Maricopa's Mental Health Freedom Trails

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Stops on The System Trail

This journey to better understand the relationships between key people, organizations and policies that make up our current mental health system has led me on a curious path. To this end I search and speak to key players, stakeholders and policymakers related to the topic of mental healthcare in Maricopa County. Every interview, phone call, literature search and discussion reveals a new perspective depending on which sector of the system the person comes from. I am discovering that when it comes to our current system, people that have been “in the game” for a long time have a deeper view of “the way we used to run things in the city” vs how we run the system today.

My work of better understanding the system has led to a logical starting point of developing a network system, or process map. It seems like a no brainer that before implementing an intervention in a system as large and complex as Maricopa County’s mental health system, that a first step would be to examine the current process flow. When I realized that this overall system mapping work has not been done in our county (or at least has not been published, or publicly shared) it seemed to be a clear starting point. Developing a simple map of the processes regarding the publicly funded crisis mental health system of Maricopa, is really actually not that simple at all.

When developing a network map one must first decide on the nodes (or actors) and the ties (or relationships) between the nodes in the network. For this work it is important to identify and label the actors in the system. I outline some of the important actors and relationships in the points below.

After deinstitutionalization in the late 1970’s Arizona chose to distribute federal funds that were earmarked for state’s appropriation to administer a comprehensive community mental health system for ALL Arizonans by way of the Arizona State Department of Health (AZDHS).
The historical timeline of Arizona’s mental health system was previously highlighted in my last blog post. Does it seem strange that from the historical milestone in 1981 until 2014 the timeline seems to have a huge gap? As I continue to explore the historical framework that built Arizona’s contemporary mental health “system” most avenues seem to land me at a pivotpoint in 1981- Arnold vs. Sarn court case.
ADHS and Arizona State Hospital were sued in court case Arnold vs. Sarn. The decision which stated that “Arizona has failed to meet its moral and legal obligations to our state’s chronically mentally ill population”. The decision required a system delivery change to community-based programs and services for discharged patients.
This is when the move from AZDHS as fiduciary of government appropriations for state mental health care moved to AHCCCS and then RHBA’s were developed.
In Arizona, the primary points of contact for SMI popluation fall under Regional Behavioral Health Authorities (RBHA), which serve the entire state.
RBHA Regional Behavioral Health Authorities- (soon to be renamed the Regional Behavioural Health Administrators) are the contracted organizations who’s fiduciary responsibility is to provide comprehensive mental health services to Arizona’s SMI populations (in addition to other medicare recipients with chronic and acute mental illness). They are divided between three regions in Arizona (Northern, Central and Southern) and serve these regions through multiple networks of sub contracted providers, who then further contracted services to providers within their network.
Private System: Hospitals, Emergency Rooms, Psychiatric Intake Facilities, Ambulance Companies
Public Community Systems: First Responders (Police/Fire/ Crisis Response Teams/ Crisis Phone line)
People- Arizona has estimated 41,511 people designated as “seriously mentally ill” (SMI) April 1, 2019

Seriously mentally ill persons are adults whose emotional or behavioral functioning is so impaired as to interfere with their capacity to remain in the community without supportive treatment. The mental impairment is severe and persistent and may result in a limitation of their functional capacities for primary activities of daily living, interpersonal relationships, homemaking, self-care, employment or recreation. The mental impairment may limit their ability to seek or receive local, state or federal assistance such as housing, medical and dental care, rehabilitation services, income assistance, or protective services.

Seriously emotionally disturbed are persons between birth and age 18 who currently or at any time during the past year have had a diagnosable mental, behavioral, or emotional disorder that resulted in a functional impairment, which substantially interferes with or limits the person’s role or functioning in family, school, or community activities.

Finally I circle back to Arnold vs. Sarn case that was settled in 2014 with requirements to provide key outcomes measured against national benchmarks for Arizona’s SMI population.
In 2019 AHCCCS Service Capacity Assessment Report was published displaying the status of Arizona’s RHBA efforts to meet its fiduciary responsibility to uphold the agreement of the Arnold v Sarn case.
Now in 2020, the structure of our mental health delivery system is changing again. Just a few days ago I attended a meeting hosted by AHCCCS, “The future of the RHBA”. has put out a request for proposals for a competitive contract expansion which will change the way care is delivered once again. The process is difficult to understand and seems to not be in the final stages. The meeting details some were decisions till not yet finalized. Below is a timeline for the planned changes.

I have interviewed first responders (police and fire), social workers, case managers (I’m really growing a great dislike to that title ”case managers’ ‘). I have interviewed multiple key people serving at AHCCCS, and contracted provider networks. I have interviewed ambulance companies and doctors who work in our local ED. I have interviewed people who work in psychiatric intake facilities. Yesterday, I even got the honor of interviewing Mr. Chick Arnold! Yes, the Mr. Arnold vs. Sarn character! (More to come from this interview see the preview video below)
There is a gap in my navigation of exploring this network of key players in our mental health system. I have focused a great deal on the delivery of care, and the policy that influences the delivery of care. However, I have not yet gained the perspective of the people for whom this system exists to serve. These people are the often missing perspectives from important decision tables in our system. It is my aim to gain a comprehensive understanding of ALL the key players in the system. This must include the ones who’s lives literally depend on the success of the mental health system, the ones most deeply vested–the patients. I have somehow regarded them as outsiders, and afterthoughts. What a big mistake.

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Dashboard Indicators…Lights & Sirens

Our National Numbers

600,000 people living with chronic mental illness have been either prisoners or homeless in the U.S. in 2017
Number of people living without homes has increased for the first time in seven years
25% of homeless population have a serious mental illness
Mortality rate for people living on the streets is 4 to 9 times higher than general population
People living with chronic mental illness are more likely to be arrested and cycle through criminal system

References:

Markowitz, F.E. (2006). Psychiatric hospital capacity, homelessness, and crime and arrest rates. Criminology, 44, 45– 72.
Roy L, et al. Criminal behavior and victimization among homeless individuals with severe mental illness: a systematic review 2014 Psychiatric Services. 65(6): 739-750.
Greenberg, G.A., & Rosenheck, R.A. (2008). Jail incarceration, homelessness, and mental health: a national study. Psychiatric Services, 2, 170—177.

hudexchange.info/resource/5639/2017-ahar-part-1-pit-estimates-of-homelessness-in-the-us/

The 1947 Freedom Train Inspiration

https://www.freedomtrain.org/freedom-train-home.htm

1885

The 13th Territorial Legislature met to appropriate $100,000 for the construction of the Territorial Insane Asylum at Phoenix, Arizona.

1887

The “Territorial Insane Asylum at Phoenix, Arizona” opened.

1911

After a fire the State Hospital was rebuilt in 1913 and named the “State Asylum for the Insane”.

1963

Arizona Community Mental Health Centers Act of 1963 passed. State plans for building comprehensive mental health centers.

1970

Restrictions were such that made it impossible to get in the State Hospital and easy to be released. Many patients who had been at the hospital for years were released in downtown Phoenix and the patient census dropped from almost 2,000 to 300 within a few months

During the height of the human rights movement, the Arizona Legislature passed Senate Bill 1057(A.R.S. 3655) which required that a patient must be dangerous to themselves or others in order to be confined to the State Hospital.

1981

ADHS and Arizona State Hospital were sued in a class action court case Arnold vs. Sarn. The decision which stated that “Arizona has failed to meet its moral and legal obligations to our state’s chronically mentally ill population”. The decision required a push toward community-based programs and services for discharged patients.

1986

Division of Behavioral Health is created at ADHS by statute.

1987

ADHS implements the first Behavioral Risk Factor Survey (BFRFSS)

1990

Concern about mental health became a federal issue, generating reports from the Surgeon General’s office and from high-ranking advocates. The Arizona State Hospital adopted Psychiatric Rehabilitation, a new model of patient care that encompasses all disciplines.

1992

New Arizona Behavioral Health System implemented – Regional Behavioral Health Authorities (RBHA’s) are started.

2012

Arizona Governor Jan Brewer, State health officers and plantiffs’ attorneys announced a two-year aggreement that included funding for recovery-oriented services including supported emplyment, living skills training, supported housing, case management, and expansion of orginazations run by and for people living with SMI

2014

A final agreement was reached in the Arnold v. Sarn case. The final settlement extends access to community based services and program agreed upon by the State and plaintiffs, including crisis services; supported employment and housing services; ACT; family and peer support; life skills training and respite care services. The State was required to adopt national quality standards outlined by SAMHSA, s well as annual quality service reviews conducted by an independent contractor

Arizona Mental Health Timeline Reference:

Arizona Department of Health Services, Historical Timeline

Sustainability & Innovation???

Sadly sustainability and innovation are not terms that easily describe our nation’s mental health care. Lack of financial investments from insurance companies are at the core of the barriers preventing innovation in this health sector.

In a recent report published in JAMA-data from 2012-2017, the researchers identified 3.2 million adults with mental health conditions, 294,550 with alcohol use disorders, 321,535 with drug use disorders, 178,701 with heart failure and nearly 1.4 million with diabetes with coverage under employer-sponsored insurance plans.

Patients with behavioral health conditions were more likely than those with physical health problems to end up seeing out-of-network physicians. Costs were also higher for those with behavioral health issues. On average, individuals with mental health conditions ended up paying $341 more than those with diabetes. Those with drug use disorders ended up paying $1,242 more than those with diabetes.

People with behavioral health problems have a heavy burden to bear in navigating the complex system of accessing care. Innovations are needed throughout the stream of the system, particularly upstream where prevention could save millions in downstream traumatic drags such as incarceration and homelessness. However, much like the response to a sinking ship, many are working feverishly to scoop out water–rather than to have the forethought and action to design a more effective boat in the first place.

Did you know that people who are homeless but spend at least seven days in a prison, or hospital bed- are considered “housed” and on the intake assessments for receiving services, these people will not score as poorly on the vulnerability index as a person who slept every night on the streets.

Policy makers and industry leaders need to take a holistic account of the state of the mental health system including the places where people live, work and include the important sectors like the criminal justice system. In looking at the system as a whole, there are clear points where drains are evident calling for innovation. Synergies are needed at the points in the system that intersect. For instance, noting that a bulk of crisis care 911 calls are received from the local Greyhound bus station– and end with an expensive and largely ineffective trip to a local hospital.

An innovation leader might look at that node in the system and begin to ponder how to obtain better outcomes. Asking, what people and industries could coordinate to formulate a better way here? Often times- we look to sophisticated technological advances as the way to innovation. However, innovation that is meaningful, and sustainable, is doing something new in a manner that simply–work better.

Using the example of the Greyhound Bus Station– innovation would be to form a pilot program where basic services can be found at that geolocation. Perhaps articulate an agreement with a mental health ACT team where they make rounds at the Greyhound station twice a day , or have some method of communicating with people there in need. This is a perspective that can be gain through examining the system as a whole, and creating hospital-community partnerships is the way to creating sustainable innovation.

SOURCE: bit.ly/34HCUE3 JAMA Network Open, online November 6, 2019.

Click to access creating-effective-hospital-community-partnerships.pdf

Tech Enhanced Mental Health

Dawn Augusta

Jade 16th and Buckeye 4/6/2020

with Chris at 27th ave &Bethany 4/5/2020

Arizona 211/ Crisis Response Network

Boehmer, K. R., Barakat, S., Ahn, S., Prokop, L. J., Erwin, P. J., & Murad, M. H. (2016). Health coaching interventions for persons with chronic conditions: A systematic review and meta-analysis protocol. Systematic Reviews, 5(1), 146. https://doi.org/10.1186/s13643-016-0316-3

Kelly, E., Duan, L., Cohen, H., Kiger, H., Pancake, L., & Brekke, J. (2017). Integrating behavioral healthcare for individuals with serious mental illness: A randomized controlled trial of a peer health navigator intervention. Schizophrenia Research, 182, 135–141. http://dx.doi.org.ezproxy1.lib.asu.edu/10.1016/j.schres.2016.10.031

Kivelä, K., Elo, S., Kyngäs, H., & Kääriäinen, M. (2014). The effects of health coaching on adult patients with chronic diseases: A systematic review. Patient Education and Counseling, 97(2), 147–157. https://doi.org/10.1016/j.pec.2014.07.026

Private Sector Tracks

Arizona’s Mental Health Private System consists of hospitals, emergency rooms, psychiatric intake facilities, ambulance companies, private non-profit organizations, and private insurance providers. All of these service providers are a link in the chain of a system of care in Maricopa County, yet the links are often tangled, looped, and even missing.

The navigation of the mental health system from the consumer side is complex and even when entities like COPA Health provide navigation assistance the system itself, the way that it is structured creates a barrier to access. When people who seek treatment end up abandoning treatment regimes because they experience barriers to treatment simply because of the way the system is organized is called structural non-compliance. This category of patient has been labeled by health professionals as “non-compliant”. We have labeled people as non-compliant as if they do not care enough to adhere to their treatment plan. When in reality there are two factors really at play. Structural barriers to care created by poor systems design and personal barriers created by complex issues surrounding the burden that treatment itself puts on a patient. This burden is called treatment burden, that often leads to a tipping point in which the person does not have the capacity to continue the uphill battle of seeking, navigating, advocating for their own care and gives up. Since mental illness remains an unseen illness (much like hypertension) people can more easily let it go untreated. Much like hypertension, untreated chronic mental illness continues to progress into acute states of crisis. The crisis pathways of our mental health system are the most expensive, ineffective, yet highly used system pathways. Parts of the crisis pathways are managed by public sector entities like ambulance, police and fire EMS sector handing off to private sector entities like hospitals who then hand off to long term follow-up providers.

All of this hand-off adds layers of complexity, especially when the hand offs are not connected under one unified policy. This is where the links in the chain begin to erode. The policies and practices of one service entity (say fire EMS) do not necessarily create a seamless continuum of care. In speaking to front line fire personnel many attest that the system they must operate does not make sense at all. The process flows that dictate when they must take people and how calls are routed prevent inefficient and ineffective care. Leaving people churning in that endless loop of ineffective, expensive treatment. This looping creates a burden to the system and a burden to the person seeking care (treatment burdeon).

There are more than 24,700 providers of mental health and substance abuse providers in Maricopa County. All of which have their own barriers to entry, fee schedules and operating policies.

Local first responders have a burden when navigating which port of entry they can take a person experiencing mental health crisis. The call can be complicated by co-occurring illness states (mental health in addition to a chronic physical illness). In fact 6 in 10 American adults have a chronic disease 4 in 10 have two or more chronic diseases. People over 65 are more likely (1:4) to have chronic comorbidities[3].

While there are local entities like NAMI (National Alliance on Mental Illness) that aim to bring a unified approach to local actors in the system, the system remains complex and each entity has competing priorities that often do not match up in creating a true alliance. In Arizona there are eleven chapters. The Maricopa County chapter stated mission is: NAMI Valley of the Sun is dedicated to improving the quality of life for people with mental illness and their families through support, education, and advocacy.

This mission statement does not speak to the alliance of unifying the varied actors in Maricopa County’s complex mental health system. So, then who is to serve as a unifying source in aligning and coordinating all the complex players in this system with an aim at simplifying and unifying the structure?

I discovered David’s Hope. David’s Hope leads the Arizona Mental Health Criminal Justice Coalition. A mental health criminal justice advocacy non-profit organization with a stated mission to, in part:

Improving Collaboration between Arizona’s Mental Health and Criminal Justice Systems

Summary

Many Americans live with complex chronic health conditions that each carry their own workload of treatment (Treatment Burden)
The system of accessing preventative normal follow up care is complex (often times one provider for each separate chronic illness (treatment Burden)
Leaving people feeling overwhelmed to the tipping point of giving up on the effort it takes to seek treatment (Structural Non-Compliance)
The system itself is comprised by a myriad of complex public and private actors (Complex Structures)
Most often the complex actors within the system do not have coordinated policies or processes that allow for coordination in the continuum of care (Complex Structures)

What do you think is needed to fill in the missing links?

https://www.cdc.gov/chronicdisease/resources/infographic/chronic-diseases.htm

https://namivalleyofthesun.org/about/

http://davidshopeaz.org/

https://findtreatment.samhsa.gov/locator

Publicly Funded Mental Health “System”

Maricopa County’s mental health terrain is littered with tracks that often do not meet at the ends, leaving people to essentially jump the tracks in attempt to land themselves at the necessary hubs or stations seeking the much needed services that contribute to overall mental health stabilization and well-being. The terrain of mental health services within Maricopa County includes a complex web of public and private entities offering services to multiple special population groups. The web of services is more like disconnected locations on a geo-spatial map than an interconnected network of care. This blog post focuses on the portion of the web of services that constitute the publicly funded mental health system of Maricopa County.

Maricopa’s publicly funded mental health system on the broadest level is comprised of EMS (911), police, fire, hospital ED, department of corrections, inpatient and community mental health care administered through contracts with Arizona State appointed Regional Behavioral Health Authority (RHBA), Mercy Care (via Arizona Health Care Cost Containment System (AHCCCS)). Each of these providers of care represent points along the terrain of local services. Each one of these large, complex service entities have operating policies that are mission guided and often influenced by interests of liability avoidance and cost efficiency factors. Additionally, with regard to the topic of mental health, only one of the public agencies listed, (Mercy Care), has a mission dedicated to serving the needs of people living with mental illness in our community. The other nodes in the publicly funded “system” of mental health care have a divided focus and mission. Emergency medical service provider systems (911, police, fire and hospital emergency departments) have missions aimed at saving human lives when acute physical trauma has been experienced. The nexus between the nodes in this system for acute physical injury have strong connections, at least in terms of design. The ties between the nodes in that system have clear alignment in terms of policies that facilitate the flow of critical interagency actions such as communication, transfer of care, and follow-up/preventative services.

The Department of Corrections (DOC) seems like an unlikely node in a system aimed at mental health and wellness because their mission is to serve and protect the people of Arizona by securely incarcerating convicted felons, by providing structured programming designed to support inmate accountability and successful community reintegration, and by providing effective supervision for those offenders conditionally released from prison. Their policies and network of interaction between police, jail, prison and probation are designed to facilitate an integrated system of interagency communication, collaboration, transfer of care and follow-up/preventative services.

Finally, the system dedicated to providing comprehensive public mental health services in Maricopa County is Mercy Care (AHCCCS) and its network of mental health care provider community clinics, hospitals and assertive community treatment (ACT) teams. The publicly funded mental health system is connected in terms of policy designed to align continuum of care, interagency collaboration, transfer of care and follow-up services. However, it is very difficult to connect the driving force behind policy design as being the improving patient outcomes when the name of agency empowered to design organizational operations through policy development is, Arizona Health Care Cost Containment System. The title highlights a driving mission focus, cost containment.

Arizona is underfunded when it comes to developing and providing a comprehensive mental health care system. Because of the lack of funding for a comprehensive system, there remains a scarcity of services, leaving people needing care, undertreated. The long term effects of lacking mental health treatment services are seen when mental illness further deteriorates into an unstable crisis state which all too often results in lost employment, housing, and/or incarceration.

Unfortunately all of these nodes comprise the Maricopa County mental health “system”. The navigation terrain is brindled in an array of disconnected mental health care access points most of which are undedicated to the care mission of providing mental health services. This lack of undedicated services leaves people in our community struggling to access mental health care by whatever means are most accessible. This is seen in the high utilization of the 911 system for non-emergent, mental health issues. It also means that EMS or DOC professionals trained to deliver services to a specific population are now fatigued by an ever widening “scope creep” as they becoming the new front line mental health professionals that they were never trained to be.

This train is running off the tracks. Tracing the tracks from the hub in the system the drivers of policy development become clear to this issue being a state funding and service alignment issue. The agency whose mission is to provide comprehensive mental health services to meet the needs of our population is not meeting the federal mandate. Using measures of rates homelessness, incarceration, and utilization of crisis nodes in the system it is clear to assess that Arizona is not yet meeting it fiduciary mandate set by our U.S. Mental Health Block Grant funding.

In an attempt to illuminate this complex terrain a group of interdisciplinary professionals at ASU (including this DNP scholar) is working collaboratively with local public agencies to develop a systems map of the Maricopa County mental health crisis pathways. The aim of the map development is to provide data visuals displaying frequency use nodes in this “system” and the associated costs utilization of the current, inefficient and ineffective crisis care pathway. The mapping work is developed to be a tool for policy makers improved understanding of the current system, the associated costs, as well as some of the stories from first responders and consumers for whom the system is failing. It is our hope to highlight a financial case to drive new tracks for comprehensive policy change which will drive system redesign for this critical social terrain.