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New Hampshire’s
roadmap to reform unveiled
(April 2008
Issue)
By Nan Shnitzler
New Hampshire's Commission to Develop a Comprehensive State Mental
Health plan released the results of two year's work at a standing-room-only
legislative breakfast Jan.31. Since then, the commission's report,
"Fulfilling the Promise: Transforming New Hampshire's Mental Health
System," has become something of a best seller, says project coordinator
Linda Fox Phillips, LICSW.
"We're getting many, many requests. It feels like our timing coincides
with broad community readiness to start thinking about mental illness,"
Phillips says. "For those who have been in the field for decades,
it's enormously gratifying that people are beginning to grasp the
key principles."
The commission was formed by legislative action in 2005, championed
then chaired by Rep. James R. MacKay, Ph.D., a psychotherapist.
Its purpose was to come up with a comprehensive plan to deliver
mental health services to the entire population in the face of such
stumbling blocks as the stigma around mental illness, a fragmented
delivery system and the limitations imposed by insurers.
Recommendations and action items in the 32-page report were boiled
down from research conducted by volunteers in five working groups,
plus a leadership group. (A sixth working group on Corrections and
Mental Health convened only a year ago and will report later). About
100 volunteers from both the public and private sectors included
clinicians, consumers, academics, advocates, legislators and government
agency officials.
"Everyone came to the table to represent groups with a stake in
the mental health system," Phillips says.
The commission took as a baseline the idea that mental health issues
are common, treatable and fundamental to overall health to describe
a system of service delivery that must be person and family centered,
widely available, based on science, high quality, technology enabled,
integrated with physical health care and individualized.
"It's the first document of this type since the Wheelock-Nardi
report," says Michael Cohen, M.A., CAGS, executive director of NAMI
New Hampshire, who served on the integrated health care working
group. "It's an opportunity for us to grab onto something new and
move forward."
Twenty-five years ago, New Hampshire embarked on a similar endeavor
and issued the Wheelock-Nardi report, which recommended a system
of community-based services. As a result, the state created 10
regional mental health centers that delivered comprehensive services,
a model that reduced the number of patients destined for acute
care by an order of magnitude and earned plaudits from the National
Institute of Mental Health.
But in the past decade, the system has been eroded by cuts in state
funding and insurance reimbursements that have led to a loss of
psychiatric unit beds as well as treatment providers. A population
boom has contributed to increases in residents without health insurance,
prisoners with mental illness and patients with mental health issues
being treated by primary care practices.
With the data and recommendations in the report, the commission
hopes to stem the downward spiral and guide government leaders,
residents and stakeholders in their efforts to change the administrative
rules, state laws and insurance company strategies that shape the
state mental health system, the report states.
"This commission is hoping to develop a system that can evolve
and change with the mental health, legislative and global environments
to create a self-sustaining infrastructure," says commission member
Kathryn Saylor, Psy.D., executive director of the New Hampshire
Psychological Association.
A key next step is for the commission to align itself with a non-profit
organization to be its "fiscal home." As a legislative entity, the
commission doesn't have legal standing to pursue a wide range of
funding. So far, the Endowment for Health has funded the commission's
work. A Request of Interest has been issued and response has been
favorable, Phillips says.
The commission has also started morphing into implementation mode
with committees proposed to promote education and awareness, tackle
public policy issues and pursue transformative opportunities, Phillips
says.
In the meantime, the report offers many opportunities to go after
"low hanging fruit," as Cohen puts it.
"From our point of view, stigma needs to be addressed, as was
reinforced by the report," Cohen says. "We're working on that already.
It won't cost more money to continue."
Likewise, as the commission identified and built consensus around
key priorities, the Bureau of Behavioral Health looked for opportunities
to implement them, says director Erik Riera.
For example, the bureau was awarded a federal technical assistance
grant to train community mental health providers in person-centered
treatment planning to promote patient participation in their recovery,
one of the report's key tenets. A pilot program starts in April,
Riera says.
The bureau continues to focus on evidence-based practices, which
are steadily being adopted statewide. Last spring, supported employment
was launched to help adults with severe mental illness seek competitive
jobs. As part of that initiative, the bureau has shared resources
with the division of Vocational Rehabilitation to improve outcomes
for the departments and their clients. It's a win-win for everybody,
Riera says.
A corollary to supported employment is supported housing, an acknowledged
"pressure point" and a "huge barrier for those coming out of an
institutional setting," Riera says. The Department of Health and
Human Services is working on a funding model to bridge the long
wait for federal section 8 funding, he adds.
In fact, a task force led by HHS Commissioner Nick Toumpas has
been looking at the bed shortage at New Hampshire Hospital, and
its recommendations overlap with those of the commission.
"The task force looked at the bed crisis as a symptom of change
we need to make in the community mental health system," Riera says.
While there is certain euphoria among participants in having completed
the report, Riera warns of emerging fiscal pressure. The state is
projecting a $50 million revenue shortfall in the current fiscal
year with attendant departmental cuts. Fiscal 2009 may mean more
of the same. Measurement and data collection, as mentioned in the
report, will be even more important to demonstrate positive outcomes
and to direct funding to services that are most effective, he says.
Another challenge is to reconcile service delivery in the public
and private sectors. For example, evidence-based practices are not
necessarily embraced by private practitioners who are usually free
to try varied approaches to treatment.
"I would welcome the opportunity to work with more people from
the private community in helping shape the future direction in New
Hampshire," Riera says. "There is expertise in the private sector
we don't have in the public. Part of my challenge is to figure out
ways to work together."
Download the report at the Web sites of the Bureau of Behavioral
Health [www.dhhs.state.nh.us/DHHS/BBH/default.htm] or at the Endowment
for Health [www.endowmentforhealth.org/_docs/126.pdf].
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