2020118 legislative issues€¦ · subcommittee on children’s mental health vail place wellness...

Mental Health Legislative Network of Minnesota

201 Legislative Issues 2018 Legislative Issues

MentalHealthLegislativeNetwork2018TheMentalHealthLegislativeNetwork(MHLN)isabroadcoalitionthatadvocatesforastatewidementalhealthsystemthatisofhighquality,accessibleandhasstablefunding.TheorganizationsintheMHLNallworktogethertocreatevisibilityonmentalhealthissues,actasaclearinghouseonpublicpolicyissuesandtopoolourknowledge,resourcesandstrengthstocreatechange.

ThisbookletwaspreparedtoprovideimportantinformationtolegislatorsandotherelectedofficialsonhowtoimprovethelivesofchildrenandadultswithmentalillnessesandtheirfamiliesandhowtobuildMinnesota’smentalhealthsystem.

ThefollowingorganizationsaremembersoftheMentalHealthLegislativeNetwork:

AmherstH.WilderFoundationAspireMNAutismOpportunitiesAvivoBarbaraSchneiderFoundationCanvasHealthCatholicCharitiesofSt.PaulandMinneapolisChildren’sHealthCareMinnesotaCommunityInvolvementProgramsEmilyProgramFoundationFraserGoodwillEasterSealsGuildIncorporatedLutheranSocialServiceofMinnesotaMentalHealthMinnesotaMentalHealthProvidersAssociationofMinnesotaMinnesotaDisabilityLawCenterMinnesotaAssociationforChildren’sMentalHealthMinnesotaAssociationofCommunityMentalHealthProgramsMinnesotaAutismCenter

MinnesotaBehavioralHealthNetworkMinnesotaCoalitionofLicensedSocialWorkersMinnesotaDepartmentofHumanServicesMinnesotaOrganizationonFetalAlcoholSyndromeMinnesotaPsychiatricSocietyMinnesotaPsychologicalAssociationMinnesotaRecoveryConnectionMinnesotaSocietyforClinicalSocialWorkNAMIMinnesotaNationalAssociationofSocialWorkers,MinnesotaChapterOmbudsman-MHDDPeopleIncorporatedResource,Inc.RiseStateAdvisoryCouncilonMentalHealthSubcommitteeonChildren’sMentalHealthVailPlaceWellnessintheWoodsWilder

IfyouhavequestionsabouttheMentalHealthLegislativeNetworkoraboutpoliciesrelatedtothementalhealthsystem,pleasefeelfreetocontactMentalHealthMinnesotaat651-493-6634orNAMIMinnesotaat651-645-2948.Thesetwoorganizationsco-chairtheMentalHealthLegislativeNetwork.

TableofContents� MentalIllnessandtheMentalHealthSystem.......................................Page3KeyIssuesforthe2017LegislativeSession........................................Page7AdultMentalHealthServicesandSupports........................................Page8

Housing................................................................Page8Employment............................................................Page9SupportingParentswithMentalIllnesses................................Page9ClubhouseServices......................................................Page10PersonalCareAssistanceServices.......................................Page10

AccesstoMentalHealthTreatment................................................Page12

CrisisResponse..........................................................Page12PatientFlow.............................................................Page12MentalHealthParity.....................................................Page13AccesstoMedication....................................................Page15EarlyIntervention/FirstEpisodePrograms..............................Page16

MentalHealthServices............................................................Page18

ReimbursementRatesforMentalHealthServices........................Page18MedicalAssistancePaymentsUnderManagedCare.......................Page18MentalHealthWorkforceShortages......................................Page19ExpandedUseofTelemedicine...........................................Page19LicensureandSupervisoryRequirements.................................Page20DutytoWarn.............................................................Page20

Children’sMentalHealth..........................................................Page21

EarlyChildhoodConsultation............................................Page21School-LinkedMentalHealth............................................Page21Children’sResidentialTreatmentFunding................................Page22PsychiatricResidentialTreatmentFacilities..............................Page22TransportationtoChildren’sMentalHealthServices......................Page23AlternativestoSuspension...............................................Page23EducationinCareandTreatmentMentalHealthPrograms................Page23KognitoSuicidePreventionTraining.....................................Page24

CriminalJustice..................................................................Page25

AdministrativeandDisciplinarySegregationinPrison....................Page25InvoluntaryAdministrationofMedicationinJails.........................Page25MedicationsandAssessmentsinJails.....................................Page26OmbudsmanforMentalHealthServicesinCorrections....................Page26CommunityMentalHealthServicesintheCriminalJusticeSystem........Page27

OtherIssues......................................................................Page29

ImprovingCareCoordinationThroughHealthIT..........................Page29 CivilCommitment........................................................Page29

MentalIllnessesandtheMentalHealthSystem

MentalIllnesses

Mentalillnessesaremedicalconditionsthatdisruptaperson'sthinking,feeling,mood,abilitytorelatetoothersanddailyfunctioning.Mentalillnessesaffectaboutoneinfivepeopleinagivenyear.Peopleaffectedmoreseriouslybymentalillnessnumberabout1in25.Thereisacontinuum,withgoodmentalhealthononeendandseriousmentalillnessesontheotherend.

Examplesofseriousmentalillnessesincludemajordepression,schizophrenia,bipolardisorder,obsessivecompulsivedisorder(OCD),generalizedanxietydisorder,panicdisorder,post-traumaticstressdisorder(PTSD),eatingdisordersandborderlinepersonalitydisorder.

Mentalillnessescanaffectpersonsofanyage,race,religion,politicalpartyorincome.Mentalillnessesaretreatable.Mostpeoplediagnosedwithaseriousmentalillnesscangetbetterwitheffectivetreatmentandsupports.Medicationaloneisnotenough.Therapy,support,gooddiet,exercise,stablehousing,meaningfulactivities(school,work,volunteering)allhelppeoplerecover.

Somepeopleneedaccesstobasicmentalhealthtreatment.Othersneedmentalhealthsupportservicessuchascasemanagement(and/orcarecoordination)toassisttheminlocatingandmaintainingmentalhealthandsocialservices.Stillothersneedmoreintensive,flexibleservicestohelpthemliveinthecommunity.

Dependingontheseverityofmentalillnessandwhethertimelyaccesstoeffectivetreatmentandsupportservicesareavailable,mentalillnessmaysignificantlyimpactallfacetsoflivingincludinglearning,working,housingstability,andlivingindependently.Furthermore,socialrelationshipslikefamilyandfriendsalongwithsocialintegrationintothecommunitymaybeaffected.Somepersonswithmentalillnessexperiencearevolvingdoorrelationshipwiththecriminaljusticesystemwhileotherscycleinandoutofthesheltersystem.Povertyiscommonplaceamongstthoselivingwithseverementalillness.Althoughwehaveeffectivetreatmentsandrehabilitation,thecurrentmentalhealthsystemfailstorespondtotheneedsoftoomanychildren,adultsandtheirfamilies.Timelyaccesstothefullpanoplyofnecessarymentalhealthbenefitsandservices,whethertreatmentorrehabilitation,isoftenlimitedduetoinsuranceorpublicprogramaccessissues,unavailabilityofmentalhealthprovidersorcommunitybasedbeds,orgeographicaldisparities.Therearelongstandingstructuralbarriersinthesystemthatimpedestheflowofpatientsfromoneproviderbasedservicetoanother.Toooftenaperson’smentalhealthwillworsenastheywaitforhelp.Ensuringtimelierhandoffsinthecontinuityofcarecontinuumwillleadtomoreeffectiveprovisionofserviceresultinginenhancedqualityoflifeforthosepersonswhomustnavigatethecomplexmentalhealthcaresystem.

TheFederalHHSAdministration,SAMHSA,hasestablishedaworkingdefinitionofrecoverythatdefinesrecoveryasaprocessofchangethroughwhichindividualsimprovetheirhealthandwellness,liveself-directedlives,andstrivetoreachtheirfullpotential.Theadoptionoftherecoveryapproachbymentalhealthcaresystemsinrecentyearshassignaledadramaticshiftintheexpectationforpositiveoutcomesforindividuals.Recoveryisbuiltonaccesstoevidence-basedclinicaltreatmentandrecoverysupportservices.Recoveryischaracterizedbycontinualgrowthandimprovementinone’shealthandwellnessthatmayalsoinvolvesetbacks.Resiliencebecomesakeycomponentofrecovery.Thevalueofrecovery-orientedmentalhealthcaresystemsiswidelyacceptedbystates,communities,providers,families,researchers,andadvocatesincludingtheU.S.SurgeonGeneralandtheInstituteofMedicine.

Therangeofservicesrequiredforapersontorealizerecoveryfrommentalillnessinthehopesofachievinggreatermentalhealthvariesdependingonahostoffactors.Therangeofservicesisasvariedastherangeofmentalhealthconditionsandco-occurringdisordersthatmaybepresentinanyoneperson.Somepeoplemayonlyneedaccesstostandardmentalhealthtreatmentinahealthcaresettingwhileothersmayneed,inaddition,afullerspectrumofintensive,flexiblerehabilitationandrecoveryservices.Abroadrangeofeffectiveandadequateservicecomponentsacrossthecontinuumarerequiredtomakerecoverypossibleforpersonslivingwithmentalillness.

Minnesota’sMentalHealthSystem

InsuranceCoverage:Themainaccesstothementalhealthsystemisthroughinsurance–eitherprivatehealthplansorastateprogramsuchasMedicalAssistance(MA)orMinnesotaCare.Forthosewhohavenoinsuranceorpoorcoverage,accessisthenthroughthecountyoracommunitymentalhealthcenter.MAisaninvaluableprogramforchildrenandadultswithmentalillnessesandtheirfamilies.Formany,itistheonlywaytoobtainaccesstotreatmentandsupports.

Coverageformentalhealthtreatmentisnotcurrentlymandatedforself-insuredplansorcommercialorprivateinsurance.MentalhealthparityonlyrequiresplanstoensureparityIFtheycovermentalhealthorsubstanceusedisordertreatment.Thereareexemptionsforindividualpoliciesandsmallbusinesses,althougheveryplanofferedthroughMNSuremustcovermentalhealthandsubstanceusedisordertreatmentandfollowmentalhealthparitylaws.

AccesstoBenefits:Ifmentalhealthtreatmentiscoveredunderprivateinsurance,whatiscoveredisvariable.FewprivateplanscoverthemodelmentalhealthbenefitsetwhichisincludedunderMedicalAssistanceandMinnesotaCare.Themodelmentalhealthbenefitsetisbaseduponresearchandevidenceofeffectivenessandincludeservicesuchascrisisservices,AssertiveCommunityTreatment(ACT),IntensiveResidentialTreatmentServices(IRTS),Children’sTherapeuticServicesandSupports(CTSS),etc.

CommunityServices:Somepeoplewhohavethemostseriousmentalillnessesneedadditionalservicesinthecommunitysuchasaffordablesupportivehousing,communitysupports,employmentsupports,educationalservices,respitecareandin-homesupports.Grantfundingwascutover$52millionbetween2009and2011whichnegativelyaffectedpeoplewithmentalillnessesandthusgreatlyreducedpeople’sabilitytoaccessneededsupportstolivewellinthecommunity.

Workforce:Psychiatry,psychology,clinicalsocialwork,psychiatricnursing,marriageandfamilytherapyandprofessionalclinicalcounselingareconsideredthe“core”mentalhealthprofessions.Formanyyears,Minnesotahasexperiencedashortageofprovidersofmentalhealthservices.Thisshortagehasbeenfeltmostprofoundlyintheruralareasofthestate.Thereisalsoanongoing-shortageofculturallycompetentandculturallyspecificproviders.

ReimbursementRates:Historically,poorreimbursementratesinpublicmentalhealthprogramshavecontributedtotheproblemsofattractingandretainingmentalhealthprofessionals.Improvedpaymenttomentalhealthprovidersincreasesconsumerpurchasingpower,attractsqualifiedprofessionalstoservice,improvesearlieraccesstotreatment,andsupportssavingmoneyandtime.Increasedreimbursementenablesagenciestohireandsupervisequalifiedworkers,whichreducesturnoverandsavestimeandmoney.Withoutadequatesalaries,qualifiedmentalhealthprofessionalsleavetheircareers.RatespaidthroughmanagedcareMedicalAssistanceareoftenlowerthanfee-for-servicerates.

LookingtotheFuture

Morethaneverbefore,weknowwhatworks.Earlyintervention,evidence-basedpracticesanda“modelmentalhealthbenefitset”havecreatedthefoundationforagoodmentalhealthsysteminMinnesota.Unfortunately,workforceshortages,poorreimbursementrates,andlackofcoveragebyprivateplanshaveresultedinafragilesystemthatisnotavailablestatewideandisnotthereforeabletomeetthedemand.

Peopleoftenlookfor“quickfixes”suchasmorebeds.Childrenandadultswithmentalillnessesspendthemajorityoftheirlivesinthecommunity.Thus,the“fix”ismorecomplexinthatweneedtoworktoensurethattheservicesthatsupportpeopleinthecommunityarereadilyavailabletoprovideearlyidentificationandintervention,addressamentalhealthcrisis,andprovideongoingsupportsinthecommunity.

Whilethefocustendstobeonthedeliveryofmentalhealthtreatment,otherareasneedattentionaswell.PeoplewithmentalillnessesrelyontheCADIWaiver(CommunityAlternativesforPeoplewithDisabilities)oronCommunityFirstServicesandSupports(whichwillreplacetheoldPCAprogram)forday-to-dayhelpintheirhomes.Yetchangestobothoftheseprogramshaveresultedinthembeinglessavailable.

Affordableandsupportivehousingareveryimportanttorecovery.Ifyouarehomelessorhaveunstableorunsafehousing,itisdifficulttofocusongettingbetter.Everyoneneedsareasontogetupinthemorningandyetpeoplewithseriousmentalillnesseshaveoneofthehighestunemploymentrates.

Graduatingfromhighschoolisimportanttofuturesuccess.Manyyoungpeoplewithseriousmentalillnessesdropoutofschool.Oftentheylagbehindtheirpeersduetobeingindayorresidentialtreatmentandyetcannotaccesssummerschool.Thesestudentsfacetheuseofseclusionandrestraintsmorefrequentlyandschoolsareoftenatalossastowhattodo.

Ourjuvenilejusticeandcriminaljusticesystemhavebeenusedforover50yearstocareforyouthandadultswithmentalillnesseswhohavecommittedlargelynonviolentcrimes.Stepshavebeentakentoaddressthisincludingtrainingofpublicsafetyofficers,thedevelopmentofmentalhealthcourtsandthecreationofmentalhealthcrisisteams.

SuicideratesareincreasinginMinnesota.Thedata,whichismorethantwoyearsold,tellusthat726peoplediedbysuicidein2015.

Lowratesandworkforceshortagesaddtothestressorsonthesystem.Providersarenotpaidforwhattheyarerequiredtodo.Lowratesmakeitdifficulttoattractnewpeopletothefield.Workforceshortagesmakeitdifficulttohireenoughpeopletomeettheneeds.

OnthefederallevelthereisdiscussionaboutrepealingtheAffordableCareActandblock-grantingMedicaid.LegislatorsshouldknowthattheACAprovidedanopportunityforpeopletohaveinsurancetocovertheirneededmentalhealthtreatmentforthefirsttimebynotallowingdenialofcoverageduetoapre-existingcondition,byallowingyoungadults(akeyagetodevelopamentalillness)tostayontheirparents’planuntilage26,byexpandingMedicaidtolow-incomechildlessadultssothattheydon’thavetosaytotheSocialSecurityAdministrationthattheywillneverworkagainandbyrequiringpoliciesofferedthroughMNSuretocovermentalhealthandsubstanceusedisordertreatmentandfollowmentalhealthparity.Thementalhealthsystemwasnotbuiltduetodependenceonfundingthatwasturnedintoafederalblockgrantthatgavefundingtostateswithfewstringsattached.WebegantoseriouslybuildourmentalhealthserviceswhentreatmentandserviceswerebilledthroughMedicaidandMNCare.Weareveryconcernedabouthowactionsonthefederallevelcoulddestroywhatwehavebuiltthelastdecade.

TheMentalHealthLegislativeNetworkbelievesthesechallenges,thoughverysignificant,arenotinsurmountable.Again,weknowwhatworks.Let’sbuildonthis.

KeyIssuesforthe2018LegislativeSession

• Stabilizingandincreasingaccesstoeffectivementalhealthcarethroughoutthestatebyincreasingratesandfundingandeliminatingbarrierstodevelopment

• Expandingthementalhealthworkforce• Providingsupportsandeducationthatenablechildrentolivewiththeirfamilies• Endingtheinappropriateuseofthecriminalandjuvenilejusticesystemsforchildrenand

adultswithmentalillnessesandprovidingadequatementalhealthcareinthesesystems.• Helpingpeoplelivingwithmentalillnessesobtainhomesandjobs.• Expandingaccesstohomeandcommunitysupportsthroughwaiversandin-homeservices.• Expandingaccesstointensivetreatmentandsupports.• IncreaseenforcementofMentalHealthParitylaws.

AdultMentalHealthServicesandSupports

Housing

Issue:Thereislimitedaccesstoaffordableandsupportivehousing.

Background:Peoplewithmentalillnessescannotachieverecoverywithoutstablehousing.Theshortageofaffordablehousing,includingsupportivehousing,hasledtopeopleremainingattheAnokaMetroRegionalTreatmentCenterlongerthannecessaryandresultedinpeoplebeingdischargedfromhospitalsandIntensiveResidentialTreatmentServices(IRTS)toshelters.

BridgesprovideshousingsubsidiestopeoplelivingwithseriousmentalillnesseswhiletheyareonthewaitinglistforfederalSection8housingassistance.AswithSection8,peopleonBridgesrentanapartmentattheregularmarket-rateandpay30%oftheirincomeforrent.Theprogramprovidesvoucherstocoverthebalance.BridgesisadministeredbylocalhousingauthoritiesorotherentitieswhomanageSection8programs.

Thelegislaturein2013approvedanadditional$400,000fortheBridgesprogram.MHFAprovidedacompetitiveRFPforthefundsandreceived12proposals,requestingatotalamountof$1.4millioninordertoserve187householdspermonthatfullutilization.Onegranteeacceptedapplicationsforonedayonlyandreceivedabout100applicationsforonly12vouchers.Thereareanestimated1366householdsonwaitinglistsforBridgesasofJuly2014.Itwouldtakeanestimated$17.147millioninbiennialbudgetjusttoserveallhouseholdsonthewaitinglist.ThisfiguredoesnotincludeservingareaswithoutcurrentaccesstoBridgesfunding.

ThegrantprogramcalledHousingwithSupportsforAdultswithSeriousMentalIllnessprovidesgrantstohousingdevelopers,countymentalhealthauthoritiesandtribestoincreasetheavailabilityofsupportivehousingoptions.Supportivehousingisaneffectiveandinexpensivewaytoassistpeoplewithseriousmentalillnessestoliveinthecommunity.Supportivehousingoftenprovideshousingstability,preventshomelessnessandevenhospitalizations.Inthe2017LegislativeSession,supportivehousingfundingwasincreasedby$2.15milliondollars.

HousingSupport(formerlyknownasGroupResidentialHousing,orGRH))paysforroomandboardcostsforadultswithlow-incomewhohavedisablingcondition.RecipientsofHousingSupportliveinlicensedfacilities(e.g.AdultFosterCare,BoardandLodge,AssistedLiving)orintheirownhomewithasignedlease.Ineithercase,aprovideror“vendor”managestheroomandboardexpensesonbehalfoftheindividual.However,somepeopleprefernottoliveinalicensedfacilityand/orhaveavendormanagingtheirroomandboardneeds,andwouldrathermanagetheirownbudgettomeettheirneeds.

MinnesotaSupplementalAid(MSA)HousingAssistanceprovidesadirectbenefittoindividualswithdisabilitiestohelpthemaffordhousing.However,theamountofMSAHousingAssistanceisnotenoughsupportmorepeopletoliveinthecommunityandisnotavailabletopeopleonGRHwhowanttomoveoutofagroupsettingand/ormanagetheirownroomandboardneeds.

InJune2015,theCentersforMedicareandMedicaidServices(CMS)issuedanInformationalBulletinregardingthecoverageofhousing-relatedactivitiesandservicesforindividualsunderMedicaid.Thebulletinidentifieshowhousing-relatedactivitiesandservicescanbeincorporatedintoaMedicaidbenefitsetforindividualstoachieveoptimalcommunityintegration.The2016legislaturedirectedDHStodesignahousingsupportservicetohelppeoplewithdisabilitieslocateandsecurestablehousingaswellasmaintainhousingthroughsupportservices.

Recommendations:

• IncreasefundingfortheBridgesProgram.

• Increasefundingforhousingsupportsforadultswithseriousmentalillnesses.• IncreasetheMSA-HousingAssistancebenefitandexpandeligibilitytopeopleleaving

HousingSupport(formerlyknownasGroupResidentialHousing,orGRH).• PursueaHousingSupportServicesMedicaidbenefit

Employment

Issue:Personswithmentalillnesseshavethehighestunemploymentrateandyetemploymentisanevidence-basedpractice,meaningithelpspeoplerecover.Programsthataredesignedspecificallyforpersonswithmentalillnessesareunderfundedandservealimitedamountofpeople.

Background:Peoplelivingwithmentalillnessesfaceanumberofbarrierstofindingandkeepingajob.Theyoftenfacestigmaanddiscriminationwhenapplyingforjobsandmayfaceotherobstaclessuchaslosinghealthinsurancecoveragefortheirmentalhealthtreatmentandmedicationsorlackoftransportation.Inaddition,fewreceivethesupportedemploymentopportunitiesshowntobeeffectiveforpeoplewithmentalillnesses.

Duringthe2013legislativesession,Minnesotalawmakersmadeanumberofimportantchangestothelawgoverningsupportedemploymentprogramsforpeoplewithmentalillnessestoreflecttheevidenced-basedmodelofIndividualPlacementandSupport(IPS).ChangeswerealsomadetoMinnesota’sAdultMentalHealthActtounderscoretheimportanceofcompetitiveemploymentandtoencouragecountiestofundIPSprograms.Inthe2015specialsessionIPSemploymentreceivedanadditional$1millionayeartocontinuetheprojectsthatwereconvertedtoIPSlastyear.Thenextstepistoprovideon-goingfundingandtoincreasethenumberofIPSprogramstohelpallMinnesotanswithamentalillnesswhowanttoworkfindameaningfulandwell-payingjobandmakesureDEEDprogramsknowhowtohelp.

PolicyRecommendations:HF1783/SF1441

• RequirethecommissionerofDEEDto,inconsultationwithstakeholders,identifybarriersthatpeoplewithmentalillnessesfaceinobtainingemployment,identifyallcurrentprogramsthatassistpeoplewithmentalillnessesinobtainingemploymentandsubmitadetailedplantothelegislature.

• RequireDEEDtofundworktrainingprogramsforpeoplewithmentalillnessestoassisttheminsecuringemploymentoftheirchoicethatpaysatorabovethefederalminimumwage.

• Fundprograms,suchasIPS,thatprovideemploymentsupportservicestopersonswithmentalillnesses.

SupportingParentswithMentalIllnesses

Issue:Parentswithamentalillnessfaceuniquechallengesascaregivers.Thiscanincludedevelopingahealthyattachmentwiththeirchild,treatmentchallengesforfamilieswherethechildandparentbothhaveamentalillness,andadditionalburdensaccessingandcoordinatingservices.

Background:InaDHSreportfrom2013,therewere13,000parentswithaseriousmentalillnesscurrentlycaringfortheirchildren,withover60%offamiliesinthechildprotectionsystemhavingissueswithmentalhealthandorsubstanceusedisorder.Theseparentsrequireadditionalsupportsandservicestocarefortheirchildren.

Familieswhoareonchild-onlyMFIP,wheretheparentisdeemeddisabledandisonSupplementalSecurityIncome(SSI)/SocialSecurityDisabilityInsurance(SSDI),donothaveaccesstochildcare.Itisverydifficultforaparenttoengageintreatmentwithoutdependableandqualitychildcare.A

personmayneedintensivetreatmentthatcouldpotentiallyinvolveattendingtreatmentdailyduringaweektoproperlyaddressandfullymanagementalhealthsymptoms.Parentsshouldnothavetochoosebetweencaringfortheirchildrenandaddressingtheirownmentalhealthneeds.

Anumberofwellsupportedstudies,suchastheAdverseChildhoodExperiences(ACEs)study,identifythathavingaparentwithamentalillnessisariskfactorforpoorqualityoflifeinthefuture.Parentswhohaveaccesstosubsidizedchildcarecanaccessmentalhealthtreatmentandchildrencanhaveastableadultintheirlives.

Multigenerationaltreatmentsareanevidence-basedpracticedesignedtoincreasesupportiveandresponsivecaregivingofparentswithseriousmentalillnessandtoconductanindependentevaluationoftheeffectivenessoftheseinterventions.Researchhasshownthatmanyparentswhohaveaseriousmentalillnessalsohaveachildwithmentalhealthchallengesandthismodelseekstoaddresstheneedsofboththeparentandtheirchildreninanintegratedfashion.

Thementalhealthblockgrantwasusedtofundmulti-generationalgrantsinDuluth,St.Cloud,andSt.Paulwithgreatsuccess.Unfortunately,theblockgrantcannotbetappedagainasafundingsource.Thatmeansthatstatefundsmustnowbeutilizedtobeginofferingthesehighlyeffectiveservicesagain.

PolicyRecommendations:HF2101/SF1978

§ Expandchildcareassistancetofamilieswhohaveachildundertheageofsixandareonchild-onlyMFIPforupto20hoursofchildcareperweekasrecommendedbythetreatingmentalhealthprofessional.

§ Appropriate$575,000tofundmultigenerationalmentalhealthprogramsforthreeyears.§ IncreasetherateforMotherBabyprogram.Thereimbursementrateforintensive

outpatientservicesdoesnotreflectthelevelofcareprovidedaswellasthefactthattreatmentisprovidedtoboththemotherandthechild.

Fundearlychildhoodmentalhealthconsultation.

ClubhouseServices

Issue:IncreaseaccesstoClubhouseservicesacrossthestate

Background:Clubhouseprogramshelppeoplewithmentalillnessesstayoutofhospitalswhileachievingsocial,financial,educational,andvocationalgoals.Peoplearemembers,notclients.StudiesshowthatClubhousemembersaremorelikelytoreportthattheyhaveclosefriendshipsandsomeonetheycouldrelyonwhentheyneededhelp,meaningthatClubhouseprogramsreducedisconnectedness.“Clubhousemembers(versusclients)appearedtoexperiencetheWOD(WordOrderedDay)asmeaningfulbecauseithelpsthem,atitsbest,reconstructalife,developtheiroccupationalselfandskillsetsandexperientiallylearnandlivewhatparallelsagoodlifeinthegeneralcommunity.Itappearsthattheseexperiences,interconnectingwiththefundamentalhumanneedsforautonomyandrelationship,pointtowellbeingandrecoveryaspartofpersonalgrowth”(Tanaka,K.&Davidson,L.(2014)PsychiatricQuarterly.)Thereareover12clubhousesinMinnesota,althoughonlyoneiscurrentlyaccredited.Thisisonemodel,butitisnotdesignedtoreplacecommunitysupportcenters.

CommunitySupportPrograms,includingthoserunbyClubhouseprograms,relyonalimitedfundingstream:CommunitySupportGrants(partoftheStateAdultMentalHealthgrants)andlocalcountydollars.Relianceonthisoftenat-riskfundingrestrictsthefurtherdispersionofClubhouseprogramsacrosstheStateofMinnesota,despitethefactthattheyareamongthemostcost-efficientcommunitysupportservicesavailable,andhavebeenproveneffective–reviewedandacceptedbySAMHSAforinclusionontheUSANationalRegistryofEvidenceBasedProgramsandPractices(NREPP).Thisisonemodelandisnotdesignedtoreplacedrop-incenters.

Recommendation:Ensurethatstatefundingtocountiesisusedtosupportclubhouses

PersonalCareAssistanceServices

Issue:Forapersonaltobeeligibleforpersonalcareassistanceservicestheymustrequirecuingandconstantsupervisiontocompletedailytask.Personslivingwithmentalillnessescanbenefitfromthisservice,butdonotnecessarilyrequireconstantsupervisionandthus,mayhaveverylimitedeligibilityforPCAservices.

Background:Personalcareassistance(PCA)isahomecareservice.Personalcareassistantsprovideservicesandsupporttohelppeoplewhoneedassistanceinactivitiesofdailyliving,health-relatedtasks,observationandredirection.

In2009,MinnesotapassedPCAreformlegislationwhichincludedchangestotheassessmentandauthorizationprocessrequiredtoaccessPCAservices.Asaresult,individualswhowerenotconstantlydependentonaPCAworkertocompleteatleastondailytasklostthisservice.Ina2010,areportfromtheDepartmentofHumanServicesoutlinedarequirementthat“DHSmustimplementanalternativeserviceforpersonswithmentalhealthandotherbehavioralchallengeswhocanbenefitfromotherservicesthatmoreappropriatelymeettheirneedsandassisttheminlivingindependentlyinthecommunity.”

Duringthe2011specialsession,legislationwaspassedtorestorelimitedeligibilityofahalfhourperdaytosomechildrenandadultswhowouldhavebeenterminatedfromPCAservicesunderthecutsadoptedin2009.However,therearestillindividualswhoeitherlostorcannotaccessservicesbecauseofcurrentstatutelanguage.

ThelegislaturedirectedDHSin2015tolookatwholostservices.Theirreportestimatedthat1,877peoplecoulduseCFSSiftheword“constant”wasremoved.

PolicyRecommendation:Removetheword“constant”fromthePCAstatutesothatindividualswhowouldbenefit,butwhodonotneedconstantsupervisioncanstillaccesstheseservices.HF1132/SF1102

AccesstoMentalHealthTreatment

CrisisResponseServices

Issue:Minnesotaresidentsdonothavetheappropriatelevelofmentalhealthcrisisservicesavailabletotheminanappropriateoreffectivetimeframe

Background:Existingservicesarespottyacrossthestatewithmentalhealthcrisisresponseservicesavailablemostlyinthemetroarea.Countiesallhaveacrisisnumberbutnotallhaveamobilecrisisresponse.Anappropriatecontinuumofcrisisresponsecareshouldincludeataminimum:

• 24/7crisisphone• Mobilecrisisresponse• Residentialandfostercarecrisisbeds• Urgentcareorwalkinclinics• 911andemergencydepartmentcollaborationwithcrisisteams• Crisishomes

Crisisservicespreventmorecostlyhospitalizations.Overthepastseveralyearsdatashowthatforbothchildrenandadultsover80%ofthoseservedbycrisisteamswereabletoavoidhospitalizations.Providingamentalhealthresponsealsolimitsinteractionswithpolice.

PolicyRecommendations:ContinuetobuildMobileCrisisResponsetoachieve24/7coverageacrossthestateby2018.Tostabilizeandexpandmobilecrisisservices,twokeyissuesneedtobeaddressed–workforceshortagesandfunding.

Manyruralandevenmetroteamsstrugglewithhiringappropriatelevelofstafffortheirteams.Thenatureofcrisisservicesmakesitanunattractiveopportunityandmanycrisisteamsarestaffedwithnewandinexperiencedstaff.Increasingpaytoemployeesprovidingthisservicewouldassistinkeepingandhiringstaff.Buildingteamsaroundmentalhealthpractitionersandcertifiedpeerspecialistswillalsocreatealargerpoolofresources.

StategrantsweredevelopedtocovertheuninsuredpopulationandMedicaidratesareinsufficienttocoverthecostsofmobilecrisisteams.Somecountiessubsidizetheteams,butnotall.PrivateinsuranceinMinnesotaisrequiredtocovercrisisteamsastheydoforambulanceservicesbutithasnotbeenimplemented,leavingalargepartofthepopulationnotcoveredordependingonthepublicsystemtocovertheirshare.Mostifnotallmobilecrisisteamsarestrugglingtocovertheirbottomlines.Thisalsomakesitdifficultforproviderstopayhigherratestoattractmoreexperiencedstaff.

TheLegislatureincreasedstatefundingby$800,000inonetimefundingforthebienniumtoexpandcrisisservices,includingco-locatingcrisisservicesinurgentcareclinicsandtodeveloppsychiatricemergencyrooms.

Statefundingshouldmakethisincreasepermanentandcontinuetogrowinthefuture.

PatientFlow�

Issue:PeoplearewaitingintheemergencyroomforabedandincommunityhospitalstogetintoAnokaMetroRegionalTreatmentCenter(AMRTC)oranIntensiveResidentialTreatmentServices(IRTS)facility.The‘48hourrule”givesjailinmateswhoarecommittedprioritytoaccessstate

facilities,inparticularAMRTC.Asaresult,patientsinthecommunitywhomaybemoreillandneedtocontinuetheircareatAMRTCareunabletotransitionoutofcommunityinpatientbedsandintoAMRTC.Thishascreatedasignificantbedflowproblemforcommunitypsychiatricunits.Tomakethesituationworse,alargepercentageofpeople–rangingfrom20%to50%-ofpeopleatAMRTCdonotneedthatlevelofcareandarewaitingtotransitionintothecommunity.TheMinnesotaHospitalAssociationreportsthatroughly20%ofthepeopleinaninpatientunitarewaitingforanotherlevelofservice.

Background:InMinnesota,thereare1,124inpatientcommunitymentalhealthbedsstatewide:960foradults,164forchildren/adolescentsincommunityhospitals.Therearealso646availablebedsatIntensiveResidentialTreatment(IRTS)andcrisisfacilitiesandseven16-bedCommunityBehavioralHealthHospitals.

Inpatientcommunitymentalhealthbedsarenottheonlywaytotreatpeoplewithaseriousmentalillness,buttheyareanimportantpartoftheservicecontinuum.Currently,thelackofinpatientpsychiatricbedshasbecomesoextremethatpatientsareessentiallybeingboardedinemergencyroomforweeksorevenmonthswhiletheywaitforanopening.Thisneedhasbecomesodirethatitisnecessarytoprovidemoreoptionsandnewincentivestoencouragethedevelopmentofinpatientmentalhealthbeds.

Minnesotaalsoneedstoaddmentalhealthcaretocurrenturgentcarecenterstoproviderapidaccesstotreatmentwhenitisneededinaverycost-effectiveway.WealsoneedtoincreasesupportforpsychiatricEDservices,whichcanofferafasterhand-offwhenpolicebringsomeoneintotheED;crisisteams;crisishomes;andmoresupportivehousingforpeopletotransitionoutofAMRTC.The2013LegislaturecreatedtheTransitiontoCommunityInitiativetohelppeoplebeingservedatAnokaMetroRegionalTreatmentCenter(AMRTC)andtheMinnesotaSecurityHospital(MSH)whonolongerrequirethelevelofcareprovidedatthesefacilities,totransitiontothecommunity.Theinitiativeprovidesaccesstoarangeofservices,includinghomeandcommunitybasedserviceswaivers,tohelppeopleleavethesefacilitiesandlivesuccessfullyinthecommunity.

Severaladditionalgroupsofpeoplewouldbenefitgreatlyfromtheinitiative.Theyincludepeopleoverage65,individualsatastate-operatedCommunityBehavioralHealthHospital(CBHH),andadultswhoarewaitinginourcommunityhospitalsand/orontheAMRTCwaitlist.AswithpeoplecurrentlyservedatAMRTCandMSH,manyoftheseindividualsfaceseriousbarriersthatpreventthemfromtransitioningbacktothecommunitywhentheynolongerneedthelevelofcareprovidedinthosefacilities.

Peopleoverage65faceanadditionalsetofuniquechallenges.Formanyindividualsage65andolderwhoaretransitioningbackintothecommunity,theindividualbudgetsavailablethroughtheElderlyWaiver(EW)arenotsufficienttomeettheircomplexneeds.Individualsage65andoverwhowerebeingservedonBrainInjury(BI)waiverorCommunityAlternativesforDisabledIndividuals(CADI)priortoturning65cancontinuetobeservedunderthesewaivers,buttheycannotentertheseprogramsafterturning65.Thelackofsufficientresourcesforhomeandcommunity-basedservicescreatesabarriertoanappropriateandtimelydischargeforthispopulation.

PolicyRecommendation:Addressthe“flowissues”thatarebackingupouremergencyrooms,hospitalsandAnokaMetroRegionalTreatmentCenter(AMRTC)by:

§ Repealthe48hourruleandprovidefundingformentalhealthtreatmenttoinmatesinjail.• ExpandingtheTransitiontoCommunityInitiativetoservepeopleoverage65,peoplein

CommunityBehavioralHealthHospitals(CBHHs),andpeopleincommunityhospitalsseekingadmissiontoAMRTC.

• Reworkhospitalconstructionmoratoriumtoeliminatebarrierstothedevelopmentofadditionalin-patientpsychiatricbeds.

• CreateapilotprojectforspecializedIRTSfacilitiestoservepeoplefromthecriminaljusticesystemtopreventpeopleenteringandtoassisttheminleavingAMRTC.

• RemoverequirementsplaceduponnewandexistingproviderstoexecutehostcountycontractsinordertoenrollasaMHCPproviderforvariousbehavioralhealthservices—specificallyACTservices,IRTS,andResidentialCrisisStabilizationServices.

• Removerequirementsplaceduponneworexpandingsubstanceusedisordertreatmentprovidertoprovethatneedforsuchservicesexistwithinaspecificgeographicarea,andinsteadallowneworexpandingproviderstoproceedwiththelicensureprocessandbelicensedabsentaspecificfindingbyDHSthatcurrentservicesaresufficientandadditionalserviceswouldbedetrimentaltoindividualsseekingsuchservices.

• Allow,underlimitedcircumstances,foratransferofalicenseorcertificationofcertainbehavioralhealthproviderssothatcontinuityofcareandcontinuedaccesstoservicescanbemaintainedincircumstanceswhereexistingprovidersareunabletocontinueexistingoperationsshortofutilizingthevoluntaryreceivershipprocessescurrentlyavailableinstatute.

MentalHealthParity

Issue:Mentalhealthservicesarenotcoveredbyinsuranceinthesamewayasmedicalhealthservices.

Background:TheMentalHealthParityandAddictionEquityActof2008(MHPAEA)isafederallawaimedatpreventinggrouphealthplansandhealthinsuranceagenciesthatprovidementalhealthorsubstanceusedisorderservicesfromimposinglessfavorablelimitationsonmentalhealthandsubstanceusedisorderservicesthanonothermedicalservices.

Thethreepillarsofmentalhealthparityare:

• OutofPocketCosts:mentalhealthparityrequires,withfewexceptions,thatcopaymentscannotbehigherformentalhealthcarethanothermedicalsurgicalbenefits,norcantherebeadifferentdeductibleorhigherout-of-pocketmaximumsformentalhealthcare.

• TreatmentLimits:Healthplanscannotestablishdifferentquantitativelimitsformentalhealthcarethanothermedicalbenefits.Forexample,itisaparityviolationtoofferunlimitedprimarycareappointmentsbutonlythreementalhealththerapyappointments.

• NQTL: A Non-Quantitative Treatment Limitation (NQTL) makes non-numerical limitations to the scope or duration of benefits for treatment. An NQTL can take the form of step-therapy for a medication, different standards for a provider to enter a network including reimbursement rates, or other limits based on facility type or provider specialty that limit the scope or duration of health plan benefits. Mental health parity stipulates that the standards that a health plan uses when making an NQTL cannot be any more stringent or restrictive for mental health and substance use disorder treatment than it is for other categories of health care.

Whileallthreeoftheseparityviolationsstilloccur,themostcommonformofdiscriminationthatmentalhealthandsubstanceusedisorderpatientsexperienceisthroughNQTLsfromtheirhealthplan.

Forexample,manyplanspayforrehabinanursinghomeafterahipreplacementbutwon’tpayforrehabinanIntensiveResidentialTreatmentProgramforsomeonewithaseriousmentalillnessleavingthehospital.

PolicyRecommendations:

HF1974/SF2028

• Annual reporting: Require health plans that offer mental health and or substance use disorder services to submit an annual report to the commissioner that documents every NQTL applied to mental health or substance use disorder benefits and medical and surgical benefits, as well as an analysis that confirms that the standards for determining an NQTL for mental health and substance use disorder treatment are not more stringent or restrictive than for other medical or surgical benefits.

• Enforcement: Department of Commerce and the Department of Health should monitor the implementation of mental health parity and ensure that health care plans are following mental health parity requirements.

• Regular market analysis: Because there often substantial differences in access to in-network mental health care and out-of-pocket costs when compared with coverage for other medical conditions, it is very important for the Department of Commerce to conduct regular audits of the health insurance market to ensure compliance with federal parity regulations.

AccesstoMedication

Issue:Individualsexperiencebarrierstoobtainingprescribedbest-choicemedicationduetofrustratingandproblematicregulations.

Background:Findingtherightmedicationandtreatmentforamentalillnesscanbedifficult.Adherencetoatreatmentplancanbeevenmoredifficult.Researchhasshownthatwhenanindividualwithamentalillnessisengagedindevelopingthetreatmentplanandwhenthereisshareddecisionmaking,theoutcomesarebetter.Theindividualandtheirphysicianshouldworktogethertodetermineabest-choicemedicationbasedupontreatmentgoalsandriskofside-effects.

Steptherapy,whereyoumuststartwithtypicallythecheapestandoldestmedicationandmust“fail”beforetryinganothermedication,doesnotallowforbestpracticesintermsoftreatmentengagementnordoesitallowthephysiciantorecommendwhichmedicationmayworkbestbasedonanumberofitemsincludingresearchandfamilyhistory.Somesideeffectsaremoretolerablethanothers,whichmeansitiscriticalthattheindividualbeinvolvedinthedecisionmaking.Mentalillnesseshaveageneticcomponent.Ifafamilymemberhas,forexample,depressionandhasfoundamedicationthatworkswell,itmaybeappropriateforanotherfamilymembertotrythatmedicationfirst.

Controllingcoststhroughfail-firstapproachesconflictswithmostclinicaltreatmentguidelinesformentalillnesses.Bylimitingthearrayofmedicationoptionstopeoplewithmentalillnesses,bothphysiciansandindividualsareforcedtocompromisetheirtreatmentdecisions.Whilestudiesmayshowthatthereisrelativelylittledifferenceintheeffectivenessofaclassofmedication,thesestudiesprovidenoinformationondiscontinuationofmedicationsorintolerablesideeffectsorfailuretoadequatelycontrolsymptoms.These“costsavingmeasures”oftenplacepeoplewithmentalillnessesatriskofpooroutcomessuchaspsychiatricdecompensationandre-hospitalization,withlittleevidencethattheysavemoneyorimprovequalityofcareoverthelong-term.

Anindividualmayalsohavetochangeamedicationthathasbeenworkingforthemshouldtheydecidetoswitchtoaninsuranceplanthatbettermeetstheirneeds.Peopleshouldnotbelimitedtocertainhealthcareinsuranceplansforfeartheymightloseaccesstotheirprescribedmedication.

Often,apersonwithamentalillnesswillhavetofailononeormoremedicationsbeforetheyareallowedaccesstothemedicationtheywouldhavetriedasaninitialtreatment.Itispoorclinicalcaretodelaythestartofeffectivetreatmentandexposeapersonwithmentalillnesstoincreasedrisks.

PolicyRecommendation:Advocatethatstatelawsdonotinterferewithpeopleobtainingthemosteffectivemedication.

HF747/SF593

• AnypriorauthorizationforaprescriptiondrugmustremainvalidforthedurationofthecontractyearunlessthedrughasbeendeemedunsafebytheFDA,thereisevidenceofenrolleesabuseormistreatmentofthedrug,

• Ahealthplanthatprovidesprescriptiondrugcoverageandusesaformularymustdiscloseitsformularyandrelatedbenefitinformationatleast30dayspriortoannualrenewaldates.

• Onceaformularyisestablished,ahealthplancanonlyremoveabrandnamedrugorplaceitinahighercostbenefitcategoryifthisdrugisreplacedwithagenericdrugdeemedtherapeuticallyequivalentorabiologicdrugratedasinterchangeableaccordingtotheFDA.

StepTherapyLegislation

• Thelegislationallowssteptherapyonlyifcertainrequirementsarefollowedindevelopingthesteptherapytool.

• Thelegislationalsoallowsaprescriberorpatienttorequestanoverrideoftheprotocolinspecificcircumstanceswhennon-prescribeddrugislikelynotmedicallyappropriateforthepatient.

EarlyInterventionandFirstEpisodePsychosisPrograms

Issue:Therearelimitedprogramsandservicesavailableforpeopleexperiencingtheirfirstpsychoticepisode.Theresultsareadverseoutcomesanddisabilitycausedbytheiruntreatedmentalillness.

Background:Individualsexperiencingtheirfirstpsychoticormanicepisodearenotreceivingtheintensivetreatmenttheyneedtofosterrecovery.Onaverageapersonwaits74weekstoreceivetreatment.Ourmentalhealthsystemhasreliedona“fail-first”modelofcarethatessentiallyrequirespeopleexperiencingpsychosistobehospitalizedorbecommittedmultipletimesbeforetheycanaccessintensivetreatmentandsupports.Thiscostsoursystemagreatdealandcoststheindividualevenmore.Thereiscompellingevidencethatintensiveearlyinterventioncanfosterrecoveryandpreventadverseoutcomesfrequentlyassociatedwithuntreatedpsychosis.

ToaddresstheneedinMinnesotaweestimatethateightteamswouldbeneededandeachwouldserve30youngpeopleatonetime.Peoplestaywiththeteamanaverageoftwotothreeyears.Eachteam,basedoncalculationsusedinNewYork,wouldcostroughly$250,000,inadditiontoreimbursementbyinsurance.

Duringthe2015legislativesessionfundingof$260,000,inadditiontothetenpercentfromthefederalmentalhealthblockgrant,wasmadeavailabletocreateevidence-basedinterventionsforyouthatriskofdevelopingandexperiencingafirstepisodeofpsychosis.Projectswilloffercoordinatedspecialtycareincludingcasemanagement,psychotherapy,psychoeducation,supportforfamilies,cognitiveremediation,andsupportedemploymentand/oreducation.Theseprogramsprovideintensivetreatmentrightawayforsomeoneexperiencingsymptomsofpsychosis.IngreaterMinnesotathegeographiccatchmentareatoreachtheneededpopulationwillbegreat

meaningthathousingmustbemadeavailablefortheyoungpersonandtheirfamilytoaccessthisoutpatienttreatmentprogram.CurrentlythereareonlythreeprogramsinMinnesota.

In2017,thelegislatureappropriatedanadditional$1illiondollarsinonetimedollarsforthebienniumtofundfirstepisodeprograms,includingtheuseoffundstoensurethatindividualswholiveinruralareascanaccesstheprogrambypayingfortravel,housing,andadditionalbarrierstoaccess.

• Increasethenumberoffirstepisodepsychosis(FEP)programssothatyoungpeopleexperiencingtheirfirstpsychoticorfirstmanicepisodereceiveintensivetreatment.Wewillrequire8FEPprogramstoadequatelymeetstatewidedemandforthisevidence-basedpractice.

MentalHealthServices

ReimbursementRatesforMentalHealthServices

Issue:Existingpublicprogram(MedicalAssistanceandMinnesotaCare)ratespaidtomentalhealthprovidersareinsufficient.Asaresult,communitymentalhealthprovidersarehemorrhagingfinancially.Theexistingrates,andinadequateratesettingprocess,threatenstheon-goingoperationofmentalhealthservices,particularlysafetynetservices.Background:ExistingmentalhealthreimbursementratesaretoolowandnotsufficienttosustainMinnesota’smentalhealthsafetynetnetwork.Planningrelatedtobuildingamoresustainable,integratedbehavioralhealthcaresystempromisestoenhancethefunding,accessibility,andqualityofmentalhealthservicesstatewide.Thesereforms,however,taketimetoshapeandimplement.Tosustaincoreservicesforthelow-incomeindividualsandtheuninsuredintheshortterm,thereisanurgentneedtoincreasereimbursementratesformentalhealthproviders.Thenegativeimpactofhistoricallylowratesiscompoundedbyincreasesintheminimumwage,newfederalovertimemandates,increaseddemandforservices,andmuchhigherwagesofferedbycertainfor-profitprivateprovidersandgovernmentagencies.Withsomecurrentratestoprovidersbetween0.37to0.50centsonthedollar,thisisnotsustainable.

PolicyRecommendation:Reviewfederalregulationsformanagedcaretoensurethattheseplansofferadequateratesandaccessformentalhealthtreatment.

MedicalAssistancePaymentsUnderManagedCareIssue:ThefinancialdistressbeingexperiencedbycommunitymentalhealthprovidersisfueledinpartbyPMAPsnotpayingthefull,approvedMAfee-for-serviceratesforsomeorallservices.Background:Inthewordsofoneprovider,“nothingisconsistentwithanyofthepaymentsfromanyofthePMAPs.”In2016,theplanspaidbelowMAratestothemajorityoftheproviderswhorespondedanonymouslytoasurveyconductedbyMACMHP.Thesameinconsistentpaymentsaresimilarforthenewcodesandrecentlegislationmandatingafivepercent(5%)increaseforMAservices.

MinnesotaAssociationofCommunityMentalHealthPrograms(MACMHP)memberssurveyedexpecttoloserevenueasaresultofthenewmanagedcarecontractsin2016.Providersareinvestingasignificantamountoftimeinreprocessingclaimsandinappealingrejectedclaims.Inaddition,thereareinconsistentdecisionsaroundstaffcredentials.Overall,theinconsistency,lackofclearinformation,longdelayinreimbursementandhighlevelofadministrativeeffortismakingthebusinessrelationshipwithaManagedCareOrganizationanunsustainableproposition.

PolicyRecommendation:Ensureaccuratereimbursementsarepaidtoprovidersforservicescontractedundermanagedcare-paymentratesequaltooraboveMAfee-for-servicerates.

MentalHealthWorkforceShortages

Issue:Therearenotenoughmentalhealthpractitionersandprofessionalstomeettheneedsofthechildrenandadultsrequiringmentalhealthservices.

Background:Psychiatry,psychology,clinicalsocialwork,psychiatricnursing,marriageandfamilytherapyandprofessionalclinicalcounselingareconsideredthe“core”mentalhealthprofessions.Formanyyears,Minnesotahasexperiencedashortageofprovidersofmentalhealthservices.Thisshortagehasbeenfeltmostprofoundlyintheruralareasofthestate.Thereisalsoanongoing-shortageofculturallycompetentandculturallyspecificproviders.

NineofelevengeographicregionsinMinnesotaaredesignatedmentalhealthshortageareasbytheHealthResourcesandServicesAdministration(HRSA).Asmorepeopleseekmentalhealthtreatmentandasweworktoexpandaccesstomentalhealthservicesacrossthestate,thereisagreaturgencytoincreasethesupplyofcommunitymentalhealthprofessionals.

Addingtothis,reimbursementratesformentalhealthservicesthathavenotkeptpacewithotherhealthcareservicesorhealthcareinflation.Overthepasttenyearstherehavebeeninconsistentincreasesamountingtominorincreasesformentalhealthservicewhenaveragedovertime.

The2013legislaturepassedabillrequiringMinnesotaStateCollegesandUniversities(MnSCU)toholdamentalhealthsummitanddevelopacomprehensiveplantoincreasethenumberofqualifiedpeopleworkingatalllevelsofourmentalhealthsystem,ensureappropriatecourseworkandtrainingandcreateamoreculturallydiversementalhealthworkforce.

In2015theMentalHealthWorkforcereleasedthereportwithrecommendationstoaddressworkforceshortagesbyincreasingthenumberofqualifiedpeopleworkingatalllevelsofourmentalhealthsystem,ensureappropriatecourseworkandtrainingformentalhealthprofessionalsandcreateamoreculturallydiversementalhealthworkforce.In2016aworkforcesummitwasheldtofurtheraddressworkforceshortages,especiallyinthedirectsupportandcarefields.

• Ensureaccesstoaffordablesupervisoryhoursformentalhealthcertificationandlicensure.• Reducebarrierstomentalhealthworkersobtainingsupervisionhoursrequiredtobea

mentalhealthpractitioner.• Increasefundingfortheruralhealthprofessionaleducationloanforgivenessprogramand

setasidefundsforpeopleworkinginmetroareaprogramswheremorethan50%ofthepatientsareonMedicaidoruninsured.SF1452

• Requireinsurancetocovertreatmentandservicesprovidedbyaclinicaltrainee. HF871/SF1577

• Reviseexperienceandcredentialingrequirementsforthreeentry-levelworkermentalhealthpositions.Thisreformofcredentialingrequirementsforentry-levelworkersmustbecoupledwithanincreaseinwagesfortheseworkers.

• AddLMFTsandLPCCstotheMERCprogram. HF 1749/SF1626• Providegrantfundingforculturallycompetentmentalhealthproviderconsultation.HF

ExpandUseofTelemedicineIssue:Currentstatutelimitsthefrequencyandtypeofproviderswhocanusetelemedicinetoservepeopleexperiencingmentalillness.

Background:Telemedicinehasemergedasaviable,costeffective,andappropriatevehiclefordeliveringarangeofmentalhealthservicesinthecommunity.Statepolicyandstatutesneedtobeupdatedtosupporttheexpansionandaccessibilityofthiscaredeliverymodel.Morepeoplewillhaveaccesstoqualitycareconsistentlywhentherangeofprovidersandhoursofcareprovidedviatelemedicineareexpanded.PolicyRecommendation:Increasethecaponthenumberofencounterspermittedinaweekfromthreetoten.

LicensureandSupervisoryRequirements

Issue:PsychologistsandapplicantsforlicensureareexperiencingchallengesrelatedtothechangingimplementationofthePsychologyPracticeAct

Background:RecentlytherehavebeenconcernsraisedaboutthePsychologyPracticeActorlicensurestatuteforpsychologists.Concernshavebeenraisedabouttheclarityofstatedrequirementsforsupervisionwhicharebeingfurtherspecified.Thisrevisionstreamlinesmobilityoflicensureforindividualslicensedatthedoctorallevelinotherjurisdictions,whichhelpstoaddressworkforceissues..

PolicyRecommendations:SupportthebilltoupdateandclarifythePsychologyPracticeActtoimproveaccesstocare.

DutytoWarn�

Issue:CurrentMinnesotastatutecoversonlycertainmentalhealthprofessionalorpractitionertraineesunderdutytowarnprotectionandliability.

Background:Minnesotastatutedefinesdutytowarnasthedutytopredict,warnof,ortakereasonableprecautionstoprovideprotectionfromviolentbehaviorwhenaclientorotherpersonhascommunicatedtothelicenseeaspecific,seriousthreatofphysicalviolenceagainstaspecific,clearlyidentifiedoridentifiablepotentialvictim.Ifadutytowarnarises,thedutyisdischargedbythelicenseeifheorshemakes“reasonableefforts”(communicatingtheserious,specificthreattothepotentialvictimandifunabletomakecontactwiththepotentialvictim,communicatingtheserious,specificthreattothelawenforcementagencyclosesttothepotentialvictimortheclient.)tocommunicatethethreat.

Legislationwaschangedin2016toprovidedutytowarnprotectionfortraineesinthedisciplinesofPsychology,MarriageandFamilyTherapy,andLicensedAlcoholandDrugCounseling.SocialWorkandLicensedProfessionalClinicalCounselortraineeswerenotcoveredinthelegislation.Thesegroupsmaywishtoconsiderinclusionoftheirtraineesinthedutytowarnprotections.

PolicyRecommendation:Expanddutytowarntootherappropriatementalhealthtrainees.

Children’sMentalHealth

EarlyChildhoodConsultation

Issue:Childcareprovidersandeducatorsdonothavethenecessarytrainingorskillstoadequatelysupportchildrenwithmentalhealthneeds.Childrenaregettingkickedoutofchildcareinsteadofreceivingthesupportsandtreatmenttheyneed.

Background:Since2007,Minnesotahasinvestedinbuildinginfrastructuretoaddressearlychildhoodmentalhealththroughgrantstosupportanddeveloptheavailabilityofandaccesstodevelopmentallyandculturallyappropriateservicesforyoungchildren.Theseinfrastructuregrantsareusedtostrengtheninfrastructureandsupportdevelopmentallyandculturallyappropriateservicesforyoungchildren.

Earlychildhoodmentalhealthconsultationgrantssupporthavingamentalhealthprofessional,withknowledgeandexperienceinearlychildhood,providetrainingandregularonsiteconsultationtostaffservinghighriskandlow-incomefamilies,aswellasreferralstoclinicalservicesforparentsandchildrenstrugglingwithmentalhealthconditions.Earlychildhoodmentalhealthconsultationwouldhavethreemaincomponents:

• On-sitementalhealthconsultationandsupportforchildcareagencystaff.Mentalhealthagencieswillalsoworkdirectlywithfamiliesasappropriate.

• Referralforchildrenandtheirfamilieswhoneedmentalhealthservices.• Trainingforchildcarestaffinchilddevelopment;trauma/resilience;workingwithfamilies

whohavetheirownhavementalhealthissues;andskillstobettersupporttheemotionalhealthanddevelopmentofchildrentheyworkwith.ThesetrainingswouldbebuiltintotheParentAwareratingsofparticipatingchildcareagencies.

Somechildren,particularlywhenexposedtotrauma,wouldgreatlybenefitfromobtainingimmediatetreatment.Childrenfromculturallyspecificcommunitiesoftendonotbecomeinvolvedintreatmentduetotheneedforthefamiliestodeveloptrustandarelationshipwiththementalhealthprofessional.Therequirementthatadiagnosticassessmentbecompletedbeforetreatmentbeginshampersourabilitytoimmediatelyassistachildwhohasexperiencedtraumaandtodeveloparelationshipwithfamilies.Allowinganexceptioncouldprovideearlytreatmentandpreventdisability.PolicyRecommendations:

• AppropriatefundstoexpandearlychildhoodmentalhealthconsultationgrantsHF2101/SF1978

School-LinkedMentalHealthGrants

Issue:ExpandSchool-linkedMentalHealth(SLMH)Grants.

Background:Since2008,grantshavebeenmadetocommunitymentalhealthproviderstocollaboratewithschoolstoprovidementalhealthtreatmenttochildren.Thisprogramhasproducedwonderfuloutcomesandhasreducedbarrierstoaccesssuchastransportation,insurancecoverage,andfindingproviders.Itwassosuccessfulthatthelegislatureincreasedfundingin2013and2016.

Followingtheincreasedfundingin2013SLMHwasexpandedtoallbuteightcountiesinMinnesota.Onaverage15,000studentsareservedduringtheschoolyear.Thereare36SLMHgrantees,serving872schoolswithinmorethan230schooldistricts.Thismeansservicesin85%oftheschooldistrictsinthestateand45%oftotalschoolbuilding.

Thisprogramworkshand-in-handwithschoolsupportpersonnelsuchasschoolnurses,schoolpsychologists,schoolsocialworkersandschoolcounselors.Effortsmustbemadetoensurethattherearesufficientschoolsupportpersonneltohelpthosechildrenwhodonothaveamentalhealthdiagnosis.

§ Increasefundingforschool-linkedmentalhealthgrants HF 960/SF1369• Streamlinegrantapplicationstoallowpreviousgranteesthathavegoodoutcomesand

demonstratesupportfromtheircurrentschoolpartners• Creategrantsfor“community-college”linkedmentalhealthservices.

Children’sResidentialTreatmentFunding

Issue:Since2001,withapprovalfromCMS,MinnesotahasusedMedicalAssistancetopayforthetreatmentportionoftheperdiemforresidentialtreatmentservices.Recently,CMShasdirectedDHStorevieweachofthesefacilitiestodeterminewhethertheymeetthedefinitionofInstitutionsofMentalDisease(IMDs)whichwouldmakethemineligibleforfederalMedicaidfunding.

Background:Programsthatarelargerthan16bedsthatprovidementalhealthtreatmentareconsideredIMDsundertheCMSdefinitionandmostoftheservicesinMinnesotaareprovidedinlargerprograms.ChildrenresidinginIMDswouldalsolosetheirMedicalAssistanceeligibility.Thislossoffederalfundingwouldaffectstateandlocalbudgetsandwouldimpactaccesstotheseprogramsforchildrenandadolescents.Minnesotahasover800bedsinthecontinuumofcarethatwouldbeaffectedbythislossoffunding.

PolicyRecommendation:TheLegislaturedidprovidefundingtoreplacethelossoffederalfinancialparticipationthroughMedicaid.However,thestatefundingmustbeextendedinordertobeavailablethroughJune20,2021.

PsychiatricResidentialTreatmentFacilities

Issue:APsychiatricResidentialTreatmentFacility(PRTF)broadensthecontinuumofcarebyofferingservicesthatarelessintensivethaninpatienthospitalcarebutmoreintensivethanourcurrentresidentialprograms.

Background:PsychiatricResidentialTreatmentFacilities(PRTFs)wereestablishedunderMAforthefirsttimein2015withtheintentionofenrollingupto150PRTFbedsatamaximumof6sites.APRTFservesyouthsuptotheageof22(solongastheyenteredtheprogramwhiletheywere21).Thisprogramprovidesactivetreatmentratherthanrehabilitationmusthaveapsychiatristorphysicianasamedicaldirector,andrequire24hournursing.TheratesincluderoomandboardunderMAandthusparentsdon’tneedtogotocountiesandthroughcountychildprotection/voluntaryplacementprocess.Additionally,PRTFsareexemptedfromtheInstituteforMentalDisease(IMD)exclusion,whichprohibitsMedicaidfundingformentalhealthtreatmentinanyfacilitygreaterthan16beds.Thisfundedupto150newbedsinuptosixsitestobeopenedin2017,withadditionalbedsinsubsequentyears.

PolicyRecommendation:

• IncreasenumberofPRTFbedsfrom150to200beds.Ensurethatthisincreaseisnotmadebyremovingbedsfromanotherservice.

TransportationtoChildren’sMentalHealthServices

Issue:Childrenarebeingtransportedinasystemthatisdesignedandregulatedtorespondtotheneedsofadults.

Background:Non-emergencymedicaltransportationisanessentialservicetoensureaccesstomentalhealthservices.Childrenrepresentauniquepopulationandareoftenbeingtransportedtoearlychildhoodmentalservicesthatshouldrequirethetransportationprovidertohavetherightequipment,likecarseats,andtrainingsothatdrivershavetheinformationandskillsneededtosafelydealwithchildrenwithspecialneeds.

PolicyRecommendation:Thecommissionershouldbedirectedtoconsultstakeholdersandadvocatestodeveloprecommendationsforstandardsandfundingfortransportationproviderswhotransportchildren.

AlternativestoSuspensioninK-3

Background:Duringthe2014schoolyearchildreningradesK-3wereoutofschool8,102daysduetosuspensions.Around3,000childreninthesegradesaresuspendedeveryyear.Suspendingchildreninthisagegroupiscounter-productive.Theydonotlearnanythingwhenoutoftheclassroomandanyunderlyingissues–suchasexposuretotrauma,earlyonsetmentalillness,lagginginsocialemotionalskills–arenotaddressed.Someresearchdemonstratesthatthemoredaysachildmissesupthroughthirdgradethegreaterlikelihoodthatheorshewilldrop-outofschool.

• SchoolsshouldnotbeallowedtosuspendstudentsingradesK-3andfundingshouldbemadeavailabletoaddressthesocialemotionalneedsofthesechildren.

• Requireareportonachildinjuringateachertoonlybeforwardedtothenextteacherforoneyear.

EducationinCareandTreatmentMentalHealthPrograms

Issue:Childrenandadolescentswhoneedmoreintensivementalhealthservicesindaytreatmentandresidentialtreatmentprogramsareoftenbehindintheireducationduetotheirmentalillnessesandcurrentlawlimitswhocanprovideeducationservicesinthesesettings.

Background:Currentlawonlyallowsthelocaldistricttoprovideeducationservicesintheseprogramsaccordingtothedistrict’sschedule.Forsomedistrictsthatmeansthattheeducationhoursarelimited,noeducationisprovidedduringthesummer,andeducationstaffarenotabletobeintegratedintothetherapeuticmilieuonaconsistentbasis.Moreoptionsneedtobeavailabletomeettheneedsofthesechildrenwhenthelocaldistrictisunabletoprovidetheneededservices.

PolicyRecommendation:ChangethestatutetoallowMDEtoapproveothermodelsofeducationservicesinthesesettingsincludingcharterschools,contractsforservicesorprogramoperationoftheeducationservices.

KognitoSuicidePreventionTraining

Issue:Suicideisthethirdleadingcauseofdeathforyouthbetweentheagesof18and24,withanunderlyingmentalillnessbeingpresentin90%oftheyouthwhohavecompletedsuicide.Accordingtothe2016MinnesotaDepartmentofEducationSurvey,9,35211thgraders,9,6789thgraders,and8,6708thgradepublicschoolstudentsseriouslyconsideredsuicide.InMinnesota,48youthaged10-19completedsuicidein2016.Properlytrainedteacherscanplayaninvaluableroleinengagingyouthwithmentalillnessesandreducingtheriskofsuicide.

Background:TheMinnesotaLegislaturepassedalawin2016requiringallteacherstotakeone-hourofnationallyrecognizedsuicidepreventiontrainingaspartofrenewingtheirteacher’slicense.Changesinteacherlicensurein2017keptthisrequirementforallTierIVandVlicenses.TheMinnesotaDepartmentofHealthhassupplementedthiseffortthroughagrantthatallowsschoolstoapplytohaveaccesstotheonlineKognitoSuicidePreventionTraining.Throughthisgrant,administeredbyNAMIMinnesota,30schooldistrictsandover1,000teachersreceivedsuicidepreventiontraining.

Kognito’sonlinetrainingisaSAMHSArecognizedevidence-basedpracticethatcontainsrole-playingsimulationswhereteachersinteractwithanimatedstudentsexhibitingsymptomsofmentaldistress.Teacherslearntouseevidence-basedtechniquestoengageinaconversationwithastudentexperiencingamentalhealthcrisisandtoencouragethatstudenttoseekadditionalhelpwhennecessary.Thistrainingcanbecompletedinanhourandisavailable24/7toanyonewithinternetaccess.Inadditiontoprovidingtheteacherwithevidence-basedtechniquestointeractwiththeirstudents,theKognitoplatformalsoprovidesalinktoinformationaboutlocalmentalhealthresources.

PolicyRecommendation:MakeKognitotrainingavailableineveryschooldistrictinMinnesota.

• A 2-year contract with Kognito for the State of Minnesota would be $273,000, or about $44 per school.

• A 1-year contract with Kognito costs $183,000, or about $56 per school.

CriminalJustice

AdministrativeandDisciplinarySegregation

Issue:Segregationandisolationhavenegativeimpactonaperson’smentalhealth.Giventhehighrateofpeoplewithmentalillnessesinprison,theuseofsegregationandisolationpreventspeoplefromreceivingadequatetreatmentwhenthereislimitedtreatmentinthefirstplace.

Background:"Disciplinarysegregation"meansthestatusassignedaninmatefollowingahearinginwhichtheinmatewasfoundinviolationofafacilityruleorstateorfederallaworthestatusassignedaninmatebeforeahearingwhensegregatingtheinmateisdeterminedtobenecessaryinordertoreasonablyensurethesecurityofthefacility.

Thereisresearchtosupportthepsychologicalstressandstrainthatresultfromtheuseofdisciplinarysegregationinprisons,especiallyforpersonswithmentalillnesses.Individualswhoareheldinsolitaryconfinementspendnearlyeveryhourofthedayinasmallwindowlesscellwithnocontactwithothers.Theuseofsegregationandisolationisalsoextremelyexpensiveandcounterproductiveifthehopeistosupportrehabilitationbackintothecommunity.

InMinnesota,limitedinformationisavailableabouttheuseofsegregation;butwhatwedoknowisthatthispracticeisoftenusedonyoungadults,involvesundulyharshphysicalconditions,andcanbeextendedoverlongperiodsoftime.Disciplinarysegregationmaybeimposedforrelativelyminorviolationsofprisonrules.Therearealsodischargesdirectlyfromsolitaryconfinementbacktothecommunity,asituationwhichimposesenormousadaptivestrainsontheindividualsinvolved.

HF742/SF608

• RequiretheDepartmentofCorrectionstodevelopgraduatedsanctionsforruleviolations,sothatsegregationbecomesthelastresort.

• Establishappropriatephysicalconditionsofsegregatedunits,includingreducedlightingduringnighttimehours,rightsofcommunicationandvisitation,andfurnishedcells.

• Requiremandatoryreviewofdisciplinarysegregationstatusevery15daysbythewardenofinstitutionandevery15daysthereafter.Onceaninmateserves60daysindisciplinarysegregation,theinmate’ssegregationstatusmustbereviewedbythecommissionerordeputyorassistantcommissionerandthenevery30days.

• Notallowreleasinganinmatetothecommunitydirectlyfromsegregatedhousing.Requireinmatestoserveatleast30daysinthegeneralpopulationbeforetheirrelease.

• Ifaninmatehasbeenplacedinsegregatedhousingfor30ormoredays,theirtransfertothegeneralpopulationmustbereviewedbyamentalhealthprofessionalbeforethistransferismade.

• RequiretheDepartmentofCorrectionstoissueayearlyreporttothelegislaturethatdocumentstheuseofsolitaryconfinementincludingthenumberofinmatesinsolitary,theirages,thenumberofinmatestransferredfromsegregationtothementalhealthunit,thenatureofinfractionsleadingtosegregation.

InvoluntaryAdministrationofMedicationinJails

Issue:Apersonwhohasamentalillnessandisdetainedinajailmaynotbewillingtotaketheirprescribedantipsychoticmedication.Therearefewplacesworsethanjailtosuddenlystopan

antipsychoticmedicationandbecausethereisalackofmentalhealthserviceswithinthejailstheoutcomecanbedevastating.

Background:Therearenotenoughcommunity-basedmentalhealthservicestomeettheneed.Unfortunately,thismeansthatpeoplewithseriousmentalillnessoftenencounterthecriminaljusticesystembeforegettingappropriatementalhealthtreatment.Thecriminaljusticesystemisnotcurrentlyequippedtoprovideadequatementalhealthservices,supportorresourcesforinmateswithmentalillnesses.

AccordingtostatisticfromtheSteppingUpInitiativetherearenearly2millionpeoplewithseriousmentalillnessesadmittedtojailsacrossthenationeachyear.Onceincarcerated,individualswithmentalillnesseshavelongerstaysinjailandareatahigherriskofreturningtojailcomparedtoindividualswithoutmentalillnesses.Inaddition,thecostsacquiredbyjailsaretwotothreetimeshigherforadultswithmentalillnesses.

Thejailsarenotsetuptotreatmentalillnesses.Theyshould,however,berequiredtofollowsensibleproceduressothatthementalhealthconditionsofpeopleinjaildonotgodownhillwhiletheyareinthecustodyofthecounty.Insomecases,throughevaluation,stabilization,anddischargeplanning,theindividualmaybebetteroffatdischargethantheywereatbooking.

Inothercases,apersoninjailwhoisnottakingmedicationsmaydecompensateandbecomeadangertohimorherself.Inthesesituations,asheriffmaycontactprepetitionscreeningandseekacourtorderforcommitmenttoadministernecessarymedicationinvoluntarily.

• Authorizethesherifftoseekcommitmentandinvoluntaryadministrationofantipsychoticmedicationtoapersonwhoisincustodyandwasadmittedwithavalidprescriptionforanantipsychoticmedication,butrefusesmedication.

• AuthorizethejailhealthcarestafftoimplementacurrentJarvisorder.

MedicationsandAssessmentsinJails

Issue:Jailsfollowaformularyandarenotrequiredtoprovideapersonwhoisdetainedwiththeexactpsychotropicmedicationstheyareprescribed.Althoughjailsrequirementalhealthscreeningsduringintake,mentalhealthassessmentsandfollowupforongoingmentalhealthservicesoftendonothappen.ALegislativeAuditor’sreport(March,2016)showedvastlydifferentpracticesinthesetwoareas,aroundthestate.

Background:Althoughjailsarerequiredtoadministersimplementalhealthscreeningsduringthebookingprocess,thereisnorequirementtofollowupforthosewhoscreen“positive,”witheitheradiagnosticassessmentortheimplementationofacareplan.Asaresult,jailsacrossthestatehaveverydifferentpracticesinrespondingtonewinmateswithmentalhealthissues.

Maintaininghealthcarecostsinjailsclaimsalargeportionofthecorrectionalbudget.Inordertocutcosts,manyfacilitiescontractwithanexternalhealthcarecompanytocontrolcosts.Thesecompaniesoftenhaveextremelylimitedformularies,orapproveddruglists.Aformularytypicallycontainsonlythemostcost-effectiveversionofamedication.Jailphysiciansmayonlyprescribemedicationsfromthislist,regardlessofmedicationstheinmateiscurrentlytakingormayhaveutilizedinthepastandchangingaperson’spsychotropicmedicationwhiletheyareinjailissimplynotagoodidea.

InthestateofMinnesota,individualscomingintothejailshavetheircurrentmedicationsswitchedtoformulary-approvedmedicationsbyjailphysicians.Ifapersongetsapprovalforanon-formularymedicationwhileinjail,Minnesotahasnosupplementalprotocolsinplacewhilewaiting

forthemedicationtobeapproved.Ifanon-formularymedicationweretobeapproved,theinmatewouldstillbetemporarilyswitchedtoadifferentmedication.Evenashort-termchangeinmedicationcancausesignificantsetbackstoaperson’smentalhealth.

Forthoseinmateswhoareabletoaccesstheirmentalhealthmedicationwhileinjail,itcanbeachallengetocontinuereceivingtheirmedicationsfollowingdischarge.Onepotentialsolutionistohavethejailscontractwithalocalcommunitymentalhealthprovider.Notonlywillthisallowexpertstomanagementalhealthmedicationsforinmateswhiletheyareinprison,acommunitymentalhealthprovidercanalsocontinuetoservetheindividualfollowingtheirrelease.

Inaddition,theprovisionofmedicationtopeopletopeoplebeingdischargedfromjailsisextremelyinconsistentfromcountytocounty.

HF982/SF1323

• Requireacountyofregionaljailtoprovideaprisonerwhohasavalidprescriptionforapsychotropicmedicationthesamepsychotropicmedicationwhileincarcerated.

• Requirethatanadequatesupplyofthemedicationbegiventotheinmateatdischarge.• Requirethatprisonerswhohavescreenedpositiveformentalillness,whowillbeincustody

for14daysormore,haveaassessmentbyamentalhealthprofessional(unlessthishasbeendonerecently),andthatatreatmentplanisdevelopedandimplemented.

• Contractwithlocalcommunitymentalhealthprovidertooffermentalhealthservicesandprescribemedicationsinjail.

OmbudsmanforMentalHealthServicesinCorrections

Issue:Thereisnocentralofficeoreasilyaccessiblegrievanceprocedureforindividualswithamentalillnesswhohavebeenincarcerated.Inthecountyjails,oversightisprovidedonlybyasmallstaffofstatejailinspectors,whoinspectajaileverytwoyears.Recently(March,2016),theLegislativeAuditorfoundthatmanyjailsareunderstaffed,andunabletoprovidestafftraining,andneededprogramsforinmates.

Background:Ina2016OLAreportthereisdirectandindirectsupportforthecreationofanombudsmanofficetofocusonissuesrelatedtomentalhealthservicesincorrectionalfacilities.Theindirectsupportconsistsofthemesthatrunthroughthewholereport:lackofconsistentpracticesaroundthestate,andabsenceofoversightastohowjailsactuallyapplytherulesthatdoexist.Besideshelpingindividualswithspecificissues,anOmbudsmanforMentalHealthServiceswouldbeaforceforgreateradherencetostatutesandrules.

HF982/SF1323

• Establishastateombudsmanspecificallyfocusedoninvestigatingissuesrelatedtomentalhealthservicesincorrectionalordetentionfacilities.

• AuthorizetheOmbudsmantoreportsystemicproblemtotheGovernorandLegislature.

CommunityMentalHealthServicestoSupportPeopleintheCriminalJusticeSystemIssue:AnumberofindividualswhoarecivillycommittedforcompetencyrestorationreceivetreatmentattheAnokaMetroRegionalTreatmentCenter(AMRTC),whichisastate-operated

hospital.OftentimestheseindividualsreachapointintheirtreatmentwheretheynolongerneedthelevelofcareprovidedatAMRTCbutstillneedon-goingcompetencyrestorationservices.Inaddition,someindividualswhoarefoundtobenotcompetenttostandtrialarenoteligibleforcivilcommitment.Asaresult,thereareindividualswhoeitherhavenomeansofreceivingcompetencyrestorationservicesorreceivetheseservicesinahigherlevelofcarethantheyneed,preventingpeoplewhodoneedthatlevelofcarefromaccessingit.

Background:TheOfficeoftheLegislativeAuditor(OLA)issuedareportinFebruary2016onmentalhealthservicesincountyjails.Twofindingsfromthereportinclude:(1)aneedtodevelopabroadercontinuumofoptionstosupportindividualswhohavebeenfound“notcompetenttostandtrial”andneed“competencyrestoration”servicesinordertoparticipateintheirdefenseand(2)aneedtoexpandtheavailabilityofcommunitymentalhealthservicesthataresupportpeopleinvolvedinthecriminaljusticesystem,includingForensicAssertiveCommunityTreatment(FACT)teams.

PolicyRecommendations:• Providegrantstocounties,regionalcountypartnerships,and/orcommunity-basedmental

healthproviderstodeveloplocal,community-based,competencyrestorationservices.• Providestart-upgrantfundingtoestablishnewFACTteamsaswellasfundingtoincrease

thecapacityofMinnesota’sexistingtraditionalACTteamstoserveindividualswithextensivelegal/criminaljusticehistories

OtherIssues

ImprovingCareCoordinationThroughHealthIT

Issue:Betterinformationatthepointofcareleadstobetterhealthcareoutcomes.Individualswithmentalillnessoftenreceivepoorlyintegratedcarebecausetheyreceiveservicesfromavarietyofdiversesettings.Electronicmechanismsnowavailablecanimprovecareintegration.

Background:HospitalsandphysicianpracticeshavewidespreadadoptionofElectronicHealthRecords,butmuchofthecarereceivedbyindividualswithmentalillnessoccursincommunitysettings.Manyofthesesettingsalsohaveelectronicrecords,butthereisafailuretoconnectthedotsandlinkallinformation.Behavioralhealthsettingshavestruggledbecausetheyhavebeenineligibleforresources.Stigmaandothermisinformationhaveworkedagainsttheintegrationofmentalhealthinformationthatisvitaltocare.Individualsmustalwaysgiveconsentforinformationtobeshared.Imagineaworldwhereacasemanagergetsanalertwhenanindividualisbeingdischargedfromthehospitalsothatimmediatefollowupcanprovidetheneededresourcestomaintaintheminthecommunityandavoidreadmission.Orwhereanindividual’sadvancepsychiatricdirectiveisavailablewhentheycheckintotheEmergencyDepartment,socaregiversknowtheirhistoryandpreferenceswithregardtodifferenttreatments.EMTscanknowtheindividual’sdiagnosisandmedicationlist,tointerveneswiftlyandeffectively.Anationalstudyestimatesunnecessaryofcostsof$65billionannuallyduetoafailuretocoordinatecare.SixtypercentofroutineoutpatientmentalhealthservicesarenotcapturedinthePrimaryCareProvider’sElectronicHealthRecordbecauseservicesareprovidedoffsite.RecordsofacutepsychiatricservicesaremissingfromthePrimaryCareProvider’srecord89%ofthetime.Allprovidersmusthaveaccesstokeymentalhealthinformation.

Policyrecommendations:

• Makesmallstrategicinvestmentsinelectronichealthrecordsanddataexchangetosupportcommunicationbetweencommunitymentalhealthandacutecaresettings.

• Encouragebighealthsystemstoexchangeinformationwiththecommunitythroughalerts(admission,discharge,ortransitionincare),caresummaries,anddirectmessagingtocareteammembers.

CivilCommitment

Issue:Thecivilcommitmentstatuteneedstobereviewedandrecommendationsonpossiblechangesreportedtothelegislature.

Background:Civilcommitmentisthelegalprocessbywhichacourtordersmentalhealthtreatmentwiththegoalofprovidingnecessarycare.PatientrightsaremandatedunderMinnesotalawundertheCommitmentandTreatmentAct,MinnesotaStatute253B.

In2001,theMinnesotaLegislaturechangedthecommitmentlawbyremovingthewords“imminent”or“immediate”fromthestatuteinordertoallowcourtsorfamiliestointerveneearlierwhenapersondoesnotrecognizehismentalillnessandneedstreatmenttopreventfurtherdeteriorationorcrisis.Assoonasadangerisposedtothepersonwithmentalillnessorothersaroundher,theCivilCommitmentprocesscanbestarted.However,aformalreviewoftheentirecivilcommitmentstatutehasnotbeencompletedinover20years.

PolicyRecommendation:ThecivilcommitmentstatuteisoutdatedanddoesnotreflectthewayMinnesotacurrentlytreatspeoplewithaseriousmentalillnessinthecommitmentprocess.Stakeholderscametogethertoaddressthecivilcommitmentstatuteinamorecomprehensiveway.

Theupdatedcommitmenttaskforcebillwill:

• Removeoutdatedlanguage.• Provideadditionalclarityforemergencyholds,transportationholds,andwhohas

responsibilitythroughoutthecommitmentprocess.• Createagraceperiodsothatacivilcommitmentdoesnotendduetoapaper-workerroror

misseddeadline.

For additional copies or if you have questions, please contact NAMI Minnesota at

651-645-2948, 1-888-NAMI HELPS

or Mental Health Minnesota at 651-493-6634, 1-800-862-1799.

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