2006-2010 Statewide Comprehensive Plan for Mental Health Services
Chapter 6
Identifying Strategic Priorities and Initiatives to Continue Advancing the Quality Agenda

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In collaboration with stakeholders, the Office of Mental Health (OMH) has made considerable progress over the last year in articulating and refining a comprehensive planning framework. As part of the balanced scorecard approach, OMH has also critically reviewed other perspectives through a scan of environmental trends, challenges and opportunities facing the national and State public mental health systems.

For the purposes of this discussion, environmental trends include developments unfolding within the national and New York State public mental health systems as well as the broader societal issues that impact these systems of care. Challenges, on the other hand, relate to the pressures exerted on an organization based on consumer needs or expectations, service needs, or financial, societal or other needs as well as an organization's capabilities, including human and other resources.¹ Opportunities are the circumstances or events that serve to move an organization forward in line with its strategic plans.

An important focus of OMH strategic thinking addressed in this chapter is the point at which quality mental health care, as envisioned in the Strategic Plan Framework, interacts with the broader environment in which the public mental health system operates.

Balanced Scorecard Processes Leading to Performance Management

Figure 6.1 provides another way of viewing the balanced scorecard process. The first level, shows refinement of the Strategic Plan and an examination of environmental trends and challenges. The next level depicts the selection of strategic priorities and consideration of opportunities to better align activities with the goals and objectives of the Strategic Plan. This is followed by the choice of initiatives and programs to meet the priorities and finally measuring and monitoring performance to continuously improve quality.

Figure 6.1 - Processes Leading to Performance Management and Continuous Quality Improvement

This chapter focuses primarily on OMH's selection of strategic priorities for both 2005-2006 and 2006-2007, the types of initiatives and programs selected to align the agency's daily work with its strategic direction, and ultimately Executive Budget initiatives to support this work. Chapter 7 focuses on performance and quality improvement processes and their importance in fostering positive change and accountability.

Strategic Priorities

Based on the processes of refining the Strategic Plan and analyzing environmental trends and challenges, OMH has identified eight strategic priorities. Overall, these priorities are intended to maintain or strengthen the structural integrity of the existing service system capacity and provide targeted service system expansion where needed and supported by the evidence base. These eight strategies include:

• Enhancing access to effective community-based services for children and families
• Promoting public health by reducing the risk of suicide
• Providing access to safe and affordable community housing
• Enhancing community-based program models to recruit and retain a qualified workforce and respond to other inflationary pressures
• Enhancing access to effective community-based services for older adults
• Providing access to efficient and high-quality inpatient services
• Implementing an effective performance and accountability infrstructure
• Increasing public safety through the civil commitment of sexually violent predators, where appropriate, to secure treatment facilities for care and treatment

The remainder of this chapter provides an overview of each strategic priority in the format shown at the top of the next column:

Strategic Priority

• Trends and challenges (presents brief descriptions that are not meant to be exhaustive but rather to give the reader a sense of the types of issues considered)
• Opportunities to foster alignment between goals and objectives and agency activities
• Delineation of goals and objectives on which the strategic priority is focused
• Choice of programs and initiatives and budgetary support to achieve goals. Reflected under the strategic priorities is Governor Pataki's commitment to make substantial multi-year investments in response to them.

Strategic Priority 1
Enhancing access to effective community-based services for children and families

Trends and challenges
Onset and prevention. In the largest epidemiological study of its kind, Kessler and colleagues confirmed earlier findings demonstrating that mental illness substantially affects the young.^2,3 The Kessler study found an average age of 14 for the onset of mental illness and urged a focus on early childhood interventions to prevent primary disorders from progressing.⁴

Another recent study notes marked delays between when an illness manifests and when diagnosis and treatment occur. With anxiety disorders, which have the earliest ages of onset, delays in diagnosis and treatment span from 9-23 years.⁵

Delayed access to care for children exposes them not only to the consequences of the disorder but also the results of deferred developmental milestones and serious social, academic and emotional vulnerabilities. Such effects are seen by individuals served by the foster care system. The Northwest Foster Care Alumni Study, for example, showed that 54 percent of adults formerly served in foster care had major mental illness by the age of 24, with rates of PTSD twice that of returning U.S. war veterans.⁶

The impact of serious emotional disturbance. The adverse impacts on the developmental stages of childhood and adolescence can be substantial and have lifelong consequences. As noted in Chapter 4 at least 1 in 10 young people may have a serious emotional disturbance that severely disrupts his or her ability to function effectively at home, at school, and in the community.⁷ For the 2001-2002 academic year, only 3 out of 10 children age 14 and older with emotional disturbance graduated with a standard high school diploma. Among all disabilities, emotional disturbance was associated with the highest rate of school dropout.⁸ Nationally, suicide is the 3rd leading cause of death among children and adolescents, with a rate of 1.5 per 100,000 children in the 10-14 age group and 8.2 deaths per 100,000 for teenagers between 15 and 19 years.^9,10

While little research has been conducted on the cost of treating mental illness in children, a study in 1998 showed direct costs for treating emotional and behavioral mental health problems in children to be approximately $11.75 billion. Preventive interventions have the potential to reduce the financial and societal burden of mental illness by reducing the need for mental health and other related services and potentially benefiting developmental outcomes.¹¹

The effectiveness of available treatments and supports. The President's New Freedom Commission on Mental Health notes incredible advances in the diagnosis and treatment of mental illness. Mental illness is clearly treatable and recovery is a possibility for all. The gap between the evidence base and services routinely available remains substantial. In particular, as noted by the MacArthur Foundation, the largest gap between research and practice exists for children.¹² Identifying evidence-based treatments that make a difference in day-to-day life and developing methods to promote the use of effective interventions requires a sustained focus and mechanisms to bring research into everyday practice. Research has demonstrated that scientific evidence of effectiveness alone is not sufficient to create adaptation and that adaptation to new practices requires attention to the context in which they are being introduced and factors such as provider and family acceptance.^13,14

Opportunities to foster alignment
Early and effective access. Opportunities include identifying mental illness early and providing access to treatment and supports that keep our children's development on track, while they are at home with their families; creating new mechanisms to engage treatment programs in performing community-based screening, comprehensive assessments and in-home services for children; and increasing access to evidence-based, community-based services for vulnerable children.

Enhanced service quality. Opportunities include promoting the availability of effective, flexible, evidence-based services that support a family's ability to care for their children at home; increasing access to child psychiatrists in rural and underserved areas; and sustained education and clinical support to New York's clinicians in the implementation of evidence-based practices.

Goals and objectives supported

Goal 1
Public Mental Health Promotion

• Objective 1.5. Promote screening, early intervention and prevention strategies, particularly with primary care physicians, other health care providers, and community providers important to consumers.

Goal 2
Positive Outcomes for Children, Families and Adults

• Objective 2.3. Promote services with the potential to help individuals achieve success and satisfaction in living, learning, work, and social environments.

Goal 3
Research to Practice

• Objective 3.4. Reduce the length of time it takes to disseminate research findings to key stakeholder audiences.

Goal 4
Continuous Quality Improvement

• Objective 4.2. Increase the quality of services through the incorporation of evidence-based practices in routine care.
• Objective 4.6. Maintain adequate resources to ensure that high-quality services are able to be provided.

Goal 5
Access to Services

• Objective 5.1 Improve access to appropriate and effective services for children with serious emotional disturbance and their families.

Programs, initiatives and Executive Budget actions
In 2005-2006, actions to implement this strategy included efforts to enhance access to clinic services for children and families and to expand access to effective community-based services for at-risk children.

• The 2005-2006 Budget for the Office of Children and Family Services provided $2.3 million ($9 million annualized gross) in new State funding for 245 additional Home and Community-based Waiver (HCBW) slots for children in foster care or at risk of institutional placement.
• The 2005-2006 Budget also provided increased funding for freestanding mental health clinics for children through a statewide fee increase and increases to children's clinics providing evening and weekend services.

The 2006-2007 ExecutiveBudget recommendations build on the investments from the prior year by including financial support for an interrelated set of services that support early recognition of children with emotional disturbance, improve access to interventions that have been proven by science to be effective, expand access to in-home and community-based services, provide the expertise of child psychiatrists to rural areas and ensure that evidence-based treatments are widely available across New York State.

• The Child and Family Clinic Plus will transform treatment services for children and their families. With the $16.1 million ($21.5 million annualized and $33 million annualized gross) in funding, hundreds of thousands of lives will be touched each year through the adoption of a public health approach to the early recognition of emotional disturbance. Children in need of treatment will have access to a comprehensive assessment that utilizes the practice guidelines from the American Academy of Child and Adolescent Psychiatry as well as evidence-based tools and scales. Children and families requiring treatment will find that Clinic Plus brings improved access, in-home services and treatments that have been shown through science to work. This expansion more than doubles the admissions to children's mental health clinic treatment.
• Serving more children in the HCBW program. The $5.2 million ($7.2 million annualized and $14.3 million annualized gross) in funding is to expand the Waiver program by 450 (300 OMH and 150 Office of Children and Family Services) slots, bringing the total slots to 1,436 and increasing individuals served annually up to 2,160 children and families. This expansion continues program development to flexibly provide services for children with serious emotional disturbance to remain at home and in their communities.
• Providing child psychiatry services to New York's rural areas. This $0.4 ($0.5 annualized) million initiative supports a child psychiatrist who will be available to provide designated rural areas with up to 600 comprehensive evaluations/consultations each year. A one-time purchase of the technological equipment is also included for the designated sites.
• The New York State Evidence-Based Treatment Dissemination Center (EBTDC) will be a nationally recognized leader in improving the quality of clinical interventions for children and their families. Funding in the amount of $0.5 ($0.6 annualized) million is designated for a sustained clinical education model in evidence-based treatment protocols and in specialized consultation to support the organizational changes necessary to transform the way in which mental health services are delivered. As many as 400 front-line clinicians from across the State will be trained annually.

Strategic Priority 2
Promoting public health by reducing the risk of suicide

Trends and challenges
The impact of suicide. As noted in Chapter 5, suicide is a serious public mental health challenge. More people in our nation die from suicides than from homicides each year. Suicide is the 11th leading cause of death in the United States and affects all age groups. In 2001, 3,971 suicides were reported nationally in young adults¹⁵ from 15-24 years of age and 5,393 adults over the age of 65 committed suicide.¹⁶ Suicide risk extends from childhood through adolescence, with 1 in 10 of our teenagers reporting that they made a suicide plan within the past year,¹⁷ to older adulthood where 17.6 percent of all suicides were completed by individuals 65 years of age and older. Nearly 1,300 lives are lost each year in New York to the self-directed violence of suicide.¹⁸

Awareness of risk and preventive factors has been expanded in New York State. In addition to broadening public awareness of risk and preventive factors through the Suicide Prevention Education and Awareness Kit (SPEAK) Campaign, OMH has developed a statewide suicide prevention plan, Saving Lives in New York: Suicide Prevention and Public Health. As described in Chapter 4, OMH also convened the first-ever Statewide Summit on Suicide Prevention in November 2005 to help communities develop capacity and plans to reduce the incidence of suicide across New York. The Summit represented a public/private partnership helping to advance and transform future suicide prevention efforts in New York State.

Opportunities to foster alignment
Focusing on effective interventions. Suicides are preventable if people know what to look for and when to speak up. Research has shown that suicide prevention and early intervention efforts are successful at saving lives.^19,20 Consistent with the coordinated approach envisioned by the National Strategy for Suicide Prevention,²¹ New York State is combining individual and societal approaches into its statewide suicide prevention. Specifically, OMH is striving to:

• Integrate population-oriented public health prevention measures with currently available clinical and medical interventions to address the needs of groups of individuals bearing greater burdens of risk
• Move from building awareness of the need for suicide prevention to taking concerted actions that lead to reductions in the loss of life and remedy conditions that frequently foster it.

Goals and objectives supported

Goal 1
Public Mental Health Promotion

• Objective 1.1. Increase public awareness of the prevalence of suicide and of risk and preventive factors.
• Objective 1.3. Improve public understanding of the causes, effects and treatment of emotional disturbance in children and mental illness in adults.
• Objective 1.5. Promote screening, early intervention and prevention strategies, particularly with primary care physicians, other health care providers, and community providers important to consumers.

Goal 4
Continuous Quality Improvement

• Objective 4.3. Minimize the risk and occurrence of adverse consequences resulting from harm, neglect or suboptimal care or treatment.

Programs, initiatives and Executive Budget actions
Actions in 2006-2007 build upon efforts undertaken during 2005-2006, including support for initiatives aimed at increasing awareness of the prevalence of suicide, and improving public understanding of the causes, effects and treatment of emotional disturbances that underlie suicidal ideation and behavior. OMH continues to focus on promotion of screening, early intervention and prevention strategies, particularly with primary care physicians, and other healthcare providers. The 2006-2007 Executive Budget includes a dedicated resource to continue these activities and initiate implementation of County suicide prevention initiatives.

• Reducing the risk of suicide. The 2006-2007 Executive Budget recommends $1.5 million in addition to a $400,000 Federal grant to support the implementation of the New York State Suicide Prevention Plan and related County suicide prevention initiatives.

Strategic Priority 3

Providing access to safe and affordable community housing

Trends and challenges
Access to housing. A landmark study by Culhane and colleagues in 2003 demonstrated the effectiveness of providing housing in combination with mental health services in reducing shelter use among persons with mental illness and a history of homelessness.²² A more recent qualitative study in Canada²³ sheds light on other factors that may be at play in improving the quality of life for individuals in supportive housing. In addition to the reductions in homelessness and hospitalization, individuals experienced attributes associated with recovery such as stability in their lives, supportive relationships, and a sense of dignity. In 2003, the Department of Health and Human Services asserted that linking affordable housing with treatment and support services would lead to substantial and permanent reductions in the occurrence of chronic homelessness.²⁴ The President's New Freedom Commission has also noted the lack of decent, safe, affordable, and integrated housing as one of the most significant barriers to full participation in community life for people with mental illness.

Opportunities to foster alignment
Providing additional Supportive Housing capacity. Opportunities include providing additional capacity for individuals and families affected by homelessness and serious mental illness.

Goals and objectives supported

Goal 2
Positive Outcomes for Children, Families and Adults

• Objective 2.4. Promote services with the potential to help individuals achieve success and satisfaction in living, learning, work, and social environments.

Goal 4
Continuous Quality Improvement

• Objective 4.6. Maintain adequate resources to ensure that high-quality services are able to be provided.

Goal 5
Access to Services

• Objective 5.9. Improve access to safe and affordable housing for individuals with serious emotional disturbance and serious mental illness.

Goal 6
Service System Capacity

• Objective 6.1. Promote the capability of State and Local service systems to provide appropriate and effective services.
• Objective 6.4. Improve system capacity for the delivery of services identified by individuals with mental illness and their families as effective in meeting their recovery goals.

Programs, initiatives and Executive Budget actions
The 2005-2006 Budget provided operational and capital funding for Local programs to maintain the existing residential system and continue the development of previously authorized community beds. It supported 27,000 beds operating at that time, 1,600 new beds from prior year initiatives, and another 2,500 beds in various stages of planning and development. Included in capital funding was a new $75 million appropriation for development of the remaining 1,000 residential beds authorized by the Governor in 2003-04. These efforts bring the total number of community beds authorized to 31,100.

In 2006-2007 strategies include developing additional Supportive Housing capacity in a partnership with New York City.

• New York/New York III Supportive Housing Agreement. The 2006-2007 Executive Budget provides $7.7 million for the first year of State operating costs associated with this joint agreement between the State and New York City, which will develop an additional 9,000 supportive housing units for individuals and families who are living on the streets or in the emergency shelters in New York City. The initiative will increase the availability of stable housing for individuals and their families affected by homelessness and mental illness by 5,550 units over 10 years (as part of the overall 9,000 unit effort).

Strategic Priority 4
Enhancing community-based program models to recruit and retain a qualified workforce and respond to other inflationary pressures

Trends and Challenges
Escalating rental costs for supported housing providers. In 2002, people with disabilities were priced out of every housing market area in the United States. Of the 2,702 market areas, not one offered modestly priced rents for efficiency or one-bedroom units for people with disabilities receiving Supplemental Security Income (SSI).²⁵ In 2005, the findings from the report two years earlier confirmed that more and more people with disabilities who rely on SSI payments are not gaining access to affordable housing.²⁶

Escalating operating costs. Operating costs associated with the voluntary-operated, community-based service system have increased more rapidly than anticipated, resulting in funding levels that have not kept pace with inflation and placed strain on this critical infrastructure.

Recruiting and retaining a qualified work force. Public mental health providers are hard pressed to recruit skilled, licensed professionals such as child psychiatrists, nurses and pharmacists. These professionals are in short supply and high demand nationally. In the United States, for example, there are approximately 6,300 child and adolescent psychiatrists and their distribution is severely inadequate in rural and in poor, urban areas, thereby limiting access in these areas.²⁷

Mirroring national trends,²⁸ pay levels for direct care workers in the locally operated public mental health system are not competitive in some instances because reimbursement levels for these programs have been fixed and providers have not received regular cost-of-living adjustments or trends for inflation. Voluntary provider employee turnover in some programs has reached unacceptable levels. Recruitment of nonprofessional staff in local programs has become increasingly difficult as salary levels become uncompetitive with other employment opportunities.

Opportunities to foster alignment
Closing the gap between rental costs and stipends. Opportunities include increasing rental stipends to assure the ongoing financial viability of Supported Housing providers.

Closing the gap between operating costs and funding levels. OMH will continue working with community-based providers to ensure that funding is used in the most efficient and effective manner to meet the needs of recipients and families, particularly by strengthening the voluntary, community-based infrastructure.

Goals and Objectives Supported

Goal 2
Positive Outcomes for Children, Families and Adults

• Objective 2.4. Promote services with the potential to help individuals achieve success and satisfaction in living, learning, work, and social environments.

Goal 4
Continuous Quality Improvement

• Objective 4.6. Maintain adequate resources to ensure that high-quality services are able to be provided.

Goal 6
Service System Capacity

• Objective 6.1. Promote the capability of State and Local service systems to provide appropriate and effective services.
• Objective 6.2. Improve retention and recruitment to ensure a qualified workforce.
• Objective 6.5. Improve system capacity for employee skill development and competency.

Programs, initiatives and Executive Budget actions
Actions in 2005-2006 recognized that investments to maintain the existing service system must accompany ongoing initiatives to expand it. Thus, the 2005-2006 Budget included $6.5 million to provide for Supported Housing stipend rent increases.

The 2005-2006 Budget actions also included strengthening outpatient clinics and providers with an increase of $6 million State share of Medicaid for Article 31 outpatient clinics. This represented a $24 million increase in gross Medicaid revenues to be used for Article 31 clinics, including a statewide fee increase, increases to children's clinics providing evening and weekend services, and other targeted enhancements.

The 2006-2007 Executive Budget recommends providing a three-year annual cost-of-living adjustment (COLA) tied to the Consumer Price Index (CPI) for targeted OMH nontrended programs, to reflect actual inflation-related growth; and shoring up funding for existing Supported Housing beds.

• Supported Housing stipend increases. The Budget allocates $6.5 million in funding on top of prior year enhancements to address the need to close the gap between rental costs and Supported Housing rent stipends. The goal is to maintain the existing base of Supported Housing capacity.
• Cost-of-living adjustment. Funding in the amount of $16.6 million ($22.1 million annualized and $30.9 annualized gross) is earmarked to strengthen programs by providing annual COLAs tied to the CPI through 2008-2009. A focus will be on recruiting and retaining staff reflective of a program's culture and community.

Strategic Priority 5
Enhancing access to effective community-based services for older adults

Trends and challenges
Impact of stigma. Mental illness in older adults provides the combined impact of stigma associated with aging and the stigma of mental illness. As noted during the White House Conference on Aging in 2005, "Worse than being invisible, an older person suffering from depression or dementia is devalued and dismissed."²⁹ In light of the importance of stigma as a barrier to care, as Americans live longer and as the aging of the baby boomers takes place, meeting the needs of older individuals with mental illness will be even more challenging over the next two and one-half decades.

Demographic trends in New York. Since last enumerated by the 1990 Census, dramatic shifts have occurred in the age, marital status, housing, minority characteristics, and living arrangements of older local populations in New York State. The composition of New York's population will change dramatically from projected migration patterns, from the aging of post-World War II baby boomers (individuals born between 1946 to 1964) and from continuing increases in life expectancy. The 60 and older population is projected to remain at about 3.1 million until 2010 when it is expected to rise to 3.4 million with the initial influx of baby boomers. It will then grow to 4.4 million in 2025 when all baby boomers will be in the range of 60-to-79 years of age, representing an increase of 40 percent over 30 years.³⁰

Changing service needs. As the population ages, there will be a greater demand for mental health services specifically designed to meet the needs of older adults. Among the top 10 of 50 resolutions adopted during the White House Conference on Aging is one to address the pressing issues surrounding aging and mental illness. It calls for improvements in the recognition, assessment, and treatment of mental illness and depression among older Americans.³¹

Opportunities to foster alignment
OMH and its network of community providers will be engaging in collaborations to develop services targeted to better enable the diagnosis, treatment and management of mental illness for this population.

Goals and objectives supported

Goal 2
Positive Outcomes for Children, Families and Adults

• Objective 2.4. Promote services with the potential to help individuals achieve success and satisfaction in living, learning, work, and social environments.

Goal 5
Access to Services

• Objective 5.6. Improve access to appropriate and effective services for older adults.

Goal 6
Service System Capacity

• Objective 6.1. Promote the capability of State and Local service systems to provide appropriate and effective services.

Programs, initiatives and Executive Budget actions
The 2006-2007 Executive Budget includes funding support for demonstration programs to address the mental health needs of older New Yorkers, a group dramatically increasing in size over the next 25 years.

• The 2006-2007 Executive Budget provides $2 million in funding to support demonstration programs under the 2005 Geriatric Mental Health Act. This program will be administered by OMH in cooperation with the State Office for the Aging. Grants may be awarded to providers of care to older adults with mental disabilities for purposes that may include one or more of the following: community integration, improved quality of treatment, integration of services, workforce development, family support, finance, specialized populations, information clearinghouse, and/or staff training.

Strategic Priority 6
Providing access to efficient and high-quality inpatient services

Trends and challenges
Resource allocation. Mental health spending of $85 billion in 2001 represented 6.2 percent of all health care spending in the United States. Three trends have been important in accounting for the increase in the cost of care: a rise in public payment from 57 percent of total mental health spending in 1991 to 63 percent in 2001; an increase in mental health prescription drug expenditures of 17 percent per year between 1991 and 2001; and a reduction in inpatient expenditures from 38 percent in 1991 to 22 percent in 2001.³²

A disproportionate share of OMH's funding of the New York State public mental health system supports the 25 State-operated psychiatric centers serving slightly more than 5,000 inpatients contrasted with more than 93,000 inpatients served in 1955. The declining need for adult, inpatient psychiatric center beds allowed New York State to eliminate unneeded inpatient capacity and invest the savings in expanded, evidence-based, community-based services.

Historical and anticipated demand for inpatient services. Nationally, the closure of state psychiatric hospitals continues, but more slowly than during the 1990s. Moreover, about one-half of states are in the midst of reorganizing their psychiatric center systems and nearly three-quarters have experienced bed shortages owing to downsizing trends and bed closures in general and in private psychiatric hospitals.³³

In New York State, the utilization of adult inpatient psychiatric beds in State psychiatric centers and hospitals licensed under Article 28 of the Public Health Law has declined substantially over the last 20 years. This trend is discussed in detail in Chapter 4 of the 2004-2008 Statewide Comprehensive Plan. Four State-operated inpatient psychiatric centers have closed since 1995 and Middletown Psychiatric Center is due to close April 1, 2006. An analysis of more recent trends shows no decline in demand for access to adult State psychiatric center inpatient services in the last three years and no signs of further decline in the near future.

The ability to further close or consolidate State psychiatric center inpatient capacity does not appear to be warranted at this time due to the leveling off of previously declining demand for inpatient services, utilization of current inpatient capacity, and the need to evaluate future inpatient capacity requirements.

Physical plant considerations. In line with national accrediting environment of care standards,³⁴ organizational risk assessments permit safe, functional, supportive and effective environments for the individuals served and their families, staff and visitors. They provide a foundation for minimizing the risk of adverse consequences. Within the public mental health system, some older psychiatric centers are in need of substantial physical plant renovations to maintain a safe and therapeutic environment.

Opportunities to foster alignment
Assessing future inpatient capacity needs. Consistent with an approach taken by many other states,³⁵ OMH is taking the opportunity to thoughtfully assess future State psychiatric center inpatient capacity needs before taking any new actions related to either psychiatric center closures or reductions in inpatient bed capacity. Any such actions will take place in collaboration with the Governor Pataki's new Commission on Health Care Facilities in the 21st Century, a broad-based, nonpartisan panel that will examine the needs and capacities of the health care system and make recommendations to "right-size" hospitals and nursing homes. Created as part of the 2005-2006 Budget, the Commission has 18 permanent members and a group of regional members. While studying ways to best reconfigure and consolidate the health care system, the Commission will examine a number of germane factors, including the impact that closing a facility might have on the local and regional economies, the geographic needs and delivery of health care services, and the costs and benefits of closing any facility.

Addressing physical plant renovation. OMH has the opportunity to identify psychiatric center campuses where there is a clear and compelling need to maintain inpatient capacity for a period of time that would justify the expenses related to renovation activities. The opportunity also allows OMH to capitalize on environment assessments to promote safe and effective care.

Goals and objectives supported

Goal 2
Positive Outcomes for Children, Families and Adults

• Objective 2.4. Promote services with the potential to help individuals achieve success and satisfaction in living, learning, work, and social environments.

Goal 4
Continuous Quality Improvement

• Objective 4.6. Maintain adequate resources to ensure that high-quality services are able to be provided.

Goal 5
Access to Services

• Objective 5.4. Improve access to appropriate and effective services for individuals involved in the criminal justice system.

Goal 6
Service System Capacity

• Objective 6.1. Promote the capability of State and Local service systems to provide appropriate and effective services.

Programs, initiatives and Executive Budget actions
The 2005-2006 Budget actions included the April 1, 2006, closure of Middletown Psychiatric Center. It called for reinvestment of 100 percent of the $7 million in annual savings associated with the closing to expand State-operated community services in Middletown's catchment area of Orange and Sullivan Counties. At the same time, the actions did not result in a reduction in inpatient beds. Inpatient services provided at Middletown are transitioning to Rockland Psychiatric Center in Orangeburg.

The 2005-2006 Budget also provided $7 million to continue Governor Pataki's commitment to expand mental health treatment capacity and clinical staffing for prisoners with serious and persistent mental illness.

In 2006-2007 actions to provide efficient and high-quality services include providing capital funds to support design and construction of inpatient capacity at State psychiatric centers and continuing to support expanded access to services for individuals with serious mental illness in correctional settings.

• Provide funding for rebuilding state-of-the-art adult and children's psychiatric centers at the Bronx.
• Provide resources for the capital design at Kirby Forensic Psychiatric Center.
• Further enhance services for inmates with mental illness in Department of Correctional Services and OMH facilities. The $0.3 million ($0.6 million annualized) is designated for enhanced staffing associated with expanding capacity to provide services to inmates with mental illness.

Strategic Priority 7
Implementing an effective performance and accountability infrastructure

Trends and challenges
National focus. The World Health Organization, President's New Freedom Commission, Institute of Medicine, and other prominent international, national and governmental organizations are stressing the importance of accountability, performance management, transformation of government operations through structural and service enhancements, and improvements to operational efficiency and outcomes using technology. Critical is the desire to achieve these results without jeopardizing the quality of care and priority services.

Nationally, the care of individuals with serious mental illness is being challenged fiscally by reduced revenue streams and increasing costs, which have been intensified by the growth in Medicaid.³⁶

New York State focus. As part of his State Government Reform initiative for the 2005-2006 State Fiscal Year, Governor Pataki noted the responsibility of government to act prudently in its stewardship of public funds.³⁷ Among the key management reforms advanced by Governor Pataki has been the recommendation to institute State agency strategic planning processes to define goals and priorities and to attend to the relationship between performance outcomes and financial decision making. Specifically, with respect to mental health, the Governor committed to advancing community-based care and service opportunities to New Yorkers with special needs and maximizing limited resources; responding to budget realities through cost-efficiencies and alignment of funding with priorities and needs; and investing targeted resources from savings and new revenues to promote the mental hygiene workforce and nonprofit program model.

Scope and complexity of the New York State public mental health system. OMH's oversight and performance management role is increasingly large and complex, overseeing 58 Local governmental units, one of which covers New York City entirely, more than 2,500 mental health agencies and its own large and diverse State-operated system. It is continually challenged by a dynamic and changing operating environment, wherein one of its primary responsibilities is to bring together key stakeholders to continually strengthen services and improve outcomes, the quality of life and well-being for New Yorkers served in the public mental health system.

Opportunities to foster alignment
Leveraging the existing performance measurement and information systems infrastructure. The agency will leverage the extensive development work already undertaken to support initiatives that make available the necessary resources and tools to permit the State and Counties to monitor quality of care and cost-effectiveness. The infrastructure will also aid performance-based outcomes measurement and provider certification and licensing processes. The balanced scorecard presents OMH with the opportunity to take the best of performance measurement strategies developed and bring them together into a comprehensive system that will promote accountability for results.

Goals and objectives supported

Goal 2
Positive Outcomes for Children, Families and Adults

• Objective 2.4. Promote services with the potential to help individuals achieve success and satisfaction in living, learning, work, and social environments.

Goal 4
Continuous Quality Improvement

• Objective 4.1. Improve service quality through fidelity to the principles of informed choice, recovery-focused and person-centered care.
• Objective 4.4. Ensure that the State and counties have the tools and resources necessary to measure and monitor the quality of care.
• Objective 4.5. Increase the State's and counties' capability to improve performance-based outcomes measurement.

Goal 7
Accountability for Results

• Objective 7.1. Improve the State and Local mental health planning and oversight process to promote accountability. Program, initiatives and Executive Budget actions

Program initiatives and Executive Budget actions
Actions to implement this strategy include supporting initiatives that allow OMH to have the capacity to develop the infrastructure needed to monitor quality of care and improve performance-based outcomes measurement.

• Continue to develop information systems and share data with the counties.
• The 2006-2007 Executive Budget provides $1.5 million (plus $0.5 million in the Office of Alcoholism and Substance Abuse Services (OASAS) budget) to support more efficient and effective services to persons with co-occurring disorders through the implementation of State-sponsored managed care programs. This initiative builds on efforts under way to facilitate coordinated care planning for individuals with co-occurring mental illness and substance use disorders.
• The 2006-2007 Executive Budget provides $0.5 million to develop strategic financial directions not only to shore up base revenues and funding streams, but also to identify opportunities for additional revenue maximization.
• The 2006-2007 Executive Budget provides $0.2 million to assure mechanisms to promote timely and efficient enrollment of service recipients into Personalized Recovery-oriented Services (PROS).
• The 2006-2007 Executive Budget provides for savings of $0.6 million by eliminating special, unjustified Medicaid rates for certain Article 28 mental health programs that have not been demonstrated to enhance treatment outcomes.

Strategic Priority 8
Increasing public safety through the civil commitment of sexually violent predators, where appropriate, to secure treatment facilities for care and treatment

Trends and challenges
While individuals who sexually offend others cannot be cured, they can be treated. Cognitive behavioral therapy, a recognized best practice in mental health treatment, has been shown to be of value in assisting offenders to gain new coping skills, avoid circumstances that place them at risk for re-offending, and learn methods to stop them from acting on impulses.³⁸ In a study by Hanson and colleagues in 20002, cognitive behavioral therapy was demonstrated to reduce re-offending by as much as 40 percent.³⁹ Treatment offers offenders a road to recovery whereby they are enabled to make a commitment to adopt healthier patterns of living.⁴⁰

As with any form of treatment, however, it can fail, and when it does, unsuccessful treatment is often associated with higher rates of recidivism.⁴¹ Among sex offenders found to re-offend are pedophiles who prey on boys and rapists of adult women. In these cases, recidivism rates over a 25-year period of 52 percent and 39 percent, respectively, have been reported.⁴² These individuals are often termed "sexually violent predators." While the definition of a sexually violent predator varies from state to state, the term often includes the following elements: behavioral and/or mental health disorders, victimization of strangers, a predilection toward violence and weapons use, infliction of harm, multiple victims, and repeated offenses.⁴³

Nationally, the issues of community safety and violent sexual predatory behavior have been addressed legislatively. The Federal Jacob Wetterling Crimes against Children and Sex Offender Registration Act of 1994 mandated the creation of programs in all states to register sex offenders and authorized discretionary community notification. In 1996, Megan's Law strengthened the Wetterling Crimes Act by mandating that states provide the public with information about sexual offenders in their communities.

Civil commitment of sexual predators is a legal option being increasingly employed by a number of states for also enhancing community safety. It occurs when a convicted sexual offender has completed jail time, been assessed clinically as having a serious mental or personality disorder, and is judged likely to engage in predatory sexual violence that necessitates treatment at the end of a prison term. The civil commitment law enacted by Kansas in 1994 has been upheld twice by the United States Supreme Court, first in 1997,⁴⁴ and again in 2002.⁴⁵

Since 1998, Governor Pataki has proposed civil commitment legislation that would enable New York State to civilly commit sexually violent predators, if a jury of 12 individuals unanimously agrees beyond a reasonable doubt that an individual has a mental abnormality and presents a substantial risk to the safety of the community. The Governor's Program Bill is modeled after the United States Supreme Court decisions and is similar to laws in 16 other states (including New Jersey, Massachusetts and Virginia) and the District of Columbia.⁴⁶

As a result of legislative inaction, since mid-September 2005, New York State instituted civil commitment proceedings for sexually violent predators about to be released from State prison. When judged medically a danger to themselves or others, individuals have been civilly committed. Twelve offenders challenged civil commitment in court and on November 15, 2005, the New York County Supreme Court acknowledged the seriousness of the Governor's concerns with respect to the risks posed to the public by repeat sexual offenders. The Court, however, ruled that the same civil commitment procedures utilized by the State for individuals with serious mental illness were inappropriate for sexually violent predators being released from prison.

While awaiting the State appeals of the Court's decision, Governor Pataki and other legislative and law enforcement leaders have again called for passage of the Governor's Civil Commitment legislation, which has been specifically developed for sexually violent predators, consistent with the guidance provided by the United States Supreme Court. On January 5, 2006, the Governor announced a five-point plan to protect New Yorkers and their families, including requiring the civil confinement of dangerous sexual predators; imposing longer sentences for those who molest and rape children, or commit violent or repeat sexual assaults; strengthening New York's Megan's Law; ending the statute of limitations on rape and sexual assaults; and requiring all criminals to submit a DNA sample to State's DNA Databank.⁴⁷

Opportunities to foster alignment
Enhanced public safety. OMH needs to support the Governor's ongoing civil commitment initiative by developing approaches to increase public safety in New York State communities through support for civil commitment, where deemed appropriate, for the care and treatment of sexually violent predators and the creation of discrete, secure facilities for ongoing treatment of individuals civilly committed.

Goals and objectives supported

Goal 4
Continuous Quality Improvement

• Objective 4.3. Minimize the risk and occurrence of adverse consequences resulting from harm, neglect or suboptimal care or treatment.

Goal 5
Access to services

• Objective 5.4. Improve access to appropriate and effective services for individuals involved in the criminal justice system.

Programs, initiatives and Executive Budget actions

The 2006-2007 Executive Budget includes funding to support, where appropriate, the civil commitment of sexually violent predators upon their release from prison, providing care and treatment in secure facilities. Committing these individuals will protect the public and provide these persons with continued and needed treatment.

• The 2006-2007 Executive Budget provides $26.8 million to develop protocols and deliver services tailored to treat sexually violent predators that are civilly committed for secure care and treatment.
• The 2006-2007 Executive Budget provides $165 million in capital resources for new (or modification of existing) facilities and programs related to civil commitment. This includes constructing a new facility on the grounds of the Pharsalia Correctional Facility, which will be transferred from the Department of Correctional Services to OMH.

These eight strategic priorities represent a sustained effort by OMH over the past year to attend to Governor Pataki's directive to align funding with the priorities and needs of individuals served by the public mental health system. They help to set the stage for the initiation of the new balanced scorecard reporting of results, signaling the agency's ongoing commitment to accountability and continuous quality improvements. Additional information on each of the Executive Budget initiatives can be found in a series of fact sheets contained in Appendix 2. Chapters 7 and 8 will address how the balanced scorecard and performance measures will be established to provide stakeholders with quantitative measures of the agency's progress in implementing these initiatives.

Notes:

1. See Baldrige glossary: Strategic challenges. Accessed online at http://www.baldrige21.com/BALDRIGE%20GLOSSARY/BN/G-BN%20Strategic%20Challenges.html .
2. World Health Organization Mental Health Survey Consortium. (2004). Prevalence, severity and unmet need for treatment of mental disorders in the World Health Organization World Health Mental Health Surveys. Journal of the American Medical Association, 291, 2581-2590.
3. World Health Organization International Consortium in Psychiatric Epidemiology (2000). Cross-national comparisons of the prevalences and correlates of mental disorders. Bulletin of the World Health Organization, 78, 413-426.
4. Kessler RC, Berglund P, Demler O, Jin R, Merikangas KR, & Walters EE. (2005). Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Archives of General Psychiatry, 62(7), 593-602.
5. Wang PS, Beglund P, Olfson M, Pincus HA, Wells KB, & Kessler RC. (2005). Failure and delay in initial treatment contract after first onset of mental disorders in the National Comorbidity Survey Replication. Archives of General Psychiatry, 62, 603-613.
6. Casey Family Programs. (2005). Improving family foster care: Findings from the northwest foster care alumni study. Seattle: Casey Family Programs Research Service. Available online at http://www.casey.org/Resources/Publications/pdf/ImprovingFamilyFosterCare_FactSheet.pdf  (PDF).
7. Department of Health and Human Services. (1996). Prevalence of serious emotional disturbance in children and adolescents. Mental Health, United States, 1996. Rockville, MD: Substance Abuse and Mental Health Services Administration, Center for Mental Health Services.
8. Reimer M, & Smink J. (2005). Information about the school dropout issue. Selected facts & statistics. Clemson, SC: National Dropout Prevention Center/Network. Available online at http://www.dropoutprevention.org/pubs/pdfs/School_Dropout_Facts-2005.pdf  (PDF).
9. Mini–o AM, Arias E, Kochanek KD, Murphy SL, & Smith BL. (2002). Deaths: Final data for 2000. National Vital Statistics Reports, 50(15). Hyattsville, MD: National Center for Health Statistics.
10. Office of Statistics and Programming. Web-based Injury Statistics Query and Reporting System (WISQARSTM). Atlanta: Centers for Disease Control and Prevention, National Center for Injury and Prevention Control. Available online at http://www.cdc.gov/ncipc/wisqars/default.htm .
11. Ringel JS, & Sturm R. (2001). National estimates of mental health utilization and expenditures for children in 1998. Journal of Behavioral Health Services Research, 28(3), 319-333.
12. John D and Catherine T MacArthur Foundation. (2005, December 16). News from MacArthur: Mental health in America-Bringing the best of research to practice and policy. Available online at http://www.macfound.org/site/apps/nl/content2.asp?c=lkLXJ8MQKrH&b=1135955&ct=1738907 .
13. McKay MM, Hibbert R, Hoagwood K, Rodriguez J, Murray L, Legerski J, & Fernandez D. (2004). Integrating evidence-based engagement interventions into "real world" child mental health settings. Brief Treatment and Crisis Intervention 4(2), 177-186.
14. Hoagwood K. (2003, Spring/Summer). Evidence-based practice in children's mental health services. What do we know? Why aren't we putting it to use? Data Matters, 4-5. Available online at http://www.georgetown.edu/research/gucchd/datamatters6.pdf  (PDF).
15. Anderson RN, & Smith BL. (2003). Deaths: Leading causes for 2001. National Vital Statistics Report, 52(9), 1-86.
16. Office of Statistics and Programming. Web-based Injury Statistics Query and Reporting System.
17. Grunbaum JA, Kann L, Kinchen SA, Williams B, Ross JG, Lowry R, & Kolbe L. (2002, June 28). Youth risk behavior surveillance - United States, 2001. Morbidity and Mortality Weekly Report 51(SS04), 1-64.
18. New York State Office of Mental Health. (2005). Saving lives in New York: Suicide prevention and public health. Volume 1. Challenge, strategy and policy recommendations. Albany, NY: Author.
19. Mann JJ, Apter A, Bertolote J, Beautrais A, Currier D, Haas A, et al. (2005). Suicide prevention strategies: A systematic review. Journal of the American Medical Association 294,2064-2074.
20. Brown GK, Ten Have T, Henriques GR, Xie SX, Hollander JE, & Beck AT. (2005). Cognitive therapy for the prevention of suicide attempts: a randomized controlled trial. Journal of the American Medical Association 294(5), 563-570.
21. See the National Strategy for Suicide Prevention web site online at http://www.mentalhealth.samhsa.gov/suicideprevention/strategy.asp .
22. Metraux S, Marcus SC, & Culhane DP. (2003). The New York-New York housing initiative and use of public shelters by persons with severe mental illness. Psychiatric Services, 54(1), 67-71.
23. Nelson G, Clarke J, Febbraro A, & Hatzipantelis M. (2005). A narrative approach to the evaluation of supportive housing: Stories of homeless people who have experienced serious mental illness. Psychiatric Rehabilitation Journal, 29(2), 98-104.
24. U.S. Department of Health and Human Services. (2003). Report from the Secretary's work group on ending chronic homelessness. Bethesda, MD: Author. Available online at http://aspe.hhs.gov/hsp/homelessness/strategies03/
25. O'Hara A, & Cooper E. (2003). Priced out in America: Housing crisis worsens for people with disabilities. Boston: The Technical Assistance Collaborative.
26. O'Hara A, Cooper E, & Buttrick J. (2005). Priced out in 2004: The escalating housing crisis affecting people with disabilities. Boston: The Technical Assistance Collaborative.
27. Kim WJ & the American Academy of Child and Adolescent Psychiatry Task Force on Workforce Needs. (2003). Child and adolescent psychiatry workforce: A critical shortage and national challenge. Academic Psychiatry, 27(4):277-282.
28. Koppelman, J. (2004). The provider system for children's mental health: Workforce capacity and effective treatment. National Health Policy Forum Issue Brief, 801, 1-18.
29. Esposito G. (2005). Mental health policy solutions. White House Conference on Aging. Available online at http://www.whcoa.gov/about/policy/meetings/Sol_forum_agenda/2005_Mar/geraldine%20Esposito.pdf  (PDF).
30. See Demographic Projections to 2025, New York State Office for the Aging. Available online at http://www.aging.ny.gov/NYSOFA/Demographics/DemographicChangesinNewYorkState.pdf  (PDF).
31. White House Conference on Aging. (2005, December 14). White House Conference on Aging closes: Top 10 resolutions announced. Press release available online at http://www.whcoa.gov/press/releases/2005/pr_12_14_05.pdf  (PDF).
32. Mark TL, Coffey RM, McKusick DR, Harwood H, King E, Bouchery E, et al. (2005). National estimates of expenditures for mental health services and substance abuse treatment, 1991-2001. Publication No. SMA 05-3999. Rockville, MD: Substance Abuse and Mental Health Services Administration.
33. National Association of State Mental Health Program Directors Research Institute. (2005, September). State psychiatric hospitals: 2004. Alexandria, VA: Author.
34. Joint Commission on the Accreditation of Healthcare Organizations. (2005). Setting the standard: The Joint Commission & health care safety and quality. Oakbrook Terrace, IL: Author. Available online at http://www.jcrinc.com/Joint-Commission-Requirements/Behavioral-Health-Care/ .
35. National Association of State Mental Health Program Directors Research Institute. State psychiatric hospitals: 2004.
36. Pear R. (2002, February 25). Governors say states need more federal help to deal with rising costs of Medicaid. New York Times, Sect. A, 16.
37. New York State Division of the Budget. (2005, January). New York State 2005-06 Executive Budget. Albany, NY: Author.
38. Bynum T. (2001). Recidivism of sex offenders. Silver Spring, MD: Center for Sex Offender Management.
39. Hanson, RK, Gordon A, Harris AJR, Marques JK, Murphy W, Quinsey VL et al. (2002). First report of the collaborative outcome data project on the effectiveness of treatment for sex offenders. Sexual Abuse: A Journal of Research and Treatment, 14(2), 169-194.
40. Association for the Treatment of Sexual Abusers. (2005). Facts about adult sexual offenders. Beaverton, OR: Author.
41. Marques JK, Miederanders M, Day DM, Nelson C, & van Ommeren A. (2005). Effects of a relapse prevention program on sexual recidivism: Final results from California's Sex Offender Treatment and Evaluation Project (SOTEP). Sexual Abuse: A Journal of Research & Treatment, 17(1), 79-107.
42. Prentky R, Lee A, Knight R, & Cerce D. (1997). Recidivism rates among child molesters and rapists: A methodological analysis. Law and Human Behavior, 21, 635-659.
43. Association for the Treatment of Sexual Abusers. Facts about sexual offenders.
44. See U.S. Supreme Court Nos. 95-1649 and 95-9075 KANSAS, PETITIONER 95-1649 v. LEROY HENDRICKS LEROY HENDRICKS, PETITIONER 95-9075. June 23, 1997. Available online at http://caselaw.lp.findlaw.com/scripts/getcase.pl?court=US&vol=000&invol=95-1649 .
45. See U.S. Supreme Court No. 00-957 KANSAS v. CRANE. Argued October 30, 2001, and decided January 22, 2002. Online at http://caselaw.lp.findlaw.com/scripts/getcase.pl?court=us&vol=000&invol=00-957 .
46. See the testimony of Chauncey G. Parker, New York State Director of Criminal Justice before the New York City Council Public Safety Committee on November 29, 2005. Available online at http://criminaljustice.state.ny.us/pio/2005-1129testimony.htm
47. See Division of Criminal Justice Services press release of January 5, 2006. Available online at http://criminaljustice.state.ny.us/pio/inthenews.html.

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