The Forgotten Face of Healing

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• The Forgotten Face of Healing
• Comprehensive Behavioral Health

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Objectives of Presentation

• Articulate Mission-Based Rationale to provide
  Behavioral Health Services
• Provide historical and current status of
  Behavioral Health Care Service System
• The St. Marys (SMH) Story
• Your Institutions Commitment
• Discussion

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• Everyone comes in the front door.

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Our Mission Statement and Values

• Our mission is to care compassionately for those
  we serve with dedication to excellence and
  Christian ideals.
• Core Values service of the poor, reverence,
  integrity, wisdom, creativity and dedication.

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Always with us always among us

• Framed by Compassion
• Focused through the Lens of Excellence
• Grown through the Wisdom of Creativity and Love

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Community Behavioral Health

• History of Mental Health Treatment
• Current Scene

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HISTORY OF MENTAL HEALTH TREATMENT

• Spiritual/religious problem
• Physical problem
• Environmental/stress problem
• Brain disease
• Community Mental Health Movement

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Spiritual/Religious Problem

• Exorcism
• Trepanation
• Repentance rituals Opium induced visions
• Dream interpretation

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Physical Problem

• Imprisonment/shackles and chains
• Bleeding
• Purging

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Environment/Stress Problem

• Therapeutic environment
• Ice water immersion
• Straight jacket

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Brain Disease

• Insulin and electroshock
• Psychosurgery (30s 50s)
• Medication (1954)

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Community Mental Health Movement

• Demise of Asylum System
• Abuses
• Iatrogenic effects of institutionalization
• High cost
• New evidence
• Deinstitutionalization

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Community Mental Health Movement (contd.)

• Thorazine (1954) and other meds
• 1964 Community MH Act
• 1966 MC MA Acts
• 1972 must pay for work in institutions
• Combined 2 models
• 1. Constitution/environment (stress)
• 2. Brain disease/genetics (illness)

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Community Mental Health Movement (contd.)

• The current scene
• Improved medications with fewer side effects
• Community Based Programs
• Recovery Movement
• Empirical Research evidence-based practice

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Community Behavioral Health

• History of Addiction Treatment
• Current Scene

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History of Addiction Treatment

• Temperance Movement
• Washingtonian Movement
• Moral Treatment Model
• Institutionalization
• Modern Era

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Temperance Movement

• Originated in United States
• Original Goal Reduce Problems of drunkenness in
  society
• Primarily concerned about middle class
• Allied with other progressive movements in 19th
  century
• Prison reform
• Abolition of slavery
• Womens rights
• Workers rights
• Instrumental in development of self help groups

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Temperance Movement (contd.)

• Shift towards complete abstinence, teetotalism
• Goal reclaiming of drunkards for whom moderation
  had failed
• Structure of movement changed
• Regular meetings
• Regular visitation/pairing off with reformed
  drunkards
• Creating new framework for living

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Washingtonian Movement

• Experience lectures
• Practical advise on how not to drink
• Pioneered concept of involving reformed drunkards
  to help others
• Slogan Every man brings a man
• Start of recovery homes (inebriate homes)

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Failure of Washingtonian Movement

• Lacked organization no meetings, structure,
  discipline, reinforcement
• Relied on the pledge

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Moral Treatment Model - Asylums

• Non-criminal treatment of drunkards
• (1840-1940)
• Some use of mechanical restraints, legal coercion
• Psychological treatment
• Medical treatment focused on diet, cleansing
  system, sedation to promote rest

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Moral Treatment Model (contd.)

• Problems
• Drunkards were nuisances
• Controversy over alcoholism as a disease
• Overcrowding of asylums post Civil War

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Institutionalization

• Inebriate Homes
• Offshoot of Washingtonian Movement
• Dedicated to moral treatment of voluntary
  patients
• Small, urban, private
• Short term
• Physician involvement

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Institutionalization (contd.)

• Inebriate Asylums
• Modeled after insane asylums
• Involuntary commitment/use of restraints
• Large, rural, public
• Longer length of stay
• Regimen of moral treatment/correction/ discipline

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Institutionalization (contd.)

• Industrial Hospitals
• Focus on indigents, vagabonds
• Involuntary commitment/arrests for drunkenness,
  theft, petty crimes
• Large, rural, public
• Indeterminate length of stay, custodial care
• Regimen of correction/discipline
• Did not gain popularity/superfluous to jails,
  prisons, almshouses

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Institutionalization (contd.)

• Private Institutions
• Flourished into the 20th Century
• Based on moral treatment/homeopathic remedies
• Physician involvement
• Discrete (confidential)

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Modern Era

• Volstead Act 1919-1934
• Decline of public institutions
• Optimism prevailed prohibition eliminated need
  for public care
• Private institutions grew in size and number
• Rising unemployment became new social problem

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Modern Era (contd.)

• 1930s
• 1934 Repeal of Volstead Act
• 1935 Alcoholics Anonymous founded
• by Bill W. and Dr. Bob
• American Medical Association designated
  Alcoholism as a disease

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Modern Era (contd.)

• Mid Century
• Recognition that alcoholism crosses
  socioeconomic, religious, gender barriers
• Rapid growth and development of treatment
  facilities Big Business
• Government sponsored research/treatment programs
• Treatment of Substance Abuse other than Alcohol
• Development of addiction treatment as medical
  specialty.

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Modern Era (contd.)

• 1990s Present
• Impact of Managed Care limited industry growth
• Workforce changes
• Collaboration with mental health/correction system

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Current Scene in Addictions

• Current Scene
• Pharmacotherapies
• Increased Collaboration with Mental
  Health/Criminal Justice
• Evidence-based Treatment More emphasis on
  outcomes

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The St. Marys Story

• Opportunity
• Total Hospital Replacement/Block Grant
• County/Hospital Collaboration
• Federal and State Support for Capital and
  Operations

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Trends

• Time Line (see handout)
• Units of Service in 1980 vs. today
• Number of programs in 1980 vs. today
• Demographics (see handout)
• Increased Volume
• Increased Number of Children, Aging
• Adults

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Challenges Along the Way

• Challenged to reduce admissions to state
  facilities
• Managed Care
• Growth Social Clubs, Case Management, Addiction
  Services, Adult/Childrens Clinics

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Financial Picture How It Works

• Expense Summary
• Revenue Summary
• Funding Streams
• Contribution to the Margin

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Financial Picture
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Highlight Two Programs

• Mobile Geriatric
• Methadone

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Mobile Geriatric Program (MGO)

• High concentration of seniors
• Pressure on ER and MHU
• Grant-funded outreach to frail MI

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Mobile Geriatric Program (contd.)

• Assessment, referral, follow-up (RNs/CM)
• Adult Homes, Nursing Homes, Private Residences
• Treatment

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Mobile Geriatric Program (contd.)

• Outcomes
• Reduction in inappropriate ER visits and M/H
  admissions
• Improved relations with local facilities,
  agencies, physicians
• Satisfied customers

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Mobile Geriatric Program (contd.)

• Challenges
• Alternative funding
• Sustaining well-trained, motivated staff

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Methadone

• Typical Framework/structure of MMTP
• services (NYS)
• Large clinics in urban settings (300-700 patients
  typical)
• Limited access to care in Upstate area

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Methadone (contd.)

• Criticisms of MMTP services (NYS)
• Too large
• Lack of individual approach
• Limited access to traditional therapeutic
  approaches
• Limited access to care outside of urban centers

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Methadone (contd.)

• St. Marys Response to Identified Need
• OASAS White Paper
• Increased Opiate related arrests
• Increased number of probationers with Opiate
  Abuse/Dependency
• Increased DSS Medicaid transportation costs
• Lack of local services for Substance Abuse (other
  than alcohol)
• No MMTP services between Albany and Syracuse (125
  miles)

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Methadone (contd.)

• Process
• Collaboration with OASAS-Pilot Program
• Enforcement/support of Hospital Board of
  Directors, Physicians, Community Services Board
• Multi-agency Application/Certification Process
• Staff Training and Development

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Methadone (contd.)

• Program Design
• Integrated approach to care
• Small, right-sized to the community
• Easy access to care

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Methadone (contd.)

• Program Specifics
• 100 slot program
• JCAHO/OASAS/CSAT/DEA
• Physician involvement/staffing

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Methadone (contd.)

• Demographics

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Methadone (contd.)

• Challenges
• Bias against maintenance pharmacotherapies
• Integration into abstinence-based model
• Staff response/turnover
• Community concern
• Nature of Opioid Dependent patients

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Methadone (contd.)

• Benefits
• Improved service delivery system
• Staff development

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Methadone (contd.)

• Success Story.

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Institutional Commitment

• Our Challenges
• Funding
• Accountability for Outcomes
• Staffing and Morale
• Institutional Support

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Institutional Commitment (contd.)

• Your Challenges Why develop BH services?
• Assess Local Community Need Identifying gaps
• Assess your institutions level of commitment vis
  a vis mission, vision, values
• Determine whether this is a ministry to
• Explore further
• Initiate
• Continue/expand

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Institutional Commitment (contd.)

• How to obtain and sustain support.
• Internally how to convince your institution to
  commit to BH services
• Externally
• What are your next steps?