2008 Interim Report
Statewide Comprehensive Plan for Mental Health Services
February 15, 2008
New York State
Eliot Spitzer, Governor
Office of Mental Health
Michael F. Hogan, PhD, Commissioner
Office of Mental Health Planning and Transformation Processes
This February 2008 Interim Report of the Statewide Comprehensive Plan for Mental Health Services is intended to provide an update on what has transpired since the Statewide Plan was released on October 1, 2007. The purpose of this chapter is to provide a brief overview of the historical context for mental health responsibilities in New York State, the Office of Mental Health (OMH) planning foundation, the process used to create the October 2007 Plan and other important planning documents, and challenges to transforming the system of care. Chapter 2 provides a synopsis of progress on select major change efforts and an update on their status since the October release of the Plan. Chapter 3 provides highlights of Governor Spitzer’s Executive Budget recommendations for Fiscal Year 2008–2009.
An Historical ContextMental health responsibilities of the state government trace to 1836, when the Legislature authorized construction of the state’s first mental health facility in Utica. In 1873, the Office of the State Commissioner in Lunacy was created and licensure of public and private mental health institutions was required. This was followed in 1926 by the formation of the Department of Mental Hygiene, in 1954 by the creation of the first law in the country establishing local community mental health boards, and in 1977 by the division of the Department of Mental Hygiene into the offices of Mental Health, Mental Retardation and Developmental Disabilities, and Alcoholism and Substance Abuse.1
OMH has long held responsibility for a state/local and public/private safety net for mental health care. Today, while most New Yorkers receive mental health care in private settings from therapists and hospitals–care mostly covered by health insurance–the OMH safety net serves more than 500,000 individuals with the most serious mental illness annually. The mission of OMH, therefore, reflects these broad responsibilities in promoting mental health and particularly in serving adults with serious mental illness and children with serious emotional disturbance.
The Foundation: Mission, Vision and Values
Helping New York’s citizens to live full and productive lives in their communities is the overall goal of OMH. This is accomplished by promoting public mental health through education and awareness and by ensuring that adults and children diagnosed with serious mental illness and serious emotional disorders receive the clinical services and supports necessary to live, learn, work and participate fully in their communities.
OMH’s strategic planning framework is built upon its mission, vision, values and the elements of quality care known as the "ABCD’s" of mental health. Together these provide the foundation for the agency’s person- and family-centered approaches to promoting mental health, preventing mental illness and emotional disorders, providing clinical supports and services to minimize the untoward effects of mental illness, improving our knowledge of and contributing to advances in mental illness care, and enhancing recovery for children, youth and adults diagnosed with mental illness and behavioral disorders. It is upon this framework that OMH develops strategic priorities and specific short- and long-term goals that are aimed at producing the best mental health outcomes for New York’s citizens.
The Planning Process and Progress since October 2007
OMH relies upon a broad-based, inclusive and transparent approach to planning. Planning is the product of a series of processes used to assess priorities and gather information from multiple sources, ranging from individuals and local communities to data sources, advisory groups and policy-making briefs and bodies. Below are updates to major planning initiatives under way within OMH.
Statewide Comprehensive Plan for Mental Health Services
OMH produces a Comprehensive Plan annually. This process begins with guidance from the Mental Health Services Council on statewide goals and objectives. The counties and New York City each conduct local planning processes that include persons receiving services, families, providers, advocates, and other stakeholders in the development of local service plans consistent with the agency’s statement of goals and objectives. OMH then develops a Statewide Comprehensive Plan for Mental Health Services based on the review of submissions from advisory groups, the local plans from the counties and New York City, other stakeholders, and OMH Field Offices. The latest Comprehensive Plan was released on October 1, 2007, and is available at http://www.omh.state.ny.us/omhweb/Statewideplan/childrens_mental_health_act/oct2007_update.html.
The Inter-Office Coordinating Council (IOCC)
The IOCC was established to ensure that state policy for the prevention, care, treatment and rehabilitation of mental illness, developmental disabilities and addiction is planned, developed and implemented comprehensively and that gaps in services for individuals with more than one disability are eliminated. The IOCC also fosters the coordination of research projects to maximize their success and cost-effectiveness. Most recently, under Governor Spitzer’s direction the IOCC, which had long been dormant, was reinvigorated. An IOCC 2007 Report of Activities was released in December and is available at http://www.oasas.state.ny.us/pio/collaborate/IOCC/documents/IOCC2007Report.pdf (PDF).
As part of an effort to address concerns and recommendations from the "People First Coordinated Care Listening Forums" (People First Forums), the IOCC convened Friday, January 18, 2008, to continue working toward resolution of many of the interagency issues raised during the Forums. Members of the IOCC in attendance were the Commissioners of OMH, OASAS, and OMRDD. Ad hoc members to the Committee are the Commissioners of Health, Education and Children and Family Services. Meetings will be held regularly and will support the Governor’s agenda to place people at the center of health care. The January meeting of the IOCC may be viewed online at http://www.omh.state.ny.us/omhweb/webcasts/archived.html. More about strengthened relationships between the agencies appears below.
Children’s Mental Health Plan
The Children’s Mental Health Act (CMHA) of 2006 charged OMH with producing a preliminary Children’s Mental Health Plan by October 1, 2007, that would lead to the development of a final plan for a "comprehensive, coordinated children’s mental health system" by October 1, 2008. The CMHA calls for the development of a plan that offers services in a culturally and linguistically competent manner, is collaborative and comprehensive, and guides the future development of the public mental health system for children and their families. Changes that involve early intervention, family-focused and family-driven solutions, and community-wide solutions call for clear planning and strong leadership, which this effort is intended to provide.
OMH issued the Preliminary Children’s Mental Plan on October 1, 2007. The document is available at http://www.omh.state.ny.us/omhweb/Statewideplan/childrens_mental_health_act/childrens_mental_health_plan.html. The effort to produce the final plan is participative in nature and under way, with leadership being provided by the Planning and Children’s Services divisions of OMH, in affiliation with the Children’s Sub-Committee of the Mental Health Planning Advisory Council. Four multi-stakeholder workgroups are actively engaged in conducting environmental scans of areas defined under the Children’s Mental Health Act (e.g., social emotional learning, evidence-based practices and family engagement, workforce issues, integrated care). A time line has been established that calls for draft recommendations from workgroups in early April so they may be reviewed publicly and ultimately incorporated into the final plan, which is due October 1, 2008. The goal is to have a set of recommendations that will maintain the momentum established by the successful Achieving the Promise initiative and guide the continued strengthening of mental health services and supports for children and their families.
The Challenges to Transforming Care
Efforts to achieve our strategic goal to increase the quality of life for individuals with mental illness are constantly challenged by the realities of the impact of mental illness on everyday life, the fragmented nature of the mental health system of care, a lack of adequate health insurance, and difficulties related to the financing of care. These challenges also exist in many other states. Such realities include the following:
The effects of mental illness are felt broadly.
- In the United States, mental illness is very prevalent, affecting 50 percent of the population over their lifetime and 20–25 percent of the population annually. Mental illness manifests in degrees of ill health and impairment. Between adults and children, about 1 in 10 Americans annually experiences a mental illness serious enough to affect functioning. About 2–3 percent of adults and 5 percent of children have a mental illness that is severe enough to cause major disability.
- Mental illness is usually untreated; of the 1 in 5 Americans who experience a mental illness, less than half receive care. As a result, mental illness is the leading illness-related cause of disability, a major cause of death through suicide, and a driver of school failure, poor overall health, incarceration and homelessness.
- The most recent and comprehensive research concludes that the average age of onset of a mental illness is 14, while the average delay from first symptoms to receiving care is 9 years. The delays are due to a failure to recognize symptoms, the stigma of seeking care, challenges in finding it, a fragmented system and the lack of insurance coverage. These problems result in mental illness having a major impact in many sectors. In business, for example, depression alone causes annual productivity losses of more than $40 billion. The effects of these problems are felt in other systems of care as well, including education, children and family services, corrections, developmental disabilities and more.
New York faces the challenges of an exceptionally decentralized and fragmented approach to care.
- There are major state responsibilities in OMH and in the Department of Health, county responsibilities in more than 50 local governmental units, and mental health care delivered by more than 2,500 licensed private agencies. OMH operates the nation’s largest network of state-operated facilities, functioning as a kind of "safety net within a safety net" for adults and children with the most serious conditions.
- Many persons with mental illness are seen general medical sector, where mental health problems are poorly recognized and often under-treated.
- Unlike other sectors of health care, where there is a single multiply financed care system, in mental health the patients with the most serious mental illness are cared for in a state/county system that is financed, regulated and partially operated by OMH.
People with a mental illness and indeed the OMH system depend largely on mainstream benefits and programs that create limitations on transforming the system of care.
- Medicaid has become the nation’s largest payer for mental health care. Created originally without any mental health benefits, Medicaid added coverage for mental health treatment and in response New York turned to Medicaid as an important mechanism for financing care. Unfortunately, the fit has been an uneasy one because many persons dependent on the OMH network are not Medicaid eligible and because numerous essential services such as employment and housing are not covered by Medicaid.
New York and the nation face a crisis in affordable housing.
- Many factors contribute to a shortage of affordable housing, including a lack of federal leadership in assuming a low-income housing development role and distress in the housing finance marketplace. With the highest proportion of renter-occupied housing among the states, very high housing prices and large numbers of poor people with a disability, New York State–especially in the metropolitan New York City area and on Long Island–has perhaps the most significant mental health housing need in the country.
Schools face serious challenges among students whose mental disorders create learning and behavior problems.
- Between 5 and 9 percent of children have a mental illness that significantly impacts behavior, but only 1 percent of students receives special education services for "emotional disturbance." Sadly, these children have some of the worst outcomes among children in special education.
Unemployment is unacceptably high for most individuals with a mental illness.
- Although most would like to work, 85 percent of adults receiving mental health care in New York are unemployed. Reliance on Medicaid has contributed to a shortage of mental health employment services. People with mental health conditions are the largest disability group entering vocational rehabilitation, but have the worst outcomes. Mainstream employment services often do not have the expertise to assist the persons they serve who have mental illness.
Law enforcement, courts and corrections agencies are struggling to deal with offenders who have mental illness.
- Periodic reports of police difficulties in dealing with persons who have mental illness illustrate these challenges. In New York’s adult prison system, the population receiving mental health care has almost doubled to approximately 8,400 prisoners in the past 17 years. In the last several years the number of inmates has declined while the number with a serious mental illness has increased by 17 percent. In the juvenile system, research establishes the prevalence of mental illness at about 66 percent.
The effectiveness of the OMH network has been complicated through over-reliance on Medicaid financing.
- The over-reliance has contributed to gaps in care and has had unintentional effects on priorities. The budgetary, human resources, purchasing and other operating systems within New York State government are complicated, redundant, centralized and slow to change, making it very difficult to transform care.
New York is overly reliant on expensive inpatient mental health care.
- Despite this, providers and families indicate that access to inpatient care is poor. Lengths of stay are excessive because of service gaps and poor continuity of care. Responsibility for care is fragmented and New York has a history of reform proposals being defeated prior to implementation.
A lack of coordinated care and policies between agencies has reinforced barriers to care.
- In the People First Forums conducted by Governor Spitzer’s health and mental hygiene commissioners last spring, many of those who attended agreed that access to care is more difficult when one has multiple needs and requires more assistance.
The scope of mental health problems extends far beyond the OMH-managed system. In mainstream settings–doctor’s offices, early education centers, employment programs–where mental disorders could be better addressed, greater awareness and capacity are needed to deal with the challenges of mental illness. These problems are the most serious in communities where the needs and problems are the greatest, especially in central cities and in rural areas. When people do not get early assistance, often problems worsen and the overburdened mental health safety net must try to respond.
While actively engaged in a transformation process, OMH recognizes that it has fallen short in previous years in its collaborative approach with major shareholders: children, adults and families served in the system of care, providers, advocates, and local government. In some cases, as with OMH and the Department of Correctional Services, partnerships had begun prior to the start of the Administration. In several cases, however, necessary working relationships had eroded. This erosion in collaboration and communication was a core concern articulated by persons served in New York’s systems of care, families and professionals during last year’s People First Forums.
In response, OMH is engaged in several intense and productive new partnerships with other state agencies. An important aim is to improve services to individuals with the respective "dual diagnoses."
Collaboration between OMH and OMRDD
In the case of individuals with both a developmental disability and mental illness, the numbers affected are relatively small, but the impact can be catastrophic. Problems in accessing care for this relatively small but high-need population were emphasized in all of the People First Forums.
Commissioner Hogan and OMRDD Commissioner Diana Jones Ritter have worked with their senior staff to articulate a simple new philosophy of collaboration–albeit one that will require much hard work. The preference is for services and solutions that will support people in their communities rather than in institutions. And the assumption is that in most cases both service systems will have something to offer. The Commissioners have conducted a statewide videoconference with the leadership staff in both agencies, discussed the approach with county directors, and prepared modest budget proposals to enhance collaborative solutions.
Collaboration between OMH and OASAS
In the case of people with co-occurring mental illness and chemical dependency, Commissioner Hogan and OASAS Commissioner Karen Carpenter-Palumbo convened a task force to recommend improvements, accepted the recommendations of the group (see the report at http://www.omh.state.ny.us/omhweb/News/COD_TASK_FORCE_REPORT_FOR_RELEASE.html), appointed action teams to develop and implement specific recommendations–including enhancing clinical practices, removing regulatory barriers, and improving financing–and are jointly meeting with staff every six weeks to monitor and support progress. Given that one-third to one-half of individuals with mental illness or addictions experience both disorders, this collaboration has been hailed by advocates who foresee access to better integrated care.
Collaboration between OMH and DOH
Commissioner Hogan and Commissioner Richard Daines are working on addressing issues such as barriers to accessing care that substantially impact a number of New Yorkers. Problems also include an outdated and inequitable payment system that stands in the way of expanded care, and creates inadequate reimbursement levels for basic treatment as well as regulatory barriers and inconsistencies between and among state agencies.
OMH and DOH staff members are striving to simplify, streamline and improve both regulation and reimbursement. The goal is to improve access to primary health care for persons with mental illness and to mental health care for people who rely on health clinics. In addition, OMH and DOH staff members are focusing on consistent regulatory approaches that minimize burden while protecting patients.
Collaborations to address housing needs
In response to the overwhelming challenges faced by individuals with mental illness to find and keep housing, as noted above and in Chapter 2, the new collaborations among OMH, the Housing Finance Agency, the Division of Housing and Community Renewal and the Office of Temporary and Disability Assistance are essential. These collaborations include pooled financing of projects, increased collaboration, and priority to special needs supportive housing. This teamwork will yield dozens of housing projects and hundreds of units of housing within the next few years.
Under the leadership of Governor Spitzer, mental health care in New York has continued to shift toward a patient-first system that focuses on primary and preventive care. Overall, the state continues to be engaged in a restructuring of its health care system, with emphasis on quality, access, and control of Medicaid costs. The challenges outlined in this chapter underscore the importance of understanding that the process of change is complex, requiring multi-year efforts and continued action. Chapter 2 provides an overview of select change efforts and progress toward transformation of the mental health system of care.
Progress on Select Change Efforts
Chapter 2 provides a synopsis of progress on select change efforts and an update on their progress since the October release of the Comprehensive Plan. Specifically, this chapter reviews highlights of five examples of such efforts aimed at promoting transformation. The areas, which cut across strategic priorities embraced by OMH and its stakeholders, include: assessment of clinical mental health care in New York State, implementation of the Centers of Excellence in Culturally and Linguistically Competent Mental Health, the Wellness Self-Management initiative, a redesign of housing options for persons with serious mental illness, and a revitalization of the Adult Psychiatric Centers. Common to each of these areas and other initiatives under way is the development of working relationships that are helping to fundamentally shift important priorities and processes while working on many fronts at once.
Assessing Clinical Mental Health Care in New York State
In May 2007, OMH engaged in an assessment of clinical mental health care opportunities and challenges faced by New York State, by conducting an assessment in four major areas: clinical quality, workforce, science to practice, and collaborations with local government units. A report of the review was released in October 2007. (To read the report, see http://www.omh.state.ny.us/omhweb/statistics/clinical_care_assessment/assessment_clinical_mh.pdf.)
OMH approached its task relying upon a set of core values embraced by OMH and its related agencies and programs, including transparency, person-centered services and supports, appreciation for individual differences, and prudent use of public funds. Importantly, the report also recognizes that policy directives from OMH in themselves do not create the changes needed to produce positive outcomes for the individuals and families served by the mental health system. Rather, the report points to the importance of guiding the development of a mental health system that benefits from the leadership of people at all levels and is guided by a shared vision of recovery-focused, person- and family-centered care.
The recommendations were informed by dialogues with a broad sample of programs and organizations within and outside of OMH and they show remarkable consistency with respect to identified needs, challenges and opportunities. The recommendations–which cover the four areas assessed: quality of clinical treatment and services, workforce recruitment and retention challenges, promotion of research and science to improve treatment and care, and local government collaborations–include the following.
- Transparent and measurable indicators of clinical care should be used as a basis for quality improvement and for accountability.
- Quality care is not possible unless persons served by the mental health system and their families are engaged as partners; this is not possible without cultural sensitivity and competence.
- OMH’s Psychiatric Centers can be much more vigorous in providing and leading quality care. Recovery and resiliency are not just achieved through clinical treatment but require better integrated care management, improved care for people in crisis, and expanded housing opportunities.
- People with multiple needs are often poorly served. We need increased collaboration across state and county agencies and among providers to better meet the needs of those with co-occurring disorders, and an urgent focus on health and mental health.
- To provide quality care, the workforce must be strengthened. Concrete and substantial efforts to improve professional recruitment and retention (e.g., psychiatrists, psychiatric nurses) are urgently needed.
- Contributions of the OMH research institutes must continue to be strengthened, especially regarding applied research and diffusion of knowledge.
- OMH must partner with the counties, including New York City, in planning and implementing local service initiatives.
Since release of the report, it has been amended to take into account the specific needs of the aging population and minorities and to offer recommendations to improve clinical care in these two areas. Currently, OMH is using the report to guide clinical policy with its staff, facilities and institutes, with constituents and community colleagues, and with sister government agencies at the county and state levels. Thus, the final report and recommendations are serving to maintain a focus on achieving improvements in the quality and accessibility of care for New Yorkers served by the mental health system.
Promoting Excellence in Culturally and Linguistically Competent Mental Health Care
OMH established two complementary Centers of Excellence in Culturally and Linguistically Competent Mental Health in 2007. The purpose of each Center–one at the New York State Psychiatric Institute (NYSPI) and the other at the Nathan Kline Institute (NKI) for Psychiatric Research–is to investigate and disseminate best practices for the delivery of culturally and linguistically competent mental health services to diverse populations in New York State. While the two Centers are working together to increase the rigor and usefulness of their results, they are each making unique scientific contributions to promoting culturally and linguistically competent care.
NYSPI is involved in clinical investigations of community networks designed to improve engagement and linkages for persons from minority cultures who have mental health problems. The goal is to use the results to replicate networking in other minority communities of the state. Most recently, NYSPI researchers have been active in the Washington Heights and Harlem neighborhoods of New York City and have started to build these comprehensive community networks. Specifically, an overall goal of the investigation is to link primary care, mental health care and other community resources to improve health outcomes through the identification of essential components of culturally and linguistically competent clinical care.
Of late, NKI has been concentrating on adapting and studying evidence-based practices for minority cultures and disseminating those practices found to be effective. Researchers have identified four sites for examining established evidence-based practices and the clinical modifications necessary to accommodate the needs of various cultural groups. The researchers are also developing tools that will permit providers to better understand the cultural groups they serve and adapt their approaches to form a "better fit." This work will be enhanced by NKI’s inclusion of disparities elimination into current research and its commitment to develop and test cultural competence training materials and instruments.
In all, both research institutes are working together through collaboration with the OMH Multicultural Advisory Committee and enhancing their efforts by sharing consultants, tools and processes along the way.
Promoting Wellness Self-Management
OMH has been engaged over the past year with providers from around the state who share a commitment to implement and sustain wellness self-management (WSM) services for adults with serious mental health problems. The intent has been to foster fundamental change in the recovery-oriented culture of mental health organizations. This transformation is critically important in light of recent research findings showing that on average persons with serious mental illness lose about 25 years from the average life span. It is also important because of the surge nationally and in New York State of co-morbid conditions such as diabetes, heart disease, obesity, and chronic lung disease.
The current WSM initiative grows out of the agency’s experience with the national evidence-based Illness Management and Recovery (IMR) program, which is premised on two important principles for aiding people with serious mental illness to lead satisfying, functional lives:
- Services should help people to understand that recovery from mental illness is possible; should suggest multiple strategies that permit people to experiment with and to learn what helps them to manage their symptoms; and should foster each person’s ability to attain life goals and develop positive social roles.
- People who receive services and their families should have access to information about serious mental illness and what effective treatments and supports are available.
The WSM curriculum being used in New York builds upon the national IMR model and consists of a number of research-informed approaches to recovery, mental health wellness and relapse prevention. The curriculum was pilot tested in New York City among nine member agencies of the Urban Institute for Behavioral Health. Part of the project required member agencies to meet monthly as part of a learning collaborative approach. The learning collaborative was designed to enable agencies to share information, brainstorm strategies and provide constructive criticism about the WSM program. The persons served under the pilot project, practitioners and administrators found the curriculum, informational materials, training approach, and methods employed to sustain WSM services to be practical, energizing and meaningful.
The WSM curriculum is also being tailored to begin addressing, as noted above, the connection between physical health and mental well-being. This enhancement is being added to lessen the dramatic health crisis among people with serious mental health problems.
OMH continues to be engaged in expanding wellness self-management through the establishment of statewide WSM Learning Collaboratives. Most recently, OMH held regional forums to introduce the initiative and invite participation by providers. This was followed by the identification and selection of agencies desiring to implement WSM services and to establish the infrastructure to sustain WSM services, including the creation of multi-stakeholder quality improvement teams to provide leadership; participation in Learning Collaborative quality improvement activities such as training and information sharing; provision of supervision and ongoing staff development; and engagement in the development of performance indicators for use in evaluating and tracking the progress of the program implementation.
Transforming Housing and Residential Care
New York State has the nation’s most extensive mental health housing programs, with 39,000 units or housing opportunities in place or under development. These programs, many developed through the "New York/New York" partnerships between the City and State, have become national models for supportive housing and urban redevelopment. Realistically, however, the overall approach has fallen short. Erosion in the affordable housing marketplace means that housing needs are growing faster than OMH capacity. Shifting perceptions about risk and liability–for example, intense media coverage of rare incidents of violence by people with mental illness–have led to a belief that all levels of care require heightened staffing and security. New York’s success in developing an extensive "continuum of options" has also had its downside. Many staff and advocates have come to believe that persons with serious mental illness must move through many levels of care to independent living. This has continued to pose challenges because moving for persons with psychiatric disabilities may be especially stressful and can contribute to new problems and re-hospitalization.
With these issues in mind, OMH has launched a broad and multi-year reform of its approach to mental health housing. In the spring of 2007 OMH released a set of guiding principles to facilitate the redesign of mental health housing and community supports. The principles (see http://www.omh.state.ny.us/omhweb/News/housing_policy.html) make clear OMH’s commitment to safe, decent and affordable housing for persons with serious mental illness. They also recognize that housing–a cornerstone of recovery–is a fundamental problem for many people with mental illness because they often live in poverty, face a limited supply of very low income housing and rising rental market costs, and confront discrimination due to stigma. Thus, the principles put forth by OMH are based on the need to expand access to low income housing in general, provide flexible supports that are not conditional on housing itself, increase "supported housing" developed especially for people with serious mental illness, break down resistance to mental illness and address stigma at the community level, and seek opportunities to help people with serious mental illness to recover and have safe and affordable housing in their communities
Since the release of these principles and review of them with stakeholders of the public mental health system, OMH has reached out formally to its funded and licensed housing providers and to county mental hygiene directors, inviting submissions of specific ideas about how programs might be reorganized. The goal has been to foster closer alignment between the housing redesign principles and provider practices. Providers were invited to consider strategies to strengthen the connection between the principles and daily operations and to think creatively about solutions, such as having more flexibility in regulations, licensing, contracting and budgeting. Among agencies providing a range of mental health services beyond housing, OMH welcomed suggestions for integrating housing support services with other services such as clinic, case management, crisis stabilization, and clubhouse services, thereby fostering the separation of housing from supports and increasing accountability for treatment and recovery outcomes.
Recently, providers were invited to discuss ideas with their county mental hygiene directors and develop strategies for reconfiguring housing and related supports within their local systems of care. They were encouraged to seek input from stakeholders, including the residents served by OMH-funded housing and their families. Specific proposals are now being received. OMH continues to examine its current housing and support services policies and is working closely with providers and localities to tailor housing resources so they are consistent with the housing redesign principles. OMH is also working collaboratively with other state agencies–the Housing Finance Agency, the Division of Housing and Community Renewal and the Office of Temporary and Disability Assistance–to reform the agency’s approach to mental health housing. This multi-agency approach stems in part from the Governor’s proposed Housing Opportunity Fund and will enable housing production to be increased faster than it could be by OMH alone. Moreover, this approach is being enhanced by the provider community, which is offering innovative models, helping to identify challenges in need of attention, and collaborating in a process of change.
Revitalizing OMH Adult Psychiatric Centers
Mirroring national trends, access to and the availability of inpatient mental health care in New York State has declined. Currently, OMH operates 16 adult, 6 children’s and 3 forensics facilities, with a total of about 5,500 beds for inpatient care and extensive outpatient services in communities across New York and in the prison system.
The forensics and children’s systems are generally "doing the right thing right," with a focus on high acuity, and in many cases, relatively short- or intermediate-stay inpatient care backed up by community treatment and support. The adult system, however, which includes approximately 4,000 beds and an excellent network of intensive community care, has become largely inaccessible. In 2005, for example, the adult system accepted only 3,700 admissions.
To meet community needs for adult inpatient care, the Adult Psychiatric Centers are preparing to gradually move toward more accessible, shorter-stay treatment and expanded provision of intensive community services, utilizing almost constant resource levels. The process will be instituted thoughtfully and carefully, by finding or creating more appropriate settings for long-stay patients who need intensive, but not hospital care, and whose disabilities are in part the result of lengthy hospitalization. The approach is complex and sensitive and requires great care in making each discharge decision. Moreover, such transformation will require skill, time, patience, accountability, and support from control agencies.
In meeting its mission, OMH will continue to give attention to the nature and scope of mental illness, the historical and statutory framework for mental health care in the state, and the essential elements of change. These will continue, in part, to provide a basis for tackling the challenges before us, developing shared solutions, and ensuring quality mental health services and supports for New Yorkers. Priorities and initiatives used to address them will continue to be approached collaboratively and with an eye toward transformation. Chapter 3 describes specific budgetary considerations and recommendations since the October 2007 Statewide Comprehensive Plan was published.
Highlights of the 2008–2009 Executive Budget
This chapter addresses modifications to the plan of services as a result of Governor Spitzer’s Executive Budget Recommendations. These actions were informed by broad stakeholder input reflected in the Statewide Comprehensive Plan, testimony presented to the Division of Budget and Legislature by Commissioner Hogan on October 25, 2007 (see http://www.budget.state.ny.us/pubs/press/2007/publicHearings/OMH.pdf PDF), and by his testimony on Executive Budget Recommendations for 2008–2009 given January 29, 2008 (see http://www.omh.state.ny.us/omhweb/budget/2008-2009/testimony.html). Specifically, the chapter presents background information on the development of the budget in the form of excerpts from Commissioner Hogan’s testimony and provides a brief description of major proposals in the 2008–2009 Executive Budget presented by Governor Spitzer January 22, 2008 (see http://www.budget.state.ny.us/pubs/archive/fy0809archive/eBudget0809/agencyPresentations/appropData/mentalHealthOfficeof.html ).
The Context for Budgetary Decision Making
Within the context of the realities faced by OMH and the current challenges faced by the system of care, the 2008–2009 Executive Budget for OMH takes into account three essential elements: budgetary and fiscal constraints under which OMH is operating, the core mission of OMH, and a strategic analysis of the agency’s current environment. It does so by addressing three imperatives:
- Serving as stewards of mental health care in New York and efficiently sustaining the state operations that serve as the ultimate mental health safety net, as well as the community services operated by local governments, nonprofits and hospitals around New York. Together this system serves almost 600,000 adults, adolescents and children annually, and about 12,000 inpatients served in state and voluntary operated hospitals on any day. Mental illness care is not discretionary and New York State has a fundamental obligation to sustain the safety net.
- Strategically addressing the challenges faced by the public mental health system in a fashion that fundamentally transforms New York’s approach to mental health care. We face problems–some of them longstanding and some emergent–that require action. The need for mental health care is not reduced during economic downturns; if anything needs increase.
- Being mindful of the difficult fiscal environment by offering proposals that constrain growth wherever possible, but take into account realities faced. Over the past 15 years, budget patterns for OMH have emphasized cost shifting and short-term savings while unintentionally reducing capacity, innovation and accountability.
With the exception of several areas (e.g., children’s services, suicide prevention, and housing), past mental health policy in New York, for the most part, has been reactive. Mental health responsibilities in the state have been refinanced onto Medicaid in a fashion that has increased the federal share of costs while increasing fragmentation and decreasing productivity and efficiency. State psychiatric centers have emphasized long-term hospitalization, a practice abandoned by most other states. Fears of community incidents involving discharged patients have led to the criminalization of mental health care and motivated a policy of minimal discharges rather than proactive risk assessment and management. The transfer of care responsibilities to nonprofits and local governments has reduced state labor costs but led to a workforce crisis. An over-regulated environment within state government has reduced operating flexibility in hospitals. Coupled with excessive and artificial personnel controls, overtime payments have become excessive.
Investments in recent budgets, nonetheless, have begun to address these basic challenges in fundamental ways, for example, with the Achieving the Promise initiative for children and families. To sustain the momentum of reform while controlling new spending, OMH has approached budget making relying upon two fundamental strategies:
- Stabilizing and sustaining core elements of New York’s mental health system (housing programs, community-based providers, outpatient clinic care, state psychiatric centers) to achieve greater productivity and efficiency. This approach is more sound than an emphasis on cost-shifting and refinancing that erodes capacity.
- Initiating major policy shifts with modest investments that can begin to launch sustained change. For example, in many areas, New York has responded to crises or apparent opportunities such as the availability of federal funds via "high-end" solutions that may have been helpful in the short term but did not solve the underlying problems. Thus, prison mental health care is greatly improved but the rate of inmates entering prison with mental illness continues to increase. Day treatment programs provide expensive (albeit federally subsidized) care for adults while the unemployment rate among adults in care is 85 percent.
Sustaining essential operations in this environment–and providing a platform for more efficient and effective management–requires resource predictability, sound strategies and strong leadership. Moreover, it requires responsiveness to priorities identified through the statutorily required multi-stakeholder "5.07 planning process" by the Conference of Local Mental Hygiene Directors, the counties and New York City. Substantive stakeholder input into the development of this year’s priorities can be found among the appendices of the 2006 Plan and the 2007 Update at the following addresses: http://www.omh.state.ny.us/omhweb/Statewideplan/2006/interim_report/update/ and http://www.omh.state.ny.us/omhweb/Statewideplan/childrens_mental_health_act/oct2007_update.html. In particular, the October 2007 Update to the Plan contains a compilation of stakeholder feedback obtained through the People First Forums and the OMH public hearings, which took place during the summer; it also contains a copy of the interagency report on the People First Forums. Finally, actual testimony from the OMH public hearings can be viewed online at http://www.omh.state.ny.us/omhweb/Statewideplan/2006/testimony/507/.
Highlights of the 2008–2009 Executive Budget Recommendation
The 2008–2009 Executive Budget Recommendation for OMH are directly responsive to the environmental challenges articulated in Chapter 1 by addressing the systemic problems of difficulty in accessing services and service fragmentation. This Recommendation takes into account the complex, challenging environment in which the mental health system of care is now operating, and thus maintains an array of services and supports to citizens of the state while recognizing the need for additional focused services and systemic changes to assure a high level of quality, improved access to services, and decreased fragmentation. What follows is a description of each strategic priority and the funding–new or annualized–proposed to support it. More detailed information can be found in a series of fact sheets produced by OMH and available online at http://www.omh.state.ny.us/omhweb/budget/2008-2009/.
Sustaining and expanding the adult mental health ambulatory care system
Efforts to improve access and decrease fragmentation have been attempted many times in previous budgets. While some of these have met with limited success, real change cannot be achieved without addressing the inequities resulting from decades old funding mechanisms. The Executive Budget Recommendation takes steps to address these disparities in funding.
- New funding
- Implementing the first steps in a multi-year plan to rationalize funding to mental health clinics to ensure accessibility to services
- Expanding access to employment services by adding targeted new funding to Personalized Recovery Oriented Services (PROS) programs
Improving access to and decreasing fragmentation in the children’s community mental health system
Through a number of initiatives, such as the proposed expansion of the New York State Children’s Health Insurance Program (SCHIP) and the Governor’s Children’s Cabinet, Governor Spitzer has shown his commitment to the health and well-being of New York’s children. The Achieving the Promise initiative for children and families speaks to this commitment through a highly integrated series of initiatives to improve outreach efforts, recognize emotional disturbance in children at earlier stages, improve treatment protocols, and increase access to services. The Executive Budget Recommendation further enhances children’s services through the following:
- New funding
- Adding Family Support Services to the portfolio of covered services under the Child and Family Clinic Plus program. These services emphasize family control and self-determination and serve as an operational framework for treatment that is family-driven
- Removing barriers to specialty mental health services for children by allowing for the designation of more clinics that serve children enrolled in Medicaid managed care
- Expanding the Children’s Rural Telepsychiatry initiative by adding 10 more counties where child psychiatrists may not be available
- Annualized funding
- Continuing the Achieving the Promise initiative, which includes prior-year commitments to Child and Family Clinic Plus, Rural Telepsychiatry, Home and Community-Based Service (HCBS) waiver slots, and the Evidence-based Treatment Dissemination Center
- Expanding HCBS waiver slots for children by 180 as originally authorized in 2007–2008, bringing total slots to 1,620
Improving access and decreasing fragmentation for high need and high cost populations
Research shows better outcomes and reduced costs by addressing the needs of individuals who have more than one illness or disability at the same time. In collaboration with the Department of Health (DOH), the Office of Alcoholism and Substance Abuse Services (OASAS) and the Office of Mental Retardation and Developmental Disabilities (OMRDD), OMH is taking steps toward implementing better communication and collaboration strategies to meet the needs of the many individuals that are served by multiple service systems. OMH also continues its work with the Department of Correctional Services (DOCS) to improve mental health services provided in prisons.
- New funding
- Collaborating with OASAS and DOH in demonstration programs to address the treatment needs of persons with co-occurring psychiatric disabilities and addiction treatment needs
- Collaborating with DOH to implement two demonstrations of effective integration of health and mental health services–one located in Western New York and the second located in New York City
- Consistent with recent statutory changes, augmenting treatment services for prison inmates with mental illness who are currently housed in special housing units. These resources will provide service enhancements in the areas of clinical assessment, evaluation and training.
- Annualized funding
- Continuing prior-year funding for the Geriatric Mental Health Services initiative
- Continuing to work with DOCS to enhance mental health services to prison inmates with mental illness
Improving access to housing
The Governor’s Budget Recommendation recognizes that persons with mental illness need stable housing in the community. The Budget includes the creation of additional housing opportunities that, when completed, will result in nearly 41,000 community slots, including slots funded through New York/New York III. The Executive Budget Recommendation also advances Article VII language to allow for the development of housing that is more integrated into community settings by providing flexibility for agencies licensed by OMH to participate in integrated housing projects that will include access for individuals with mental illness. Proposals include the following:
- New funding
- Expanding Supported Housing slots by 1,500
- Providing capital funding to develop 500 integrated Single-Room Occupancy (SRO) units of housing
- Providing capital to purchase adult homes for conversion into OMH housing, in partnership with DOH and the Commission on Quality of Care and Advocacy for Persons with Disabilities
- Annualized funding
- Continuing the development of prior-year commitments for community housing for children and adults, including 1,000 Supported Housing units and 1,000 congregate care units originally funded in 2007–2008
Enhancing the ability to recruit and retain a qualified workforce to ensure the delivery of quality care
Quality services, in both institutional and community settings, are the foundation of a well-organized system of mental health care. To maintain quality, the Executive Budget Recommendation includes the following initiatives:
- New funding
- Implementing the final year of the current three-year cost-of-living adjustment (COLA) for certain locally operated mental health programs
- Extending the COLA commitment for another three years through 2011–2012
- Implementing the second year of a three-year commitment to increasing funding to Community Residence and Family-Based Treatment programs
- Enhancing reimbursement to Family Care providers
- Targeting salary enhancements to allow the state to offer more competitive salaries for certain clinical positions
Promoting public mental health
Although OMH places a particular focus on the needs of persons with serious mental illness, public outreach is an integral part of the agency’s mission. Outreach and education are necessary to provide the public with the knowledge it needs to maintain good mental health. The Executive Recommendation addresses these needs through the following:
- New funding
- Providing funding needed to support the implementation of the New York State Workplace Violence Prevention Law
- Annualized funding
- Continuing efforts to implement the New York State Suicide Prevention Plan aimed at increasing public awareness and promoting prevention
Enhancing mental health research to advance prevention, treatment, and recovery
Research is essential for the identification of interventions that are proven to be effective and can be incorporated into mainstream practice. The Executive Budget Recommendation includes the following enhancements to OMH’s research program:
- Annualized funding
- Continuing support for 25 research scientists at the New York State Psychiatric Institute and the Nathan Kline Institute initially authorized in 2007–2008
- Annualizing funding for the Centers of Excellence to promote the development of best practices in the delivery of culturally and linguistically competent mental health services
Reforming Medicaid rate structures to rationalize provider reimbursement
The Governor’s health care reforms seek to increase access to quality and ambulatory care while reducing reliance on more costly inpatient and emergency care. In keeping with these goals, OMH is partnering with DOH in a multi-year plan to improve access and eliminate inequities that have long plagued mental health clinic care. Funding mechanisms are being considered, including changes in Article VII bill language, to eliminate barriers to services, reduce over-reliance on inpatient care, and improve the consistency in financing among providers.
- Article VII legislation
- Advancing Article VII legislation (in the DOH Budget) to update Article 28 hospital rates (phased on a multi-year basis) for inpatient psychiatric care and transition to a new case-mix adjusted payment methodology
- Advancing Article VII legislation (in the DOH Budget) to remove reimbursement inequities by eliminating specialty rates for Article 28 dually licensed mental health outpatient programs
These Budget Recommendations have been designed to address challenges faced in sustaining and improving mental health care: the realities of serious mental illness, the complex and fragmented nature of New York’s mental health system, problems in financing care, and the scope of mental health problems that extend far beyond the system of care coordinated by OMH. In developing the Budget and its related strategies and initiatives, OMH has been mindful that one of the greatest challenges to transforming the system of mental health care is in communicating realistic hope–which itself serves as the engine of change–to people and organizations at every level.
- In 1992, the Division of Alcoholism and Alcohol Abuse and the Division of Substance Abuse Services were consolidated into the Office of Alcoholism and Substance Abuse Services (OASAS).
Comments or questions about the information on this page can be directed to the Office of Planning.