at the grassroots of Ohio

Editor's Note:  NAMI Ohio has as its core a mission to improve the quality of life for individuals  suffering with serious mental illness and their   families.  As a consumer and family advocacy organization, we recognize the valuable work done on behalf of our constituents in  communities across Ohio.  Dedicated staff at provider agencies, the boards and at ODMH are the heroes giving hope to the families  dealing with loved ones suffering with this devastating  illness. 

NAMI Ohio values the dedication of all those that are  committed to making a  difference.  In addition, we urge  all to continue to work in partnership to make the changes necessary  to ensure the most effective service delivery system possible.  As advocates for this kind of change, we remind ourselves that it is  the system that is our target, not the dedicated people in the  system.  As your partner, striving to achieve the mutual goals of recovery and integration, we will continue to work toward making  the changes needed to accomplish our shared mission.  

The  Olmstead Decision and Ohio's Community Mental Health System  Crisis

A  far-reaching decision

In 1999, the Supreme Court ruled, in Olmstead v.  L.C.1 (Olmstead), that it is a form of discrimination under the Americans with Disabilities Act ("ADA") when states cause  individuals with disabilities to remain in institutional settings by failing to find appropriate community placements for them. The court stated that the ADA requires states to serve individuals with disabilities in community settings, rather than in  segregated institutions, when this is appropriate and reasonable in light of  certain factors. To comply with the court's ruling, states must  develop comprehensive plans to end unnecessary institutionalization.  They also need to implement those plans at a "reasonable  pace."  States failing to do so run the risk of litigation against which they would be hard-pressed to defend.2

Olmstead's reach is extremely broad. The decision  covers individuals already in state institutions as well as others at risk of unnecessary institutionalization due to lack of community  services.  Examples of groups covered by Olmstead include long-stay patients in state psychiatric hospitals who do not need to be there; children in residential treatment centers  who  could be served in community settings if services were available; residents in nursing homes who can appropriately be  served in the community; individuals who frequently cycle in and out  of hospitals as a result of a lack of community services;  individuals institutionalized through incarceration in jail as a  result of failure to provide mental health services; and any other  individuals receiving services in unnecessarily segregated settings. 

Out of compliance

Ohio is out of compliance with Olmstead and the ADA. In many ways, Ohio's inadequate system of community care actually  increases the risk of institutionalization for individuals with mental disabilities. No state plan meeting Olmstead's requirements has been adopted by the state. Although the work of reducing populations in state  psychiatric hospitals has been substantially accomplished, Ohioans with mental illness still lack the services and supports needed to prevent needless institutionalization in other settings.

In this regard, ODMH reports 3 that some 100 patients within state psychiatric hospitals spend over six months institutionalized  because appropriate intensive service and housing supports are not available to them in community settings. In addition, ODMH has identified approximately 300 severely mentally disabled adults residing in adult care facilities for long periods of time who could  be more appropriately served if intensive services and housing supports were made available in the community. ODMH admits that some one-third of the remaining "most in need" persons in the community mental health system are not adequately served.

The  rapidly eroding safety net

A 2001 ODMH survey of the local mental health boards charged with providing community care4 shows that the community mental health system is practically in shambles. Seventy-five percent of boards reported that  staffing shortages cause long waits and limited access to psychiatric and nursing care. Over eighty percent reported they could not provide adequate outpatient care or provide adequate  intensive outpatient care. Two-thirds could not provide adequate crisis care. In addition to the lack of access to psychiatric or  nursing care, boards admitted that they could not provide adequate medication, care for physical illness, diagnosis, therapy, case  management, home-based and wrap-around care, continuous (24/7) crisis coverage, respite care, or mobile response capacity. 

The failure to provide community care relates directly to  lack of funds. For example, the ODMH survey reported that many of  the persons referred for community mental health care by  Child Protective Services, Job & Family Services, or local jails and court systems are denied the services they need. A primary reason is that even though these referrals are increasing, the persons needing  services are often not eligible for Medicaid, or are under-insured or uninsured. Several boards ration limited resources by providing services only to Medicaid-eligible or privately insured persons. No  mechanism coordinates cost-sharing across state systems.

Lack of  community mental health funding also blocks access to proper medication. The vast majority of boards reported they could not meet the medication needs of persons on their  caseloads.  Over ninety percent of boards reported that the spend-down rules for Medicaid as well as deductible co-pays for private insurance keep people from affording newer, more effective, but higher-priced medications. These same boards also reported that the ODMH Central Pharmacy budget was inadequate to meet demand, and  that many of the newer medications frequently were not on private insurance formularies. A majority of boards rely on pharmaceutical  industry charity programs to cope with their inability to provide essential medications. Drug company charity now makes up twenty-eight percent of pharmacy distributions throughout the state. For some boards, these charity programs make up three-quarters of pharmacy distributions.

As for support services, boards reported that persons  with mental illness frequently lacked appropriate vocational  training and employment. Prevention, family education and counselingwere also cited as wanting. Transportation was reported by forty-three percent of boards as the third most severely stressed  support service. Lack of transportation is linked to inpatient  hospitalization and is therefore critical where there  is no  public transportation.

Gaps in continuity of care from hospital to community are  particularly dire in the area of housing.  Some eighty-five percent of boards reported a lack of safe, affordable housing units. This increases risks of homelessness or incarceration for persons  with mental illness.

Child  and Adolescent Services

Care for children and adolescents is gravely wanting.  According to the ODMH survey, eighty-one percent of boards could not provide adequate outpatient care, ninety-four percent could not  provide sufficient intensive services, and seventy percent could not  provide adequate crisis services.

Ohio's youth system is out of balance in great part because  the state depends too highly on expensive residential care. Ninety-four percent of boards reported that they did not provide  sufficient access to other treatment methods which may be just as effective as residential care. These include partial  hospitalization, wrap-around, multi-systemic therapy, continuous  (24/7) crisis care treatment, foster care and home-based services.  The prospect of expensive residential care placement also increases  the risk that parents will be forced to surrender custody to the state in order to obtain treatment for their child.

Funding also drives community boards to ration care for  children and adolescents. For example, boards reported that the cost of treating an "influx of younger and sicker youth" – sexual predators; fire starters; perpetrators of heinous, violent crimes; children under age 6 with serious emotional and behavioral  disturbances often coming from families with highly complex problems  – fuels board inability to adequately serve other children. Many  boards also noted that while youth from low-income families  often were Medicaid-eligible, their adult caretakers were  not.

Moreover, lack of funds keeps boards from attracting the services of mental health professionals with the specialized training, credentials and experience needed to provide appropriate  quality care to youth and their families. Seventy-seven percent of  boards reported that recruitment and retention of staff is the most prevalent capacity issue associated with the need for additional  funding of core and support services. The ODMH survey notes that  public mental health agencies compete not only with the private sector for doctors, nurses, clinicians, case managers and support staff, but also with other public entities such as state hospitals, MR/DD, Job & Family Services, schools, and prisons that offer better salaries and benefits.

Where  NAMI Ohio stands

Based on data  from ODMH itself and from reports of  local mental health boards, it is obvious that Ohio is not in  compliance with the Olmstead decision.

NAMI is committed to a program of aggressive advocacy to bring Ohio into compliance with Olmstead and eliminate  barriers to appropriate community treatment. Ohio must end its  unlawful discrimination against persons with mental illness.

1 527 U.S. 581, 119 S.Ct. 2176 (1999).

2 See Bazelon Center for Mental Health Law, Under Court Order: What the Community Integration Mandate  Means for People with Mental Illnesses.  (http://www.bazelon.org/lcruling.html.)

3 The data in this section is taken  from Ohio Access for People with Disabilities: Final  Report

(February 28, 2001) prepared by the state's Office of Budget and Management.

4 ODMH Safety Net Survey , February 2001