Department of Mental Health FY2012 Budget
Joint Hearing of the House and Senate Committees on Ways and Means Committee February 18, 2011
The Department of Mental Health is pleased to present this written testimony concerning the FY2012 House 1 budget recommendation for the Department.
Over the course of any given year, the Department of Mental Health (DMH) provides services to approximately 21,000 individuals with severe and persistent mental illness, including children and adolescents with serious emotional disturbance and their families. The Department accomplishes this via number of ways. DMH operates two state psychiatric hospitals at Taunton and Worcester, inpatient units at Public Health Hospitals at Tewksbury and Shattuck, two inpatient units for adolescents, six Intensive Residential Treatment Programs (IRTP) for adolescents, and five community mental health centers, two of which have inpatient capacities. We provide forensic evaluation (statutorily mandated evaluations of competence to stand trial, criminal responsibility and aid in sentencing) and treatment services for the Juvenile, District and Superior Courts as well as step-down treatment for persons coming our of Bridgewater State Hospital and re-entry supports for inmates with serious mental illness returning from incarceration. Through our licensing function we assure that high standards of care and life/safety conditions are maintained in the more than 65 private licensed psychiatric facilities under our supervision.
Below is a chart that describes DMH services:
|Inpatient/Continuing Care System||DMH-operated psychiatric inpatient facilities: two psychiatric hospitals; psychiatric units in two public health hospitals; five community mental health centers that promote treatment, rehabilitation, recovery.|
|Community Based Flexible Supports (CBFS)||The DMH community service system: Rehabilitation, support, and supervision with the goal of stable housing, participation in the community, self management, self determination, empowerment, wellness, improved physical health, and independent employment.|
|Respite Services||Respite Services provide temporary short-term, community-based clinical and rehabilitative services that enable a person to live in the community as fully and independently as possible.|
|Program of Assertive Community Treatment (PACT)||A multidisciplinary team approach providing acute and long term support, community based psychiatric treatment, assertive outreach, and rehabilitation services to persons served.|
|Clubhouse Services provide skill development and employment services that help individuals to develop skills in social networking, independent living, budgeting, accessing transportation, self-care, maintaining educational goals, and securing and retaining employment.|
|Recovery Learning Communities (RLCs)||Consumer-operated networks of self help/peer support, information and referral, advocacy and training activities.|
|DMH Case Management
|State-operated service that provides assessment of needs, service planning development and monitoring, service referral and care coordination, and family/caregiver support.|
|Emergency Services (ESP)
|Mobile behavioral health crisis assessment, intervention, stabilization services, 24/7, 365 days per year. Services are either provided at an ESP physical site or in the community.|
|Comprehensive screening, engagement, stabilization, needs assessment, and referral services for adults living in shelters.|
|Services include case management, individual and family flexible support, residential, day programs, respite care and intensive residential treatment.|
|Provides court-based forensic mental health assessments and consultations for individuals facing criminal or delinquency charges and civil commitment proceedings; individual statutory and non-statutory evaluations; mental health liaisons to adult and juvenile justice court personnel.|
DMH supports children, adolescents and their families with services that include residential treatment, after school programming, and a range of community services to maintain youth at home and in school.
Research is also a critical mission of the Department of Mental Health. As a statutory requirement, research advances the treatment, rehabilitation, and recovery of individuals with serious and persistent mental illnesses. Research is conducted in a variety of settings across the state, mainly through DMH funding of two Research Centers of Excellence: the Commonwealth Research Center, located at Massachusetts Mental Health Center and through Beth Israel Deaconess Medical Center Department of Psychiatry and Harvard Medical School; and the Center for Mental Health Services Research, through the Psychiatry Department at the University of Massachusetts Medical School in Worcester. At any given time, approximately 100 research studies are taking place at DMH sites.
DMH has been engaged in transforming the delivery of mental health services in the Commonwealth into a more recovery oriented, person centered and community focused system of care. The CBFS services referenced above reflects a dramatic redesign of community services that gives providers flexibility and responsibility to provide services designed to meet the changing needs of consumers as they attain their recovery goals. The Department’s initiatives strive to align the services and supports we provide with the needs and choices of consumers we serve.
DMH is committed to its Community First Vision. This means our service system strengthens consumer choice; is client-centered, family-focused and driven by client outcomes; relies on an extensive peer workforce; and enhances clients’ ability to move through the community and inpatient systems of care.
Significant components of the DMH Community First Vision are:
Community Based Flexible Supports (CBFS)
A new model of mental health service delivery for the Commonwealth, the CBFS initiative is a striking and complete change in the DMH community system of care. Implemented in July 2009, CBFS is helping consumers realize the goal of successful recovery and community living. With less focus on purchase of individual programs and more attention to consumers’ choice and preference, CBFS is driven by recovery and the participation of peers—persons with the lived experience of mental illness. CBFS is tightly integrated with our Community First Initiative, a necessary alignment and balance of the community and inpatient systems of care that DMH provides. Prior to the implementation of CBFS, the Department purchased programs that were not structured in a way to meet individual needs but required consumers to fit into the existing program models. CBFS services are designed to maximize flexibility and adjust as the needs of consumers change. CBFS offers a continuum of services that provide for integrated rehabilitation and minimize the need for consumers to change service providers. CBFS places a major emphasis on employment and consumer driven care delivered by mental health professionals and peer workers.
Children’s Behavioral Health Initiative (CBHI)
The Children’s Behavioral Health Initiative is an interagency initiative of the Executive Office of Health and Human Services. The family and the child are at the center of our service system, strengthening and integrating services for families and their children with emotional and mental health needs. Key Provisions are early identification and education through standardized screening and assessment tools; and enhanced community based services, including intensive case coordination and Wraparound model which at its core is designed to give children and families a lead voice in determining what services they will receive and in setting their own goals.
FY 2012 House 1 budget Impact
Since the economic collapse that began in 2009, the impact on state budgets has been significant and the implications of this continue in FY2012. We have had to make difficult and painful budget decisions, but it is important to remember that DMH continues to serve 21,000 with the services and support described above. We increased the range and scope of its community services, which has resulted in decreased reliance on inpatient care. Funding has shifted in support of community services, as approximately 97 percent of individuals served by DMH live in the community. Funding for community mental health services has increased by $56.7M since FY2002.
The FY2012 House 1 budget recommends $606,993,222 for DMH. This represents a 3.4 percent decrease below our FY2011 appropriation. The Department’s overall reduction for FY2012 is $21.4 million, exclusive of inflationary factors. In FY2011 the Department was funded for approximately 3,000 FTEs and contracted for approximately $400M of services from community providers. The FY2012 House 1 recommendation will require the elimination of 250 FTEs in the inpatient services account.
The FY2012 budget reflects a $16.4M reduction in our inpatient account, a $3M reduction in adult community services and $2M in children’s community services. In considering budget realities for FY2012 and beyond, DMH continues its commitment to strengthening our community service system whenever possible. We are developing plans to expedite additional reduction of statewide inpatient capacity, and to transition inpatients ready for discharge to the community consistent with our Community First initiative.
The $21.4 million reduction in House 2 will require that the Department make cuts in services. We are committed to implementing these reductions in ways that will permit us to remain faithful to the fundamental principles mentioned earlier.
1. Reduction of Inpatient Services through Consolidation/Facility Closure:
The FY2012 House 1 funding will require that we close approximately 160 inpatient beds across our system. This will impact all remaining inpatient facilities, and may include the closure of an entire facility, as well as unit closures throughout the system. It is important to note that the Department is opening a new state-of-the-art hospital in central Massachusetts on the Worcester State Hospital campus in 2012. The new DMH hospital will have a total of 320 beds (260 adult inpatient; 30 child/adolescent inpatient; and 30 intensive residential treatment program beds). The operating costs of the new hospital are estimated at $60M annually. The funding for the new DMH hospital will be achieved through the reallocation of current facility beds, staffing, and support costs. In effect, this will require the closure and realignment of other DMH facilities. Transition to the new hospital will require an acknowledgement of one time costs to prepare staff to work within the new environment while managing parallel operations during transition to the new hospital.
This reduction in our inpatient system will, nevertheless, also impact our community service system. The individuals who will be discharged from the hospitals will generally require a high level of community support. Although we continuously manage the effective utilization of our community services system in a way that is individualized and flexible and that meets the rise-and-fall of intensity of need of mental illnesses, it will prove difficult to accommodate the individuals who will be newly discharged without a corresponding effect on community services. We are hopeful that we will be able to tap our experienced case management workforce to help mitigate this gap.
2. Reductions in some community services:
A $2M reduction in Child and Adolescent Mental Health Services will reduce Individual and Family Flexible Support Services by 15 percent. Approximately 175 children and their families currently served will no longer receive these services. A $3M reduction in Adult Mental Health Services will also result in loss of some Clubhouse services.
In addition to the opening of the new DMH hospital in 2012, the Department would like to acknowledge another major project which is underway and must be considered as we prepare to meet our budget realities in the coming next two fiscal years. The redevelopment of the Massachusetts Mental Health Center (MMHC) will make it possible for DMH clients with serious and persistent mental illness to receive care and treatment in an urban state-of-the-art facility. This project is part of a unique initiative of DMH, the Division of Capital Asset Management and Brigham and Women’s Hospital/Partners Healthcare, and has been in the planning process for many years. The new MMHC will also contain a medical clinic, designed to improve access to medical care for a population whose mortality and morbidity rates are significantly higher than the general population. The Department will also be relocating MMHC staff and programs, currently located on the Lemuel Shattuck Hospital campus, back to the Longwood Medical Area. Construction is now underway and Phase 1 includes the new MMHC, scheduled to open in late fall of 2011. The MMHC will be built at no cost to the Commonwealth.
Despite the extraordinary fiscal challenges we have faced, we are still accomplishing extraordinary things. We are creating new opportunities for the public mental health system as it is solidly grounded in recovery, resiliency, partnership and consumer choice, reflecting the vital principles of consumer voice, self-direction, hope and recovery. Consumers and stakeholders in the mental health community continue their active participation in planning and policy development, helping us further our priority to create a consumer outcome-driven system. The collection and review of data, commitment to continuous quality improvement throughout the system and a focus on promoting full and productive life expectations for adults and children, including employment, housing and education are the foundation of our efforts.
Message from Mass. Dept. of Mental Health Commissioner Barbara Leadholm, M.S., M.B.A
February 21, 2011
Last month, our mental health community was shaken by the death of Stephanie Moulton, a mental health worker with our partner provider North Suffolk Mental Health Association. We all grieve her loss and are deeply saddened for her family, friends, co-workers and clients who knew and worked with her.
Because we need to understand the factors in this very tragic death, I convened the Department of Mental Health (DMH) Task Force on Staff and Client Safety. Over the next three months, the Task Force will assess current policies and practices around safety and training for those who provide and receive Department of Mental Health services in the community.
The Department is committed to the safety of the dedicated workers who provide services and supports to DMH consumers in the community and in our hospitals and facilities. In light of recent events, I want to strengthen this ongoing commitment and be mindful of the importance of ongoing review and continual improvement of how we do our work and meet our challenges in our efforts to provide every opportunity for recovery for the individuals we serve.
I also remain committed to the vision of Community First and promoting the dignity and rights of people with mental illness to live in communities of their choice. The vast majority of individuals served by DMH live in the community. The Community First vision acknowledges that symptoms of mental illness rise and fall and our mental health system must be responsive to the changing levels of need that some individuals can experience. But ultimately, it is a home, a job, an education, relationships, social connections that people with mental illnesses want – it’s what we all want – and that is what Community First is all about.
The Task Force will be co-chaired by the Honorable Paul F. Healy, Jr., retired district court judge; and Kenneth L. Appelbaum, M.D., Professor of Clinical Psychiatry and the Director of Mental Health Policy and Research for the University of Massachusetts Center for Health Policy and Research. Task Force members are representative of all areas of the mental health community that have influenced the DMH community service system. This group is charged with evaluating specific aspects of the Department’s community system, including risk management practices, appropriate access to and utilization of criminal history information (CORI) and safety training and safety provision for provider staff. The Task Force will complete its review within three months and make recommendations for consideration.
I am pleased to have the following individuals participate on the DMH Task Force on Staff and Client Safety:
Ira Packer, Ph.D., ABPP (Forensic), Clinical Professor of Psychiatry at University of Massachusetts Medical School and Director, Mobile Forensic Evaluation Service, DMH Central-West Area, central region
Derri Shtasel, M.D., M.P.H., Director, Adult Ambulatory Psychiatry, Massachusetts General Hospital (Massachusetts Psychiatric Society)
Eva Skolnik-Acker, LICSW, National Association of Social Workers, Massachusetts Chapter
Jessel Paul Smith, Consumer Youth Advocate for M-POWER
Tina Adams, Ph.D., DMH Central Office, Manager of Juvenile Forensic Services
Matthew Broderick, DMH North County Site Director
Jonathan Delman, J.D., M.P.H., Executive Director, Consumer Quality Initiatives
Vicker V. DiGravio III, President/CEO, Association for Behavioral Healthcare
Barbara (Babs) Fenby, Ph.D., DMH Northeast-Suburban Area, Director of Community Services
Ellen Flowers, Tewksbury Hospital, DMH Hathorne Units, Director of Nursing
Phil Hadley, Representative of the National Alliance on Mental Illness of Massachusetts
John Labaki, SEIU 509 Chapter President representing the Department of Mental Health
Nancy Mahan, Director of Mental Health Services, Bay Cove Human Services Inc
Regina Marshall, J.D., DMH Chief of Staff
Marilyn Wellington, Esq., Executive Director, Board of Bar Examiners
Michael Weekes, President/CEO, The Massachusetts Council of Human Service Providers, Inc.
Anne Whitman, Ph.D., President, Jonathan O. Cole Mental Health Consumer Resource Center Board of Directors
The Task Force will also have legislative representation. Senate President Therese Murray and House Speaker Robert A. DeLeo will each recommend a member of the Senate and the House of Representatives to serve on this group.
As the Task Force co-chairs begin the task of organizing the group and scheduling meetings, DMH staff will support the work of the group. We are very fortunate to have this group of expert and experienced individuals commit their time and energy in service to improving our system and ensuring that individuals with mental illness and the dedicated workers who provide care and services are of our highest priority. I will keep you apprised as this important effort moves forward.
February 9, 2011
The Honorable Deval Patrick
Office of the Governor
State House, Room 280, Boston, MA 02133
Re: Nomination to the Parole Board
Dear Governor Patrick:
NAMI, the National Alliance on Mental Illness of Massachusetts (NAMI), recommends James P. Young, MS, LSW, LADCI to the Parole Board.
NAMI’s mission is to improve the quality of life for people with serious mental illness and their families.
Brenda Venice, President of NAMI Greater Fall River, has worked closely with Mr. Young for several years, and we are pleased to nominate him for appointment to the Massachusetts Parole Board.
Mr. Young has a Masters Degree in Criminal Justice Administration and a Bachelors in Human Services and Criminal Justice. Since 2000, he has been employed in the Forensics Division of the Massachusetts Department of Mental Health and is also a part time police officer in the Town of Norton. Mr. Young has over ten years experience of working directly in the correctional system with inmates at the state and county level.
NAMI believes Mr. Young would be an excellent person to serve on the Massachusetts Parole Board because he understands forensics and mental illness, and the valuable role that training of police officers and others in the criminal justice system can play. Mr. Young has been involved for years in the Crisis Intervention Team (CIT) model of training for police officers and others in and around Taunton, Mass.
We believe Mr. Young would help you achieve the “balance” that is called for in the governing statute, MGL c. 27, Sec. 4 and understands the critical role that parole plays in the criminal justice system.
We attach Mr. Young’s resume for your information. We hope you will consider him as a candidate for the Massachusetts Parole Board.
Cc: Mary Beth Heffernan, Secretary of Public Safety
Mark O’Reilly, Governor’s Chief Legal Counsel
M. Cowan, Chief of Staff
February 4, 2011
Letter to the Globe Editor:
There is a disturbing pattern of disproportionately higher cuts to services to people with mental illness. We fully understand there’s a budget crisis, however, Governor Patrick and his Administration needs to recognize the domino effect these cuts will have on people with mental illness and their families.
The Executive Office of Health & Human Services (EOHHS) of which the Department of Mental Health (DMH) reports along with other health, human social service agencies report, will receive a $91 million cut or 1.9% of the total state budget. A $21.4 million cut will go to DMH and $26 million cut to the Department of Public Health (DPH). This means that over half (52%) of the total cuts to EOHHS will come from DMH and DPH;
The Governor proposes cutting another 160 inpatient beds from the current hospital capacity at DMH of 658 beds, a reduction of almost 25%. NAMI has been concerned for years about the loss of our safety net hospital beds. We cannot imagine how the state will cut another 160 beds or where the extra money for community mental health services will come from once these people are discharged from the hospital.
The Governor proposed a $2 million reduction in Child & Adolescent Mental Health flexible support Services; (175 children and families will no longer receive DMH services), and Massachusetts Club Houses will also see a reduction in vital services for adults with mental illness.
Can we really afford these cuts? NAMI answers emphatically: NO.
February 3, 2011
Boston City Council, City Hall Square, Boston, MA 02201
Re: Policies and Procedures regarding emergency response to individuals experiencing mental health crisis
My name is Laurie Martinelli and I am the Executive Director of NAMI Mass (National Alliance on Mental Illness of Massachusetts). Thank you Councillor O’Malley, Connolly and other members of the Committee for holding this very important hearing.
NAMI’s mission is to improve the quality of life for people with serious mental illness and their families. Every state has a NAMI and I run the Massachusetts statewide NAMI. We also have 22 local chapters around the state. Three of those local chapters are in Boston: GB-CAN (Greater Boston Consumer Action Network, NAMI Latino and NAMI Dorchester/Mattapan/Roxbury.)
Emergency psychiatric services have long been an important issue at NAMI. Unfortunately, most NAMI members have had a bad experience with emergency psychiatric services – mostly because many first responders have not received any training on how to deal with a person with mental illness. Almost everything a first responder is trained to do doesn’t work, or has the opposite effect, on someone with a mental illness in crisis.
Last spring, NAMI Mass wrote a position paper on Emergency Psychiatric services as a way to raise awareness about a “redesigned” Massachusetts emergency behavioral health services program. Unfortunately, the ESP program as it is called is only for people with MassHealth or Medicare or anyone without health insurance (not commercial insurers). Today ESP services for someone with MassHealth or Medicare are community-based and recovery oriented. There are entire “teams” of clinical specialists who will respond to an ESP call. These services are mobile and people are encouraged to call their ESP provider to come to their home or school. ESP services for children can include up to 72 hours of crisis intervention and stabilization services. In addition to providing an evaluation by a team of clinicians, ESP services for adults include “peer” specialist, that is an adult who is in recovery from his/her mental illness who can advise the person what to expect, etc.
Not only does NAMI’s position paper describe the excellent emergency service programs that currently exist for children and adults on MassHealth, it provides some anecdotal “stories” of what NAMI members and others have encountered when someone has a psychiatric crisis.
My favorite story can be found on page 2 of this report – it’s a true story of a NAMI family north of Boston whose 20 year old son was diagnosed with bi-polar disorder. This young man was living with his parents and was having a psychiatric crisis. Not knowing about the ESP program, and on the advice of the son’s psychiatrist, his parents called the police for assistance. (afterall, who else will make house calls when someone is having a psychiatric crisis?). When the police arrived, the son was clutching a religious statute to his chest. The police asked the young man to give them the statute – the young man refused. When a police officer attempted to take the statute from the young man, the police officer cut his hand on the statute. The young man was subdued and charged with assault on a police officer with a dangerous weapon and resisting arrest. He was then driven to his local hospital and later placed on probation.
Throughout this entire time, the young man’s parents were on the phone with his psychiatrist and the police knew the man was suffering from mental illness.
The parents spent approximately $4,500 for a criminal defense lawyer and another $360 to have the son’s psychiatrist appear in court. They had to go to court four times.
Unfortunately, this story is very common. There has been an enormous increase in people with serious mental illness in the criminal justice system. NAMI National reports that back five years ago (in 2006), there were almost 353,000 people in jail or prison who were diagnosed with serious mental illness. Here in Massachusetts, we have roughly 10,000 prisoners in the Department of Corrections. Almost 1/3 of these prisoners have an open mental health case – many more are not diagnosed.
NAMI National reports that there are a number of reasons why people with mental illness end up in jail or prison: deinstitutionalization; inadequate capacity for acute, intermediate and long-term psychiatric hospitalization in state and local hospitals; more formal and rigid criteria for civil commitment; lack of adequate community support systems, including housing, for people with mental illness and the difficulties that persons coming from the criminal justice system have in gaining access to community mental health treatment.
There are training models for police and others in the criminal justice system to recognize symptoms of and to relate effectively to persons with mental illness. Law enforcement often lack adequate training on how to manage this segment of the population – how to recognize a mental illness, how to de-escalate a situation – how to handle potential violence – and what to do when a person is threatening suicide. What community resources are available and what kind of treatment will help this person as opposed to arresting them and sending them off to jail or prison?
A model that NAMI National promotes is called “Crisis Intervention Training” or CIT. This approach was developed in Memphis, TN after a tragic shooting by a police officer of a man with a serious mental illness. This tragedy stimulated collaboration between the police, the Memphis chapter of NAMI, the University of Tennessee Medical School and the University of Memphis. CIT is a 40 hour training program for law enforcement officers that includes basic information about mental illness and how to recognize them; information about the local mental health system and where to get help; hands on information from people with mental illness and family members about their experiences; verbal de-escalation training and role playing. Today, CIT has been adopted by hundreds of communities in more than 35 states and is being implemented statewide in Ohio, Georgia, Florida, Utah and Kentucky.
Many small towns in Berkshire County, including Pittsfield, are experimenting with a rural model of CIT, and Taunton has been training officers and others in the criminal justice system for years with a 3 day CIT training model. There are other pilot programs in Massachusetts that are working such as Jail Diversion and the mental health court here in the Boston Municipal Court, Springfield and new mental health court being developed in Plymouth.
Hat’s off to Boston and its police department for applying for and receiving a Jail Diversion grant from the state Department of Mental Health that will start the ball rolling to train Boston police about a mental illness and putting a clinician on call with the police whenever someone is having a psychiatric crisis.
But more needs to be done for sure – we need to find sustainable funding models for Massachusetts and Boston that will make adequate training on mental illness a priority.
Thank you for the opportunity to testify. I stand ready to help the City of Boston in any way I can.
 Previtera, C., and Martinelli, L., NAMI Massachusetts, “Massachusetts Emergency Behavioral Health Services Program,” p. 2, March 29, 2010.
 “Decriminalizing Mental Illness: Background and Recommendations, NAMI Board of Directors, September 2008, p. 2.
 Lamb HR and Weinberger, LE, “Persons with Severe Mental Illness in Jails and Prisons: A Review,” Psychiatric Services 49:483-492, 1998.
 Crisis Intervention Team Toolkit, CIT Facts, NAMI National, p. 1 (no date). (http://www.cit.memphis.edu/USA.htm)