The Federation’s recent advocacy initiatives achieved the modest success of a 6 month extension in APG government rates. In accomplishing this, we rallied other advocacy groups to put the issue on their agenda and traveled to Albany and met with dozens of legislators and presented the issue strongly to the Office of Mental Health and the Department of Health and the Governor’s Office. Subsequently the Federation was granted a meeting with the NYS Medicaid Director where members continued to discuss the crucial role played by Article 31 and 32 clinics. While it was deemed a highly productive meeting, the issues remain in flux.
Among other documents, we shared our position paper, “A Crisis Within a Crisis” and our member’s published paper, “An Examination of Treatment Outcomes at State Licensed Mental Health Clinics” with the officials in Albany. We have posted both of these documents below, and hope that you will feel free to use them with your local officials to educate them and reinforce the importance of the community-based outpatient clinic treatment model.
A Crisis Within a Crisis: The Collapse of Community Mental Health Centers
A special commission convened by the Human Services Council recently issued a report on the crisis within the non-profit sector. The collapse of FEGS and other agencies was cited in this report. In the short time since the report was issued, SCFS has also collapsed adding more dismay to this troubled sector.
Even more troubling is the story within the story; the collapse of multiple community mental health centers (article 31). At least two dozen of these clinics have closed or merged. Seven have closed in Queens alone and nine are reported as closed in the Bronx. Mergers are sometimes not counted making exact numbers hard to ascertain. As more downward pressure is placed on clinics through “managed care” and “value based payments” it is anticipated that the rate of closures will accelerate further.
Why This is a Special Crisis
The community mental health clinic is the anchor element in the state mental health system. The major goal of much health care reform is to treat individuals in the community and keep them out of expensive hospital care. Hospitalization is not only expensive it is also regressive. This is especially true for psychiatric patients. In this context, the community mental health clinic has been tasked to take on increasingly complex psychiatric cases; identify impending problems, intervene early and prevent hospitalization. Our waiting rooms look increasingly like emergency waiting rooms and our clinic staff make triage decisions without the luxury of a back-up hospital ward.
A logical and prudent response would be to direct more resources to community clinics. That has not happened. To the contrary a strong and persistent narrative has developed that these clinics are not necessary. This mantra has been repeated often and has become a belief system.
Why is Clinic Treatment an Anchor Program?
Clinic treatment is an anchor program because:
1) It is the source of psychiatric care and medication therapy.
2) It is the primary access point for most patients.
3) It promotes early intervention; a critical factor for recovery.
4) It provides a positive cornerstone for patients through regular visits to a consistent attachment figure.
5) It is the only place in the system, other than hospitals, where a team of professional mental health staff conduct clinical evaluations, promote diagnosis and immediately provide intervention.
6) Can make critical clinical decisions related to suicidal or homicidal risk.
7) Can call in useful support systems such as care management.
8) Can initiate family support.
9) Can provide consultation and promote integration with other medical systems, school systems or social service agencies.
10) Manage complex cases. There is no other model of care in the psychiatric system that provides the services listed above. Some other complex models of care have been proposed but they lack a specific plan for and implementation and they do not have professional staffing.
That said, clinic treatment combined with care management is an excellent and understandable model that is very effective.
Why This Crisis is Largely Ignored
1) There is a poor awareness of the kind of patients and problems that clinics treat.
2) The narrative that we don’t need clinics, but can still keep patients out of the hospitals is very potent but quite baffling.
3) The HSC Report states “programs intended to build human potential and social welfare are too often developed without consulting the human service providers who will be responsible for implementing them.”
4) The HSC Report also states “The state and Federal Government provided more than 7 billion to major health systems in New York State, which will help buffer the financial costs and risks of Medicaid restructuring, but there is no assurance funds will flow downstream to human service providers.” Remarkably, clinic treatment services are never ever mentioned or named in the funding dialogue.
5) There is no advocacy for clinics as stated above because there is no real money in clinic treatment. Large system have moved on to supporting funding for larger complex models that are revenue rich.
An Examination of Treatment Outcomes at State Licensed Mental Health Clinics
James McQuade and Elena Gromova
Journal of Contemporary Psychotherapy
September 2015, Volume 45, Issue 3, pp 177–183
Mental health clinics that are licensed and regulated by their respective states constitute a vast mental health delivery system. Yet these programs, while operating for the last 40 years, have not been subject to systematic review. This retrospective study of archival data investigated the relationship between intensity of clinic treatment and hospital-based treatment episodes and polypharmacy. The sample was comprised of 562 patients with diagnoses of MDD, bipolar disorder, or a schizophrenia spectrum disorder, drawn from four state-licensed community clinics. These clinics provided a relatively heterogeneous model of care consisting of psychotherapy, medication management, and critical case tracking. Subjects with the highest number of treatment visits (31 or more) had a 62 % reduction in the incidence rate ratio of hospital-based treatment episodes compared to subjects with the least visits (15 or less). Subjects with 15–30 visits also fared well with an 82 % reduction in the incidence rate ratio of hospital-based treatment. Secondarily, a diagnosis of schizophrenia or bipolar disorder resulted in a significantly higher incidence of hospital treatment than a diagnosis of MDD. Polypharmacy, measured at the .01 level, was not found to be associated with treatment intensity. The findings lend support to the outpatient clinic treatment model as a viable system that can significantly reduce costly hospital-based psychiatric care. At least for the diagnoses examined, early drop out is detrimental and increases the probability that hospital-based treatment will become necessary.
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