Minutes January 23-24, 2003
The western user group for the national Mental Health Statistics Improvement Program is sponsored by the Center for Mental Health Statistics, SAMHSA.
The regular meeting of the WSDSG was called to order at 8:30 in San Francisco, California by Denny Geertsen, Chair. Those present included:
Greg Browngoetg, Alaska
Kathy Styc, California
Richard H. Ellis, Colorado
John Jhansen, Hawaii
Don Corbridge, Idaho
Bobbi Renner, Montana
Troy Williams, Nevada
Carol Thomas, New Mexico
Jennifer Fahey, South Dakota
Dennis C. Geertsen, Utah
Marla Smith, Wyoming
Sheila Cooper, New Mexico
Bonnie Jo Schell, California
Presenters and Others
Olinda Gonzalez, CMHS
Chuck McGee, WICHE
Scott Adams, WICHE
Tom Wilson, California
Ted Lutterman, NASHMPD NRI
Dennis Prody, Montana
Michael Wylie, Hawaii
Debbie Altschul, Hawaii
Phillippe Gross, Hawaii
Hugh McDonough, Abt Research
Mary Smith, MHSIP Policy Group
Marilyn Henderson, CMHS
Ron Mandersheid, CMHS
Thursday, January 23, 2003
Call to order, introductions, announcements
Denny Geertsen, Utah Division of Substance Abuse and Mental Health, WSDSG Chair
Updates on Decision Support 2000+ IT Prototype
Hugh walked participants through the prototype web site for DS2000+. There are 2 sides to this mental health portal, a public side and a secure protected site for groups and organizations to store their own data and be able to generate reports. Data uploads may be done with any X12 or XML compliant data.
The focal point of the site is on-line data analysis and reporting. Performance indicators are available from the 16 State Project. Very exciting site. Lots of functionality. Lots of questions. Lots of development work going on. One interesting section allows for consumers to fill out MHSIP consumer surveys. There is great potential here that will be developed over time.
There is also a HIPAA compliant mapper. This will take a local database and map it to differect HIPAA requirements. (Same URL except ending in .etl instead of .org.) Currently there is a forward translation to HIPAA and a backwards translation is being developed.
Wyoming BRFSS: Adding to the Discussion Initiated Last Meeting
Chuck McGee, WICHE
(Dennis Mohatt was unable to attend the meeting and his report was postponed.)
Wyoming has taken two steps linking mental health and health: including an analysis of Frequent Mental Distress (FMD) in the annual BRFSS report; and incorporating four core BRFSS Health Related Quality of Life (HRQOL) items in the consumer survey.
Frequent Mental Distress (FMD). The annual BRFSS survey in every state includes an item asking respondents to indicate the number of days in the past month their mental health was not good (including stress, depression and problems with emotions). Individuals who indicated mental health not good for 14 or more of the past 30 days were said to experience Frequent Mental Distress (FMD). (http://www.cdc.gov/mmwr/preview/mmwrhtml/00052469.htm MMWR, 1998;47:325-31).
The following data were in the Wyoming 2001 BRFSS Report (Menlo Futa, BRFSS Coordinator, Wyoming Department of Health.)
• 8.4% of respondents reported FMD. Higher rates were reported by females (10.4%); adults divorced or separated (16%); ages 18-24 (11%); annual household income of $15,000 or less (19%); less than a high school education (18%); unable to work (27%); out of work (20%). (Editor note: rates vary in directions similar to prevalence estimates.)
• Individuals with FMD reported higher rates of risky health behavior including cigarette smoking (41% vs 20% non FMD); heavy drinking (7% vs 5%); lower rate of recommended physical activity (57% vs 46%); and obesity (25% vs 19%).
• About 29% of individuals with FMD reported their activities were limited 8 or more of the past 30 days (compared to 5% of those without FMD).
• One third of Wyoming adults with FMD MS WORD file] reported their physical health was not good 8 or more of the past 30 days compared to 9% of those without frequent mental distress. (Links to WY_FMD.doc and WY_references.doc.) References MS WORD file .
Consumer HRQOL. Findings from this survey indicated Wyoming consumers had significantly more unhealthy days than the household population of Wyoming (2.5 times the physical and 3.6 times the mental unhealthy days). Wyoming consumers with serious and persistent mental illness had even more unhealthy days. These findings indicated that consumers were indeed in need of services, and that the differentiation of consumers with serious and persistent mental illness (SPMI) was meaningful.
Facilitated by Denny Geertsen, chair
Alaska the new Greg reporting (Browngoetg – Gregg Brock moved to CO). 5-10% cutback. Merger with substance abuse. Modify CSAT to IS system. Urban and rural consumer surveys. Some providers not participating due to concern about prying. Web-based data collection.
California, Kathy Styc. After much debate the Planning Council decided to focus on 200% FPL. Adjustments are not planned for urban/rural or cost of living.
An informal survey of other states found the FPL being used for planning in CO (300%), SD (200%), MT (150%), NV (200%), and NM using several priority levels.
Handouts on Penetration Rates by Race/Ethnicity and by County. Penetration rates for the population under 200% poverty ranged from 4.12% (Hispanic) to 22.00% (White non-Hispanic).
County pentration rates ranged from .18% to 15.51%. Higher penetration rates were found in northern, more rural counties where the County was the only provider and they tended to get private pay and insurance clients.
Readmission after discharge: length of stay did not matter so much as follow up after discharge. DIG moving data collection system from mainframe to server.
Montana, Bobbi Renner. Serious budget cuts. Reduced Medicaid eligibility to individuals with SPMI and SED. Co-pay restrictions on who gets case management. Altogether there are 17 licensed independent providers. The state receives only aggregate data from providers. They are still in the process of moving to 3 regional entities that would contract with providers.
This year was the first mail out consumer survey after a prior provider hand out survey. Findings are not comparable due to change in method.
New Mexico, Cat Thomas-Gravel. There has been a lot of turn over in exempt staff with the new governor Bill Richardson. Secretary Montoya is new head of the Department of Health, Fred Sandoval in Behavioral Health. Former Ohio commissioner Pam Hyde is the Human Services Department Secretary. Katie Falls coming from the Division of Health may increase collaboration with Medicaid.
FY2002 Consumer Satisfaction Project, 20 pages in color (handout). This is the fourth year of the survey, the second for consumer representative distributions at programs throughout the five regions. The survey includes the 28 MHSIP items plus domains on substance abuse, housing, and employment.
A conference on Behavioral Health will be held March 31-April 3.
Friday, January 24, 2003
Bonnie Schell, Consumer Advisory Panel for COSPM
Legislation (2). Out Lady of Peace (involuntary commitment) act failed but will likely be reintroduced this year. CA AB1421 Outpatient Involuntary Commitment passed but there is no money to enforce. Nevertheless is gives the court the power to commit individuals to outpatient treatment to avoid hospitalization. This is the 48th state to pass legislation on involuntary commitment.
The CA Network or Mental Health clients spent lots of effort to fight involuntary commitment. Less effort to fight cuts. They have been unable to get data to support their position about outcomes and best practices. The legislature wants “numbers not words”.
Strategies being considered for cuts include: 1.) equity (cut evenly across the board), 2.) mission critical (identify and leave intact), and 3.) cut whole programs. The big money is pharmacy. Integration of mental health and substance abuse has happened on paper in our county, but the integration is not real.
Computers in Rural Areas. Sheila worked with Sylvia Caras on this NIMH funded project to try and reduce isolation. Over 100 consumers with SMI were provided computers, assistance with installation, limited training, and an E-mail listserve. A control group participated in a writing group and classes. Sheila will send the URL for the report coming out soon. Some positive stories; generally folks needed more individual hand-holding getting up and running and participating on-line.
The Rural Electic Coop monthly newsletter has an issue devoted to mental illness. Nice way to reduce stigma and reach out to isolated folks.
An article in The Atlantic on youth filing through courts, special-education, psychiatric treatment programs, orphanages and prisons is worth reading. The “At Risk Youth Industry” www.theatlantic.com/past/docs/issues/2002/12/press.htm.
Coercion is so inherent in mental health care that we don’t even realize it is there. “I will never recover from coercive treatment 20 plus times… including involuntary commitment, being forcibly medicated… I’m very fearful… It was a violation of my person…”
Ted Lutterman referred to a research project on coercion, both overt and covert, by John Monahan under a grant from the McCarthur Foundation (refer to http://macarthur.virginia.edu/coercion.html).
This is Sheila’s last meeting. She expressed pleasure at participation in the group “open, accepting, and collegial”. She is buying a bigger ranch and plans to raise sheep. Chuck appreciated her strength in sharing personal stories, thanked her for her participation and presented her a picture on behalf of the WSDSG (the Golden Gate Bridge shrouded in fog).
MHSIP Report Card ver.2 Feedback
Mary Smith, MHSIP Policy Group (via teleconference)
Mary reviewed the public and private effort going into a consolidated report card. A modular approach will include recommendations from the recovery workgroup and the children’s outcome roundtable. HSRI is developing a parallel process with toolkits on risk adjustment, data presentation, and methods, moving from version 1 to 2, assessing data quality, implementing a consumer survey, report card format, web-based resources.
Collaborating with national accreditation bodies (NCQA, CARF, JCAHO, COA).
Surveys include adult and child/caregiver. Incorporate ECHO survey. A core set of modules will cut across public and private sectors. There will be a specific module for inpatient. Working with substance abuse folks to develop a module. Modules being considered for safety, emlooyment, housing, and employment.
Next steps include work with consumer groups; look for gaps in performance indicators; integrate a cultural competence component. Anticipate a draft product at the May National Statistics Conference.
Discussion. WSDSG members raised the potential of a health module (refer to the Thursday section on the Wyoming BRFSS). Marla and Chuck will communicate with Mary.
Bill DeRisi, California DMH
Tina Wooten, California Consumer Mental Health Advocate
California takes a big step in monitoring programs and improving quality beyond relying on quantitative data. Focus groups obtain direct input from consumer and families. Consumers and family members moderate the focus groups, review findings, and report. This oversight process combines two approaches: compliance; and quality improvement/technical assistance. About 150 groups are conducted each year. Team members generate “theme lists” independently then collaborate in ranking them. A report on access, beneficiary protection, and coordination goes to the county and state.
Tina is on the oversight committee and has been doing focus groups for 5 years now. She is presenting to the group in this picture.
Bill returned from retirement 3 years ago to participate in this project. He has found it the most rewarding experience in his career.
Overheads [Powerpoint File]. Handouts included 3 Focus Groups Question Lists
Creation of an Integrated Data Base: Combining Medicaid and State Agency Mental Health and Substance Abuse Data
Linda Graver, The Medstat Group
Ted Lutterman, National Association of State Mental Health Program Directors
This was a Federal/State Collaboration between SAMHSA and Delaware, Oklahoma, and Washington. The Medstat Group was the contractor with subcontractors NASADAD and NASMHPD.
Data collected from each State included:
• Medicaid Service Files (Inpatient, Long term care, Pharmacy, All the rest – outpatient services) and
• State Agency Service Files (Outpatient SA services, Community mental health services, Institutional or residential services).
Questions We Can Answer About People
• What are the demographics of persons receiving publicly-funded MH/SA services (age, race, gender)?
• What percent of clients have MH disorders, SA disorders, or co-occurring disorders?
• What are the most frequent diagnoses?
Questions We Can Answer About Utilization:
• What types of providers give treatment to MH/SA clients?
• What kinds of services do MH/SA clients receive?
• How often and for how long do they receive services?
• What are the costs of services?
• Are services provided by Medicaid? State Agencies? Both?
• About 4 percent of the population of each State was treated for primary MH and/or SA disorders in 1996 under the auspices of State MH/SA agencies and or Medicaid
• Youth clients were predominately males, whether they had MH, SA, or co-occurring disorders. Adult MH-only clients were more likely to be female.
• Adult MH clients treated under Medicaid only were less likely to have schizophrenia, major depression, and psychoses – the most serious mental illnesses.
Ted Lutterman, National Association of State Mental Health Program Directors
Co-occurring Indicators Considered for CMHS and CSAT Block Grant
Background. Ted distributed an overview of the SAMHSA Report on Co-Occurring Disorders. SAMHSA is creating a new State Incentive Grant for Co-occurring Disorders to help enhance state infrastructure and treatment systems.
Ted distributed a discussion draft for meeting with NASADAD and NASMHPD to determine the next steps in developing a common set of co-occurring measures.
One measure is being tested now: Percent of persons served who had a dual diagnosis. This is not really a performance indicator. Concern about how operationalized, particularly in substance abuse since clinicians do not provide diagnoses.
Another measulre is in short term development: Percent of programs that screen, assess and diagnoses, and provide treatment to clients with co-occurring disorders. The pilot is looking at the individual and program levels.
The third one is in longer term development: percent of clients who experience a reduction in problems. We are not good at measuring change scores. The project is important and more developmental work needs to be done.
PPG Taking Comments
Dr. Mandersheid had E-mailed the PPG announcement describing how the Secretary intends to change the current Community Mental Health Services (CMHS) Block Grant into a performance partnership based on a continuous quality improvement model. It warns against making state comparisons. It does include a state requirement to submit data on a set of basic measures as well as other topics relevant to DIG grants. Comments are due in February.
NAMI plans a state report very different from the early 90’s report card. They have asked for data from the NRI State Profile System. Four project steps include:
• A random survey of state NAMI members
• A study of newspapers on tome of articles looking at stigma
• A study of legislation including rights and parity
• A state review
Olinda Gonzales, Center for Mental Health Services, DIG Grant Project Officer
There are four workgroups for the DIG grant and regular conference calls with representatives from each UG. Get your carry over request in. Workgroups:
• Outcomes Workgroup
• Living Situation Workgroup
• SMI/SED and Prevalence Workgroup
• Evidence Based Practices Workgroup
In the process of being released publicly. Content is being used in the DIG effort. Some content is available on the DS2000+ site reviewed yesterday.
The National Conference
Is a joint effort with Block Grant Planners. Lots of consumer reps including researchers. Expect to see presentations on strategies for budget cuts, needs assessment, recovery, and more on DS2000+.
MHSIP Policy Group
Marla Smith, Wyoming Mental Health Division
Incorporation of MHSIP
The Policy Group has decided to pursue incorporation of the MHSIP Association. This provides a framework to apply for funds for research activities addressing concerns, trademarks the work of MHSIP, and an “organizational “presence in collaborating with other organizations on national data initiatives.
(The summary below was organized from a free flowing discussion at the meeting and prior presentations. For this background, refer to Minutes from the last meeting (/info/wsdsg/2002-08min.htm) and the additional work in Wyoming reported on Thursday by Chuck.)
At the last meeting the WSDSG made recommendations to CMHS, MHSIP, and NRI on two strategies in strengthen the public health approach: A.) increasing involvement with the BRFSS household survey, and B.) including 4 core items in the MHSIP Consumer Survey. The intent of the discussion is to clarify the benefits of following those recommendations.
Background. The BRFSS is an ongoing, state-based, random-digit-dialed telephone survey of non-institutionalized adults. The surveillance system tracks the prevalence of key health and safety-related behaviors. Four core Health Related Quality of Life (HRQOL) items ask about general self-rated health and the number of days during the preceding 30 days when physical health was not good, mental health was not good, and usual activities were limited. (There is also an expanded module with 14 HRQOL questions asking about specific types of activity limitation and physical and emotional symptoms http://www.cdc.gov/mmwr/preview/mmwrhtml/00051443.htm.
A. Benefits of BRFSS Data
• de-stigmatizing mental health by asking questions of the public, by reporting findings along with other health concerns, and subsequent discussion among policy makers
• provide a population mental health assessment (limited in the core items and strengthened in the expanded module)
• make a connection with substance abuse as well as other health conditions
• point out risky health behavior of individuals with FMD
• have the potential to assist in modifying programs, setting priorities and developing priorities
BRFSS Findings. States have used BRFSS data to monitor population mental health and FMD over time and across regions. Several western states indicated they work with their BRFSS surveyors (ID, NM, MT, NV, WY). National findings include:
• Nearly one-third of Americans say they suffer from some mental or emotional problem every month-including 9 percent who said their mental health was not good for 14 or more days a month (FMD).
• Younger American adults, aged 18-24 years, suffered the most mental health distress.
• Americans with chronic diseases or disabilities reported high levels of unhealthy days.
• The percentage of individuals with FMD has increased from 8.4 to 10.1.
• Individuals with frequent mental distress (FMD) reported higher rates of risky health behavior (smoking, heavy drinking, and lack of exercise).
B. Benefits of Items in Consumer Survey.
• Quality assurance activities. The HRQOL of consumers may be compared with population HRQOL to demonstrate the severity of problems of individuals served in terms of overall health, mental and physical health days not good, FMD, and functioning.
• HRQOL responses provide information about the general health status of consumers.
• HRQOL may help interpret MHSIP domain scores.
Findings in Consumer Survey. Wyoming included the 4 items in a survey of consumers to carry the measure into the mental health arena. This allowed A.) a comparison of consumers with the population at large, and B.) analysis of HRQOL with MHSIP domain scores.
• A. Wyoming consumers had significantly more unhealthy days than the household population of Wyoming (2.5 times the physical and 3.6 times the mental unhealthy days).
• Wyoming consumers with serious and persistent mental illness had even more unhealthy days (indicating consumers were in need of services and that the differentiation of consumers with serious and persistent mental illness was meaningful).
• B. Consumers with SPMI were significantly more negative than other consumers on all four HRQOL items (p<.001 in all cases).
• A significant relationship was found between the number of physical and mental unhealthy days and MHSIP domain scores, particularly for individuals with SPMI. (correlations were found with the outcome domain, r = 0.30 and r = 0.47 for unhealthy physical and mental days respectively.
• Survey respondents who are no longer receiving services compared to those who are reported somewhat fewer days in which mental health was a problem (10.2 vs. 11.7) (not statistically significant, p>.50).
Steering Committee Report
Denny Geertsen, chair
2003 Meeting: Denver, April 10-12 (CMHS sponsored)
(Santa Fe, August 7-9 - WICHE sponsored through your dues)
Agenda for Denver considered violence (APHA, WHO), coercion (Monahan study funded by McCarthur foundation), and safety (California study on crimes against persons with disabilities) (also a jail diversion grant). To include special reports from long standing members Dick Ellis, Denny Geertsen, and Kathy Styc.
Editorial note. The topics are related. Coercion may be a form of violence ( I had recall statements made by consumers and go to the WHO definition of violence to be comfortable with that statement.) Coercion may also not be a form of violence (Monahan‘s work may help make the distinction).
The World Health Organization defines violence as:
The intentional use of physical force or power, threatened or actual, against oneself, another person, or against a group or community, that either results in or has a high likelihood of resulting in injury, death, psychological harm, maldevelopment or deprivation.
World report on violence and health. World Health Organization, Geneva, 2002. Edited by Etienne G. Krug, Linda L. Dahlberg, James A. Mercy, Anthony B. Zwi and Rafael Lozano. http://whqlibdoc.who.int/hq/2002/a76157.pdf
WSDSG Elections resulted in Jon Collins as chair for next year. The vice chair will be selected at the next meeting.
One consumer representative will change with Sheila Cooper leaving to work with her sheep instead of us (smile). Shela Silverman will start next meeting.
Steering Committee slots will be filled at the next meeting.
Survey of State Mental Health Expenditures and Revenue
Ted Lutterman, National Association of State Mental Health Program Directors
Ted is preparing a report for State Mental Health Directors. The regular survey covers 20 years through 2001. A supplemental survey was made of the FY03 budget. There may be as many as 16 new Directors by June and this will be a good resource guide for them. The report shows some $23 billion dollars in mental health with per capita expenditures actually reduced when controlled for population and inflation.
There have been huge changes in where the resources are going with some 65% currently going to inpatient commitment. The system is becoming increasingly forensic (from 8% to 23%).
Chuck McGee, WICHE
The 16 State Study found large discrepancies in penetration rates. 4 fold discrepancies indicate the data are not comparable. We might consider some of the reasons for the discrepancies with an eye toward identifying grouping more comparable states. Though no conclusions were reached, factors leading to relatively high penetration rates include:
A.) block granting funds to local control (v FFS or managed care)
B.) including Medicaid under the scope of the SMHA
C.) frontier or rural (v urban with more resources available)
D.) not following MHSIP guidelines on discharge
E.) poor record updating to the stat
Denny Geertsen, Utah Division of Substance Abuse and Mental Health,
Budget cuts continue for most states.
Colorado is facing another 6% cut. They have had a number of retirements, including Jack Wackwitz whom we worked with. A criminal justice to devlop a mental health screen is proceeding well. The project was mandated by State statute and includes jails and prisons. After over 2,000 screens last summer, approximately 21% were flagged as potentially individuals with mental illness. They are in the process of validating findings by doing assessments for all individuals with positive assessments and about 15% of the negative assessments. The direction of the project will be determined after assessing the number of false positives and negatives. The Denver jail is conducting about 18 screens a day. A Denver jail study in the late 80’s by Jack Wackwitz found over 25% of individuals in jails had mental illness.
Hawaii is redefining their target population based on a law suit. They have received approval to start a Medicaid rehab option in July. They are getting more info on the provider side than ever before. DOE took over many services that mental health had been providing in schools.
Idaho saw a 10% cut last year. They have started a prior authorization process. Farris Stangler came out of the substance abuse side to be the acting Director.
Nevada is still the fastest growing state in the nation. The tax structure is dependent on gaming and tourism is way down. They are competing with CA in gaming in the north; the south relies more on international tourism. 3% budget reduction; 500 positions cut; hiring freeze. The Governor is sponsoring an inpatient psych observation unit.
Utah merged MH and SA into The Division of Substance Abuse and Mental Health. Substance abuse listed first because it is first in statute. 8 of 10 CMHC’s provide both. The new research director is from substance abuse. Tax revenue is down.
Wyoming is brighter with a strong economy and budget increases. The new Democratic governor has an open door policy. The Medicaid remediation contract is on hold till a new Health Director is appointed. They are conducting additional oversight of services and information. Wyoming has benefited from Utah in developing their web based information system. They have finished their FY03 consumer and caregiver surveys. DIG reporting was not a problem, nor was CSAT.
Meeting was adjourned at 12:30 by Denny Geertsen, chair.