Hot off the press!
A spokesperson from the State Sheriffs Association announced today that all inmates with serious mental illnesses, regardless of evaluation and assessment, will be released tomorrow to mark the end of Mental Health Awareness Month. A statement in the notification said:
“We agree with mental health advocacy organizations and individuals across the country that people with mental illness should not be in jail. For far too long, instead of taking up the responsibility of implementing a full continuum of coordinated psychiatric treatment and care for people living with untreated and under-treated serious mental illnesses, states and parishes have hidden them behind our bars and in forensic hospitals – out of sight, out of mind.”
There has been some pushback from the community who think that the sheriffs are just tired of dealing with litigation over neglect, abuse and wrongful death suits chalked up to the lack of facility and expertise needed to treat and care for the mentally ill.
Regardless, Parish leaders and the Governor are scrambling to address what they see as a fast approaching disaster as the state is wholly unprepared to absorb the 60-70% of people with a myriad of untreated and under-treated addictions, mental health disorders and serious mental illnesses (SMI) who are about to re-enter society. The State’s reaction seems to be an admission:
- That mental health systems requiring people to voluntarily seek services do not work for everyone,
- That there is a critical shortage of inpatient psychiatric and residential treatment beds, evidence-based outpatient programs, services and supportive housing,
- That untreated serious mental illness is associated with a risk of violence
- That where we spend dollars vs where we don’t spend has proven to be ineffective, wasteful and diverts from what works.
Emergency plans go into effect tomorrow. An Interdepartmental Serious Mental Illness Coordinating Task Force has been formed, and members consisting of all relevant department heads, as well as non-state members, have identified how provisions will be implemented over the remainder of this year. In Phase I, the three most immediate and important provisions identified to stem back homelessness, death and problematic “behavior” are:
- Include SMI in the IMD waiver for substance use disorders.
- Modify Louisiana’s civil commitment standards to include psychiatric deterioration.
- Allocate funding for Assisted Outpatient Treatment (AOT), Assertive and Forensic Assertive Community Treatment (ACT) (FACT) and Clubhouses.
*** more on these 3 provisions below.
Phase II:
- HIPAA reform. Provide better rules for compassionate communication between doctors and family members to allow for value-based continuity of care.
- Beef up wages for behavioral health providers and psychiatric teaching hospitals.
- Beef up wages and provider workforce for paramedicine to handle growing 911 calls.
- Require universities that teach psychiatry to include evidence-based programs for SMI as required learning.
- Loan forgiveness, minority fellowship programs and scholarships for psychiatry.
Phase III
- Provide education on how to delineation between mental “health” and serious mental “illness”
- In the largest urban cities, plan and build ‘One-StopShop’ – state of the art mental healthcare and research centers of excellence – with co-located services to reduce transportation and housing barriers.
- Require any government mental health program to use at least 50% of the money for the seriously mentally ill or lose it’s funding.
- Robust data collection: Require the Office of Behavioral Health to focus on the most important metrics
- Require state mental health departments, their directors, and directors of local mental health programs to report on numbers and rates of homelessness, arrest, incarceration, violence and needless hospitalization of seriously mentally ill and evaluate them based on those. Those are the most important metrics, yet are rarely measured and no mental health officials held accountable for reducing them.
The State Medicaid Director is scrambling to request that CMS include serious mental illnesses in the IMD waiver for substance use disorders (SUD). The SUD waiver was granted in 2018 and allows Federal Medicaid to reimburse institutions for mental diseases with more than 16 beds.
“Not only would amending the waiver application to include SMI increase psychiatric bed capacity and length of stays” said one state official who preferred not to be identified, “we also came to the sudden realization that long-term residential treatment facilities are also IMDs, and having more of them would help with the DOJ lawsuit requiring us to discharge people with mental illnesses from nursing homes”.
The Legislature is requesting legal assistance to modify Louisiana’s civil commitment statute to include psychiatric deterioration as a criteria for civil commitment. Statements from both the House and Senate Health and Welfare Committees reflected the sentiment that waiting until a person has to exhibit dangerous behavior to self or others, or be half dead – (gravely disabled) – before we can intervene with therapeutic treatment and care, is in itself insane. However one legislator was overheard saying:
“Without the ability to put people in jail, what are we supposed to do when they become dangerous like our laws require them to do? The sheriffs must be crazy if they think that we shouldn’t be able to lean on them to disappear our problem for us.”
*Allocate funding for Assisted Outpatient Treatment (AOT), Assertive and Forensic Assertive Community Treatment (ACT) (FACT) and Clubhouses.
The legislature is requesting emergency funding to beef up the following evidence-based practices proven to reduce incarceration, homelessness, unnecessary hospitalization and death for people living with chronic untreated SMI.
- Assisted Outpatient Treatment (AOT) – A Therapeutic Approach to Treatment Non-adherence
Bracing for the worst, some legislators are looking at leasing space in jails in other states for people living with serious mental illnesses who have difficulty staying on their meds because many simply lack insight that they are sick due to severe cognitive impairments. It’s a condition known as Anosognosia.
“It’s an expensive solution but there’s nothing we can do”, said one Senator. “ It’s a lost cause”, said another. However, one senator – who hasn’t yet retired – recalled that in 2008 the legislature passed a bill that helps folks with adherence. “It was after that police officer was killed. It’s called Nicola’s law or something or other”
Sure enough, Louisiana’s Assistive Outpatient Treatment Law – (AKA involuntary outpatient treatment) – has been on the books and practically unused for 12 years.
- If there were ever a more critical need for Assisted Outpatient Treatment (AOT) it is now. AOT is an evidence-based intervention for people living with untreated, and under-treated, serious mental illnesses that reduce the dire consequences of treatment non-adherence like repeat hospitalization, incarceration, violence and suicide. Reducing the need for institutionalization, especially now during the Covid 19 Pandemic, should be at the top of the list of priorities.
Currently, at least 3200 + people are under AOT orders in New York State and, it follows, presumably not in jails or hospitals. That’s 3200 people with significantly reduced risk for contracting Covid 19. Hundreds, if not thousands of people, live in counties that have implemented AOT programs that have helped them get control of their illnesses and their lives.
The Treatment Advocacy Center, our national partner, just announced the launch of an eight-part series of online learning modules on AOT.
The modules are packaged into 2 courses available for CME credit:
· AOT: Basic Concepts and Principles (Modules 1-3)
· AOT: Implementation (Modules 4-8)
To learn more about the AOT implementation learning modules and to join the #MissionForBetter, visit www.SMIadviser.org.
- Assertive and Forensic Assertive Community Treatment (ACT) (FACT) are evidence-based programs that provide robust wrap around services for people living with mental diseases who are unable to provide for themselves. There are strong findings that FACT interventions can improve both criminal justice and behavioral health outcomes for jail detainees with SMI. FACT is an adaptation of assertive community treatment (ACT) for persons involved with the criminal justice system. Learn more here.
- Clubhouses are critical to help integrate people suffering with SMI back into the community. “Clubhouses are strengths-based, emphasize teamwork, and provide opportunities for members to contribute to the day-to-day operation of the Clubhouse through the Work-ordered Day, with members and staff working side-by-side as colleagues to run the program (Doyle et al. 2013). The work-ordered day parallels the typical business hours of the working community where the Clubhouse is located. Clubhouses strive to help members participate in mainstream employment, educational opportunities, community based housing, wellness, or health promotion activities, reduce hospitalizations or involvement with the criminal justice system, and improve social relationships, satisfaction, and quality of life.”
This communication is satire but imagine for a moment if sherriffs actually decided to stop allowing the mental health industry to lean on the criminal justice system and began refusing admissions for people suffering with SMI and/or co-occurring substance use disorders.
Turning around the shameful history of how we treat people living with serious mental illnesses, co-occuring substance use disorders and co-morbidities is long overdue. Solutions are complex but not complicated. Let’s not imagine. Let’s not let one more day go by where we leave the seriously mentally ill behind. The clarion call is to break continuity with the past if we are to change the story for our communities.