(12-18-17) Dr. Elinore McCance-Katz, the Assistant Secretary for Mental Health and Substance Abuse, did an excellent job testifying last week about a new law designed to improve our federal mental health care system.
But in the future, the Senate Health, Education, Labor and Pensions Committee should also consider questioning one of the 14 non-federal members of the Interdepartmental Serious Mental Illness Coordinating Committee (ISMICC) when monitoring the effectiveness of federal programs.
Under the 21st Century Cures Act, Dr. McCance-Katz was put in charge of riding herd on the eight federal agencies that oversee more than an hundred mental health programs. To help her, Congress appointed a blue ribbon committee of federal and non-federal appointees. That means the 14 non-federal members, and I am one of them, on the ISMICC committee also need to be held accountable.
One of our tasks is praising agencies that are doing great work and taking others to task when it appears they are dragging their feet. For instance, the Department of Education didn’t bother to show up last week at the second ISMICC meeting.
That’s inexcusable given how important early intervention is in recovering from a mental disorder.
The ISMICC issued its first report last Thursday to Congress as required by law. But because the Trump Administration took so long to appoint Dr. McCance-Katz, the ISMICC’s federal members announced they would not have time to draft any recommendations. It would be impossible for them to get anything official through their departments’ internal clearance processes in time for our first December deadline.
Consequently, our first report was based solely on what its 14 non-federal members recommended. With the exception of Justice Department designee, Ruby Qazilbash, the associate deputy director at the Bureau of Justice Assistance, none of the other federal members participated in the telephone calls that I was on in preparing our report.
That was disappointing to me, but some of my colleagues assured me that not having the federal members’ input was a good thing. We could tell Congress and the agencies exactly what we believe their priorities should be. (Our list of recommendations is at the bottom of this blog and also online.)
But this also means the federal agencies don’t yet have any skin in the game when it comes to our recommendations. Dr. McCance-Katz and her team at SAMHSA made it clear that they are committed to reforming our mental health care system.
At our second meeting, I also was excited when Ralph H. Gaines, the principal deputy assistant to the Secretary at Housing and Urban Development, spoke enthusiastically about HUD doing its part. The other federal members presented us with lists of programs that involve serious mental illness and fall under their jurisdiction. But few volunteered any additional information. That concerns me.
What recommendations, if any, will be implemented during the next five years will depend on two things: the federal budget (you can’t implement programs without money) and how committed each of these agencies will be to transforming our system.
The budget is out of our hands, but monitoring federal agencies isn’t.
As a member of ISMICC, I will be sending emails discussing our progress or lack of it to Senators John Cornyn (R. Tx.), Lamar Alexander (R-Tn.) Chris Murphy (D.-Conn.) Charles Grassley (R-IA) and Bill Cassidy (R-La.) – all of whom were instrumental in creating our panel – as well as several key House members, such as Reps. Grace Napolitano (D.-Ca.), Eddie Bernice Johnson (D- Tx.), Diana DeGette (D.-Colo.) and Joe Kennedy (D. Mass.)
I also will be suggesting in an email today that they require the Justice Department to have a representative from the federal Bureau of Prisons assigned to ISMICC. The bureau oversees nearly 24,000 prisoners with serious mental illness. It should be setting an example for states when it comes to how it treats those inmates. It should not be releasing 13% of them directly from isolation cells back into the public, as a recent IG report found.
It is up to all of us to insist that ISMICC – both its federal and non-federal members – assist Dr. McCance-Katz and improve our federal system.
Here are the recommendations that we made public last Thursday.
Focus 1: Strengthen Federal Coordination to Improve Care
1.1. Improve ongoing interdepartmental coordination under the guidance of the Assistant Secretary for Mental Health and Substance Use.
1.2. Develop and implement an interdepartmental strategic plan to improve the lives of people with SMI and SED and their families.
1.3. Create a comprehensive inventory of federal activities that affect the provision of services for people with SMI and SED.
1.4. Harmonize and improve policies to support federal coordination.
1.5. Evaluate the federal approach to serving people with SMI and SED.
1.6. Use data to improve quality of care and outcomes.
1.7. Ensure that quality measurement efforts include mental health.
1.8. Improve national linkage of data to improve services.
Focus 2: Access and Engagement: Make It Easier to Get Good Care
2.1. Define and implement a national standard for crisis care.
2.2. Develop a continuum of care that includes adequate psychiatric bed capacity and community‐based alternatives to hospitalization.
2.3. Educate providers, service agencies, people with SMI and SED and their families, and caregivers about the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and other privacy laws, including 42 CFR Part 2, in the context of psychiatric care.
2.4. Reassess civil commitment standards and processes.
2.5. Establish standardized assessments for level of care and monitoring of consumer progress.
2.6. Prioritize early identification and intervention for children, youth, and young adults.
2.7. Use telehealth and other technologies to increase access to care.
2.8. Maximize the capacity of the behavioral health workforce.
2.9. Support family members and caregivers.
2.10. Expect SMI and SED screening to occur in all primary care settings.
Focus 3: Treatment and Recovery: Close the Gap Between What Works and What Is Offered
3.1. Provide a comprehensive continuum of care for people with SMI and SED.
3.2. Make screening and early intervention among children, youth, transition‐age youth, and young adults a national expectation.
3.3. Make coordinated specialty care for first‐episode psychosis available nationwide.
3.4. Make trauma‐informed, whole‐person health care the expectation in all our systems of care for people with SMI and SED.
3.5. Implement effective systems of care for children, youth, and transition‐aged youth throughout the nation.
3.6. Make housing more readily available for people with SMI and SED.
3.7. Advance the national adoption of effective suicide prevention strategies.
3.8. Develop a priority research agenda for SED/SMI prevention, diagnosis, treatment, and recovery services.
3.9. Make integrated services readily available to people with co‐occurring mental illnesses and substance use disorders, including medication‐assisted treatment (MAT) for opioid use disorders.
3.10. Develop national and state capacity to disseminate and support implementation of the national standards for a comprehensive continuum of effective care for people with SMI and SED.
Focus 4: Increase Opportunities for Diversion and Improve Care for People With SMI and SED Involved in the Criminal and Juvenile Justice Systems
4.1. Support interventions to correspond to all stages of justice involvement. Consider all points included in the sequential intercept model.
4.2. Develop an integrated crisis response system to divert people with SMI and SED from the justice system.
4.3. Prepare and train all first responders on how to work with people with SMI and SED.
4.4. Establish and incentivize best practices for competency restoration that use community‐based evaluation and services.
4.5. Develop and sustain therapeutic justice dockets in federal, state, and local courts for any person with SMI or SED who becomes involved in the justice system.
4.6. Require universal screening for mental illnesses, substance use disorders, and other behavioral health needs of every person booked into jail.
4.7. Strictly limit or eliminate the use of solitary confinement, seclusion, restraint, or other forms of restrictive housing for people with SMI and SED.
4.8. Reduce barriers that impede immediate access to treatment and recovery services upon release from correctional facilities.
4.9. Build on efforts under the Mentally Ill Offender Treatment and Crime Reduction Act, the 21st Century Cures Act, and other federal programs to reduce incarceration of people with mental illness and co‐occurring substance use disorders.
Focus 5: Develop Finance Strategies to Increase Availability and Affordability of Care
5.1. Implement population health payment models in federal health benefit programs.
5.2. Adequately fund the full range of services needed by people with SMI and SED.
5.3. Fully enforce parity to ensure that people with SMI and SED receive the mental health and substance abuse services they are entitled to, and that benefits are offered on terms comparable to those for physical illnesses.
5.4. Eliminate financing practices and policies that discriminate against behavioral health care.
5.5. Pay for psychiatric and other behavioral health services at rates equivalent to other health care services.
5.6. Provide reimbursement for outreach and engagement services related to mental health care.
5.7. Fund adequate home‐ and community‐based services for children and youth with SED and adults with SMI. 5.8. Expand the Certified Community Behavioral Health Clinic (CCBHC) program nationwide. Future Work of the
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