Florida Commission on Mental Health and Substance Abuse

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Florida Commission on Mental Health and Substance
Abuse

• Presentation by Martin Cohen
• July 21, 2000
• Fort Meyers, Florida

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Focus of Remarks

• Structure what you should consider about the
  organization of public mental health services.
• Finance money drives the system, so think
  carefully about creating the right incentives.
• Structure and finance in relation to the closure
  of state hospitals some points to consider.

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Structure

• Common attributes of people in need of mental
  health services
• They have an illness that requires treatment.
• They have a disability that results from the
  illness and that requires more than treatment
  help with living, learning, and working.
• They tend to have multiple needs co-morbidity
  with other health issues, addictions, etc.
• They are poor what they need will most likely
  need to be subsidized.

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Structure

• Systems of care for people with mental illness
  must respond to all of these issues very
  difficult to do
• Services are scattered among different provider
  agencies or different levels of government.
• Funds to support services are in different
  budgets.
• Systems are often under-funded.
• Boundaries are created to limit access.
• Responsibility for how services are organized,
  financed, and delivered are at different levels
  of the bureaucracy.
• Accountability is not clear and may not match
  with level of responsibility.

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Structure

• Need to structure our mental health systems to
  better respond to this organized chaos
• Understand the dimensions of what people need.
• Organize systems around those needs.
• Create mechanisms for multiple systems to work
  together.
• Reward success and punish failure.

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Structure

• Understand what functions are needed and where
  they should best be provided
• Policy development,
• Regulator,
• Purchaser,
• Provider,
• Monitor.
• Establish points of responsibility and
  accountability for each.

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Structure

• Start where the client is or to take a page
  from Tip ONeil All care is local.
• Develop a single point of responsibility and
  accountability for each consumers care.
• Give that person the authority to get the
  consumer what they need when they need it.
• If you cant give that person the authority or
  need to limit it, is there clarity about who has
  the authority and how to get it?

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Structure

• Create a similar point of responsibility and
  accountability within local communities (central
  authority) who is responsible for mental health
  care in our county? And, what authority do they
  have?
• Who needs to be part of that authority because
  they have what consumers need or because they are
  too are serving consumers? housing,
  transportation, health care, sheriff, schools,
  child welfare, etc.
• Develop mechanisms for their participation at the
  consumer and community level.

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Structure

• Create similar points of responsibility/accountabi
  lity within the state bureaucracy and bring in
  those who have whats needed (cabinet cluster).
• Develop ways for these relationships to work up
  and down the system
• Formal agreements and joint protocols.
• Out-stationing of staff .
• Joint purchasing and decision-making.
• Model behavior.

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Structure

• Reward those systems that show performance.
• Innovation funds.
• Additional positions.
• Seek change in those systems that dont or wont.

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Finance

• Problems
• Many funding streams are used to support public
  mental health services.
• Little coordination among those funding streams.
• Few financing incentives. Many disincentives.
• Financing systems built around old treatment
  modalities.
• While money should follow form, form usually
  follows the money.

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Finance

• Solutions
• Create incentives
• Local control over inpatient resources.
• Use of risk-based contracts for community care.
• Rewards and sanctions based on performance.
• Funds for innovation.
• Allow for payment to non-traditional service
  providers.
• Pay for process. If you want people to behave
  differently - pay for it.

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Closing a State Hospital

• Structure
• What is being planned as the alternative to the
  hospital?
• Not necessarily hospital beds, but system
  capacity.
• Units in general hospitals MA, HI
• Residential placements VT, GA
• Housing and supports OH, MA
• Use of other state hospitals PA
• Who goes where often has more to do with
  perception than clinical reality?

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Closing a State Hospital

• What do these new arrangements hold for
  consumers, staff, agencies?
• Consumers
• New relationships, locations, routines and
  possibly new freedoms.
• Staff
• New professional relationships and boundaries to
  negotiate.
• Administrators
• New issues of growth, span of control, and
  finances.
• Timeframe
• Give yourself time consider a phased approach.

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Closing a State Hospital

• Employees
• Value of state hospital staff in the community.
• Know the consumers.
• Know how to overcome and negotiate obstacles.
• Issues of staff integration overshadow client
  integration.
• Inequities in pay and benefits.
• Need to be part of the community team.
• Clinical Coordination and Accountability
• Is there a single point of clinical
  accountability for every client moving from the
  hospital?
• If there is, who is it? And, who knows it?
• Clinical coordination after closure - what
  happens if someone needs a higher or lower level
  of care? Who has authority?

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Closing a State Hospital

• Finances
• Potential - financial benefits of closure always
  seem great.
• Actual what you end up with is often less than
  you anticipated.
• Residual Some of the best benefits may be in
  whats left redevelopment opportunities -
  housing, jobs or a long-term income stream.
• Timing you need to prime the pump, cant wait
  for the hospital to produce savings before making
  investments in community system.

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Final Thoughts

• Two Warnings about structure and finance
• Its not about reorganizing.
• Its not about the amount of funds.
• It is about designing your system around the
  clinical and support needs of consumers, and
  ensuring that your financing system is flexible
  enough to meet those needs.