance
• Issue: Coverage of the current 24-month gap in health coverage for
disabled individuals
• receiving SSDI.
• Adopted Policy: NACo supports and urges passage of legislation to
eliminate the 24-
• month wai Adopted Policy: NACo supports and urges passage of
legislation to eliminate the 24-
• month waiting period for health care coverage, for those individuals who
have worked and paid
• in to the system and then become disabled, seeking assistance through
SSDI. ting period for health care coverage, for those individuals who have
worked and paid
• in to the system and then become disabled, seeking assistance through
SSDI.

• Resolution on Adapting to Aging Population
• Issue: Aging population is increasing demands on county health and human
services.
• Adopted Policy: NACo supports legislation to allow for and encourage
adaptation of
• local government health services to an older and larger client base.
• Background: As the “Baby Boomer” generation ages and enters retirement,
the demand
• for health and human services and the pressure on local governments to
provide those services
• will increase greatly.
• It is imperative that our health systems begin now to adapt to the different
demands,
• needs, and methods of communication that these new populations will
require. If our local
• governments are to successfully provide the basic services demanded of
them, it is essential

• Resolution on County Organized Health Systems
• Issue: Local Administration of the Medicaid and Expanded Public Programs via
• "County Organized Health Systems".
• Adopted Policy: The National Association of Counties (NACo) urges Congress and the
• Administration to remove current statutory prohibitions that prevent the establishment of
• additional County Organized Health Systems (federally defined as "Health Insuring
• Organizations"). NACo also urges the Centers for Medicare and Medicaid Services (CMS) to
• adopt a policy of encouraging the formation of County Organized Health Systems as a means to
• more effectively deliver Medicaid benefits at the local level.
• Background: County Organized Health Systems (COHS) are locally established
• independent publicly-run health plans that administer the Medicaid program, as well as other
• publicly-funded health care programs for low income populations, in either a county or group of
• counties. COHS plans have existed in California since 1983 and there are currently five plans
• serving nine California counties and over 600,000 Medicaid beneficiaries.

-2
• COHS plans are governed by boards or commissions appointed by County
Supervisors,
• and each plan develops its program to best suit the needs of the local community.
• During the last 25 years, COHS plans have proven successful in terms of both
costeffectiveness
• (saving approximately 20 percent over fee-for-service Medicaid) as well as
• improved service delivery to Medicaid beneficiaries (e.g. increased access to care,
disease
• management programs, and high immunization rates). COHS plans cover all
Medicaid eligible
• beneficiaries in their services areas and provide the entire spectrum of care - from
prenatal care
• to hospice. The expansion of the five COHS plans into four additional counties has
shown that
• the county based model can be effectively replicated in both suburban and rural
• environments. Similar models also exist in 28 rural Minnesota counties.

• Resolution on Essential Support Services for Persons with Behavioral Health and
• Developmental Disabilities
• Issue: Close coordination across health and social service programs.
• Adopted Policy: Care coordination across Federal programs that serve persons with
• disabilities should be fully maintained for current beneficiaries and expanded appropriately to
• serve the disability population newly insured through National Health Reform; social service
• programs, particularly affordable housing and job training, should be expanded so that persons
• with disabilities can become and remain fully independent in their home communities.
• Background: Close coordination across health and social service programs is essential
• to assure the effectiveness of care and supports for persons with disabilities. County behavioral
• health and developmental disability authorities are concerned that federal care and support
• programs should be available to persons with disabilities, including the newly insured, in the post
• National Health Reform environment, and that care coordination should be available to make
• them operate efficiently.

• Health services are less effective and more
costly when needed social services are either
• not available or are not coordinated well. This
Resolution is an effort to address this problem
• directly, both for the currently insured and the
new populations to be insured through National
• Health Reform.
• These tools are also very important so that
persons with disabilities can live independent
• lives in their own communities.

• Resolution Supporting Efforts in the Prevention and Treatment
of Obesity and Overweight
• Issue: Reduce obesity and overweight and improve wellness.
• Adopted Policy: The National Association of Counties recognizes
obesity and
• overweight as conditions that can persist from childhood to
adulthood, that are associated with
• chronic disease, and that cause preventable and premature deaths
in adults, adolescents and
• children. NACo supports local public health department leadership
in obesity and overweight
• prevention.
• Background:

• Resolution on Persistent Health Disparities
• Issue: Persistent health disparities.
• Adopted Policy: NACo supports legislation to reduce health disparities and address the
• social determinants of health, increase the diversity and cultural and linguistic competencies of
• the health workforce, and improve environmental justice. This must include significant direct
• federal funding for counties to implement programs designed to reduce disparities, by direct
• service delivery and in partnership with providers.
• Background: Disparities in health outcomes for vulnerable populations as defined by
• race/ethnicity, socio-economic status, geography, gender, age, disability status, risk status
related
• to sex and gender have been well documented and are well understood by county officials.
• These vulnerable populations disproportionately experience worse health and safety outcomes
• across a broad spectrum of illnesses, injuries, and treatments. These disparities are likely to be
• exacerbated during a prolonged recession.

• Resolution on Nurse Home Visitation Programs
• Issue: Nurse Home Visitation Programs.
• Adopted Policy: NACo recognizes the importance of
evidence-based nurse home
• visitation programs that serve low-income parents,
pregnant women and young children. NACo
• supports the premise that parents need access to public
health resources to promote a healthy
• environment for their families. NACo supports adequate
funding including Medicaid funding
• for all nurse home visitation programs that benefit
families. [focus on children]

• Resolution on Nurse Home Visitation Programs
• Issue: Nurse Home Visitation Programs.
• Adopted Policy: NACo recognizes the importance of
evidence-based nurse home
• visitation programs that serve low-income parents,
pregnant women and young children. NACo
• supports the premise that parents need access to public
health resources to promote a healthy
• environment for their families. NACo supports adequate
funding including Medicaid funding
• for all nurse home visitation programs that benefit
families.

• Restoring the Partnership for American Health: Counties in a 21st Century Health
• System Full Partners: County governments are integral to America's current health system and
• will be crucial partners in achieving successful reform. At the most basic level, county officials
• are elected to protect the health and welfare of their constituents. County governments set the
• local ordinances and policies which govern the built environment, establishing the physical
• context for healthy, sustainable communities. County public health officials work to promote
• healthy lifestyles and to prevent injuries and diseases. Counties provide the local health care
• safety net infrastructure, financing and operating hospitals, clinics and health centers. County
• governments also often serve as the payer of last resort for the medically indigent. County jails
• must offer their inmates health care as required by the U.S. Supreme Court. Counties operate
• nursing homes and provide services for seniors. County behavioral health authorities help people
• with serious mental health, developmental disability and substance abuse problems who would
• have nowhere else to turn. And as employers, county governments provide health benefits to the
• nearly three million county workers and their retirees nationwide. Clearly, county tax payers
• contribute billions of dollars to the American health care system every year and their elected
• representatives must be at the table as full partners in order to achieve the goal of one hundred
• percent access and zero disparities.

• Local Delivery Systems-Access for All: NACo believes that reform must focus on
• access and delivery of quality health services. Coverage is not enough. County
officials,
• particularly in remote rural or large urban areas know that even those with insurance
may have
• difficulty gaining access to the services of a health care provider, which can be
exacerbated by
• the severity of their illness. Insurance carriers participating in public programs should
berequired to extend coverage into rural areas and to contract with local providers.
Local delivery
• systems should coordinate services to ensure efficient and cost-effective access to
care,
• particularly primary and preventive care, for underserved populations. County
governments are
• uniquely qualified to convene the appropriate public and private partners to build
these local
• delivery systems in a way that will respect the unique needs of individuals and their
• communities. A restored federal commitment to such partnerships is necessary for
equity's sake.

• Public Health and Wellness: NACo believes that a greater focus on disease and injury
• prevention and health promotion is a way to improve the health of our communities and to
• reduce health care costs. Disease and injury prevention and health promotion services can be
• delivered by a health care professional one patient at a time. Local health departments, in
• partnership with community based organizations and traditional health care providers, deliver
• community-based prevention services targeted at an entire population. Population-based
• prevention services can save money by keeping people healthy and reducing the costs of
treating
• unchecked chronic disease. These critical services include assessment of the health status of
• communities to identify the unique and most pressing health problems of each community and
• health education to provide individuals with the knowledge and skills to maintain and improve
• their own health. The public health response to emergencies should be fully integrated into each
• county's emergency management plan. Local public health considerations likewise should be
• systematically integrated into land use planning and community design processes to help prevent
• injuries and chronic disease. Policies are also needed to address health inequity, the systemic,
• avoidable, unfair and unjust differences in health status and mortality rates, as well as the
• distribution of disease and illness across population groups. Investing in wellness and prevention
• across all communities will result in better health outcomes, increased productivity and reduce
• costs associated with chronic diseases.

• Expanding Coverage: NACo supports universal health insurance coverage. Existing
• public health insurance systems should be strengthened and expanded, including Medicare,
• Medicaid and the State Children's Health Insurance Program (SCHIP). As states and counties
• attempt to shoulder their legislatively mandated responsibilities to provide care for the indigent
• and uninsured, federal regulatory barriers should be removed to allow flexibility and innovation
• at the local level. Restrictions on the expansion of County Organized Health Systems should be
• lifted and they should be authorized to serve as a public plan option in their service areas.
• Furthermore, in the effort to expand coverage, reformers should not forget that the coverage
must
• be meaningful, without imposing additional mandates on county governments. The benefit
• package must be defined so as to provide the full range of services people need, including
• prevention services, pharmaceuticals, dental, full parity for behavioral health, substance abuse
• and developmental disability services. Barriers to cost-effective treatments, like living organ
• donation, should be removed.

• Maintaining a Safety Net: NACo believes that the intergovernmental partnership
• envisioned in the Medicaid statute should be restored and strengthened. Medicaid
• reimbursement rates should be enhanced and increases to the Medicaid federal
medical
• assistance percentage (FMAP) should be passed through to counties contributing to
the nonfederal
• share. Local safety nets, supported by Medicaid and disproportionate share hospital
• (DSH) payments, should not be dismantled to "pay for" universal coverage. We must
not allow
• the safety net infrastructure to be undermined. County hospitals and health systems
provide
• surge capacity, emergency and trauma services and other critical high cost services
like neonatal,
• HIV/AIDS and burn care. Safety net hospitals will continue to need extra support to
carry out their missions, including addressing health disparities. Health care is not just
coverage it is
• also access and it is the safety net hospitals where translation services for hundreds
of languages
• can be found.

• DSH payments address two otherwise unreimbursed costs: (1) services provided to the
• uninsured and underinsured; and (2) Medicaid reimbursement rates that pay less than the cost of
• providing health services. It is too early to predict the net effect of Medicaid expansion and
• reimbursement reform. In addition, unfortunately, there will always be some individuals who
• will remain uninsured. These and other at-risk populations financed by DSH are unlikely to be
• among the groups to be covered in the initial stages of reform. All individuals, including the
• uninsured, should receive treatment and DSH supports that care. Therefore DSH payments
• should not be phased out or down until health care reform is fully implemented and its effects on
• DSH payments can be accurately assessed. Assumptions should not be made that DSH can be
• cut by any arbitrary amount on some arbitrary timeline during the implementation of heath care
• reform.

• Health Workforce: NACo believes that the health professional and
paraprofessional
• workforce must be supported and enhanced. It is important that we
sustain training programs
• and sites of service that enable us to develop a complement of
health professionals that can
• address the needs of a changing, growing and aging population.
• Public hospitals have often been teaching hospitals. The sites of
service include hospitals,
• outpatient clinics, and community health centers. These settings
provide access for patients
• seeking care, and a diverse set of patient conditions and cultures
that make for a comprehensive
• learning experience. Reasonable medical education funding is an
integral part of the business
• model of these institutions.

• Every effort should be made to recruit, train, license and retain health professionals, and
• allied professionals and paraprofessionals, on an expedited basis. A large body of evidence
• supports the contribution of direct care staff, nurses and nursing assistants, to quality outcomes.
• Funding for existing education and training programs - in secondary, post-secondary and
• vocational educational settings - should be increased and targeted towards initiatives to expand
• and diversify the health workforce. Partnerships between local economic developers and
• workforce development professionals should be encouraged to meet growing health care sector
• demand. Targeted incentives including scholarships, loan forgiveness and low-interest loan
• repayment programs should be developed to encourage more providers to enter and remain in
• primary care and public health careers. Primary care providers should be empowered to - and
• compensated for - case management services.

• Health IT: The federal government should support the integration of health
information
• technologies into the local health care delivery system. NACo supports the
President's goal of
• implementing a nation-wide system of electronic health records in five years. NACo
supports
• efforts to promote the use of a range of information technologies to facilitate
appropriate access
• to health records and improve the standard of care available to patients, while
protecting privacy.
• This includes deployment of broadband technologies to the widest possible
geographic footprint.
• Other tools facilitate evidence-based decision making and e-prescribing. Using
broadband
• technologies, telemedicine applications enable real-time clinical care for
geographically distant
• patients and providers. Remote monitoring can also facilitate post-operative care and
chronic
• disease management without hospitalization or institutionalization.

• Long Term Care: Federal policies should
encourage the elderly and disabled to
receive
• the services they need in the least
restrictive environment. Since counties
provide and otherwise

• support long term care and other community
based services for the elderly and disabled,
state
• and federal regulations and funding programs
should give them the flexibility to support the full
• continuum of home, community-based or
institutional care for persons needing assistance
with
• activities of daily living. Nursing home regulatory
oversight should be reformed in order to
• foster more person-centered care environments.

• Jail Health: Reforming America's health care system must include reforms to its jail
• system. Counties are responsible for providing health care for incarcerated individuals as
• required by the U.S. Supreme Court in Estelle v. Gamble, 429 U.S. 97 (1976). This unfunded
• mandate constitutes a major portion of local jail operating costs and a huge burden on local
• property tax payers. The federal government should lift the unfunded mandate by restoring its
• obligation for health care coverage for eligible inmates, pre-conviction. Furthermore, a true
• national partnership is needed to divert the non-violent mentally ill from jail and into appropriate
• evidence-based treatment in community settings, if possible. Finally, resources should be made
• available to counties to implement timely, comprehensive reentry programs so that former
• inmates have access to all the health and social services, including behavioral health and
• substance abuse treatment, to avoid recidivism and become fully integrated into the community.

NACo
• The National Association of Counties
(NACo) is the national organization that
represents county governments before the
Administration and Congress. NACo
provides essential services to the nation's
3,068 counties.

196

NACBHDD - 1
National Association of Counties Behavioral
Health and Developmental Disabilities
[NACBHDD] is the national voice for
county and local behavioral health and
developmental disability authorities in
Washington, DC.

197

NACBHDD - 2
Through education, policy analysis, and
advocacy, NACBHDD brings the unique
perspective of our members to Congress
and the Executive Branch and promotes
national policies that recognize and
support the critical role counties play in
caring for people affected by mental
illness, addiction, and developmental
disabilities.
198

NACBHDD - 3
Newsletters: Covers legislative, regulatory,
and judicial events including notices of
grant possibilities and descriptions of
publications related to mental health
issues [includes substance related and
intellectual disabilities].

199

NACBHDD - 4
Also at the NACBHDD website:
-- Documents such as IOM reports.
-- Presentations such as slides on new
legislation
-- Reports of NACBHDD Board meetings.

200

NACBHDD - 5
• Ron Manderscheid, PhD
• Executive Director
• 25 Massachusetts Avenue, NW, Suite 500
• Washington, DC 20001
• Voice: 202-942-4296
• Cell: 202-553-1827
• E-Mail: rmanderscheid@nacbhd.org
• www.nacbhdd.org

201

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