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While the future stability of this critically needed system of health care is in doubt, there is no doubt about the opportunity for Ohio to resurrect our position as the nation’s leader in mental health care delivery. That resurrection would require that we look very hard at how we fund and how we deliver these services.
Ohio’s position of leadership was established when we became one of the first states to adopt the community-based mental health care system. With the advent of newer, more effective medications, we successfully converted our focus to delivering these services in our communities instead of putting the seriously mentally ill in institutional warehouses. This change became the first huge step toward the advocates’ dream of a mental health care system that allows families to stay together and permits persons with major neurological brain disorders to live normal lives in their community. Subsequent breakthroughs in medical science and the potential for another newer class of pharmacological treatments will add to the pressure to re-think how we will structure this treatment system in the years ahead. Just as many developments triggered the last major re-ordering of this system of care forty years ago; current developments will combine to drive the next re-structuring of our system.
Most pressing are the opposing trends of declining state funding and increased demands on our treatment providers. Over the past 10 years, state dollars have become tighter and communities have not supported new levies. Simultaneously, community planning boards feel compelled to stretch existing resources over a growing array of treatment offerings for an expanding spectrum of ills. Although the Ohio Revised Code is seemingly explicit in its description of the “essential elements” that the law requires to be available to persons with a severe and persistent mental illness, many communities have expanded the base for their services to include services for the less severely ill. This expansion of services and lack of new dollars has combined to create a system that is not adequately addressing the needs of the most severely disabled. The Ohio Revised Code speaks directly to these core services as including; basic human needs for food, clothing, shelter, medical care, personal safety and income; mental health care; emergency services and crisis care; assistance with vocational services and opportunities for jobs; access to a wide range of housing and the provision of residential treatment and support; assistance, conultation, education and support for families, friends, consumers of mental health services; and case management, which includes continual individualized assistance and advocacy to ensure that needed services are offered and procured. These services are required for both adults and children. Unfortunately, in many of Ohio’s communities these services are not readily available today.
Adding to this picture of contradiction is the mandate requiring a growing array of counseling services to Medicaid eligible citizens and the inability of community planning boards to control it. The result of this trend is that communities no longer have the ability to prioritize their limited resources to serve the most in need and instead are forced to fund less intensive services for those with less severe needs.
The Challenge
The factors contributing to this current crisis did not develop overnight and NAMI Ohio acknowledges that these issues are extremely complex. In fact, it is this complexity that creates the situation in which family and consumer advocates find themselves. While it is easy enough to call for a reorganized, streamlined system that is focused on outcomes and client care issues instead of system care issues, it is clear that not all the current stakeholders would embrace any move toward significant change in the current system structure. It is this powerful set of opposing forces that creates the challenge we face. When one considers the four perspectives of the public mental health care system to be the state, the planning boards, the provider agencies and the consumers/family members, only consumers and family members stand alone as having no direct connection to a system facing the need for restructuring.
The challenge is to design a mental health care system that eliminates all barriers to accessing the services that are needed by the most severely mentally disabled Ohioans, both SMD and SED, in the most effective and efficient manner. That may mean a close study of how the system is funded and how it is constructed. That does mean supporting what works and discontinuing the support for that which does not benefit the most severely mentally disabled citizens of our state. That means providing the services those clients need - not the services that are available. The challenge is to understand that this problem must be solved with existing resources and that it must be addressed now. Each day this issue is ignored is a day that lies before us like a deadly trap. Collectively, our responsibility is to protect those who would fall as victims into this trap.
Ohio has a proud history as an innovative leader in the successful delivery of mental health services. Once the best, Ohio is now sliding back into the middle of the pack. With the prominence and promise of the President’s Freedom Commission, the expectations are high (See NAMI Ohio Freedom Project). Unlike many states, Ohio is in an excellent position to address this challenge. The ingredients are all here – leadership at the state level, some of the country’s most experienced and dedicated mental health professionals and a history of cooperation between the system and advocates. The timing is right – everyone has recognized there is a significant problem, and the system has not yet collapsed.
The question becomes one of political fortitude, as not all stakeholder groups will welcome change. However, the question as it should be framed is, “Do we, as family and consumer advocates, value the services to this population enough to make some tough decisions regardless of which stakeholder groups are perceived as (or claim to be) losers?”
The difficulty in answering this question will vary greatly as the diverse stakeholders interpret what change might mean to their organizations. NAMI Ohio understands the problems associated with changing a structure that has so many intricately related parts, but the bottom line remains – are we getting the best outcomes possible for the priority population? As family and consumer advocates, all we ask is that we don’t quit until the answer to that question is a resounding yes!
Just as the symptoms of a serious mental illness become the catalyst for getting an individual with a major neurological brain disorder into treatment, the symptoms of a treatment system in need of restructuring cannot be ignored. In Ohio those symptoms include: costly lawsuits involving providers, funding boards and the state; excessive levels of bureaucratic barriers at each level of the funding and service delivery process; a great disparity in access to services between the best systems and the worst; problems relating to Medicaid match requirements that consume all discretionary/levy dollars in many communities ;and problems relating to the any-willing-provider language supplanting the local boards as community system planners.
What consumers and family members all over Ohio are asking is not complicated. What is needed from the public mental health care system is a basic guarantee that the critical core services are available and easily accessible. The focus should be returned to providing essential services and addressing problems such as: high case management turnover and caseloads; limited access to life-saving medications; inadequate face-to-face time with psychiatrists; and lack of available support services like appropriate housing, family supports, vocational services, socialization programs and all of the needed services to kids.
If we, as disparate perspectives in a single system, can agree to a structure that ensures that outcomes are the single most important focus, then we will be taking a significant first step toward resurrecting our state as an example for all to follow. By agreeing to focus on what we know works, we can begin to eliminate the barriers to improving the lives of the hundreds of thousands of Ohioans who depend upon us with their lives. Anything less will not be accepted.
The John F. Kennedy Mental Health Act of 1963 is celebrating its 40th anniversary. President Bush’s 2003 Freedom Commission Report gives us hope that it can be the same catalyst as the historic act of 1963. We look forward to working with our partners to move the system in a new direction that guarantees the enhanced quality of life for those we serve.
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