Report of the Social Workgroup: Continuity of Care Advisory Panel

1. Report of the Social Workgroup:Continuity of Care Advisory Panel Workgroup Participants: Clarissa Netter (cochair), Dr. Anita Smith-Everett (cochair), Herb Cromwell, Kait Roe, Nevett Steele, Jr., Lois Fisher, Kate Farinholt, Laura Cain, and Holly Ireland October 23, 2013

2. Social Workgroup • The workgroup met eight times. Meetings included presentations from a number of entities including DHMH’s Health Systems and Infrastructure Administration, the Office of Minority Health and Health Disparities, the Mental Hygiene Administration, the Maryland Department of Disabilities, and the Maryland Disabilities Law Center. Presentations are available on DHMH’s Continuity of Care website. • Workgroup participants were diverse and included consumers, family members, providers, and Core Service Agency representation.

3. Social Determinants of Health • According to the Centers for Disease Control and Prevention, “the social determinants of health are the circumstances in which people are born, grow up, live, work, and age, as well as the systems put in place to deal with illness. These circumstances are in turn shaped by a wider set of forces: economics, social policies, and politics.”

4. Social Determinants of Health Source: Healthy People 2010, Centers for Disease Control and Prevention

5. Social Barriers • The workgroup had a robust discussion identifying numerous social barriers to continuity of care. Due to time constraints, the workgroup focused on barriers in the following categories: • Urban vs. Rural • Workforce • Transportation • Housing • Gender, gender identity, and sexual orientation • Language • Race and ethnicity

6. Urban vs. RuralWorkforce • Issue: The mental health provider workforce shortage in urban and rural areas is exacerbated by the primary care workforce shortage in Maryland. • A lack of providers hinders access to services and wait times to see providers creates disruptions in continuity to care. • While workforce barriers exist in urban and suburban environments, the workgroup focused on barriers in rural communities. This was largely due to time constraints, the expertise of workgroup membership, and availability of data.

7. Urban vs. RuralWorkforce • Among other things, DHMH’s Health Systems and Infrastructure Administration (HSIA) identifies areas where there are an insufficient numbers of providers, including mental health professionals, and works to recruit and retain health professionals through various programs. • Existing Programs to Increase Access to Care: • DHMH Programs: State Loan Assistance Repayment Program, J-1 Visa Program, and National Health Service Corps. • Maryland Higher Education Commission Programs: Workforce Shortage Student Assistance Grant Program

8. Urban vs. RuralWorkforce • Planning for Access: In order to prepare for increased demand for health care services, HSIA is providing technical assistance to counties by bringing together key stakeholders to identify strategies and collaborative opportunities to overcome challenges related to access to care. HSIA assistance includes a discussion of ACA requirements, supply and demand projections, and the development of county-specific solutions. • Allegany and Dorchester counties were selected to pilot the project, each choosing to focus on access to behavioral health services. Both counties hosted their forum in September 2013 and identified challenges, recommendations, and solutions specific to their population and behavioral health system. • HSIA will continue to provide technical assistance to counties as they implement specific recommendations.

9. Urban vs. Rural Workforce Recommendations • Promote existing Loan Assistance Repayment Programs within the behavioral health provider community. • In order to create a “workforce ladder” in community behavioral health programs, clear incentives for workforce development are needed. • The State should reestablish a discrete tuition assistance program for community and mental health paraprofessionals and professionals (House Bill 459 of 1999). The State should also determine whether additional workforce incentives are needed to address the behavioral health provider shortage in Maryland. • Provide funding, training and continuing education for peer support specialists.

10. Urban vs. RuralWorkforce Recommendations • Support future HSIA efforts to provide Planning for Access to additional local jurisdictions. • In order to allow behavioral health providers to focus on treating individuals with serious mental illness, the state should engage primary care providers to treat individuals with less severe mental health issues. • This should also be considered within the context of the State Innovation Model. • Further examine urban barriers to continuity of care.

11. Urban vs. RuralTransportation • Issue: Access to transportation impacts an individuals ability to access mental health services. • In both rural and urban areas, utilizing public transportation to get to an appointment can require an individual to miss an entire day of work, adversely affecting an individual’s income. Consumers may not have sick leave, or medical leave. • Public transportation systems are disjointed, even in urban areas. • Even when transportation is available, consumers can face discrimination from other passengers. Moreover, consumers may not be able to afford public transportation. • The Motor Vehicles Administration requires individual’s to disclose certain health care conditions, such as schizophrenia and bipolar disorder when applying for or renewing a driver’s license.

12. Urban vs. Rural Transportation Recommendations • Support state policies that embrace the expansion of telemedicine and telepsychiatry in both urban and rural communities. • Promote models of care that support flexible hours (evening and weekend) for consumers of the mental health system, including Patient Centered Medical Homes. • Assure bus passes/vouchers allow minor children to accompany adults to medical appointments. • Encourage behavioral health stakeholder involvement in the Maryland Transit Administration’s Citizen Advisory Committee for Accessible Transportation and other applicable transportation advisory groups. • Reimburse friends or family who transport individuals to behavioral health appointments.

13. Housing • Issue: The affordable housing stock for consumers is insufficient. • According to the Technical Assistance Collaborative, in 2012, the average rent for a one-bedroom apartment is greater than the entire Supplemental Security Income (SSI) payment of a person with a disability. In Maryland it is estimated that average cost of rent is equivalent to 150% of an individual’s SSI. Consequently, individuals receiving SSI are priced out of the housing market. • There aren’t enough housing assistance programs, which lead to waitlists. Moreover, variation in housing assistance programs across jurisdictions further complicates access to programs for individuals with serious mental illness. • Consumers may can encounter discrimination when seeking housing based on their source of income (i.e. government or housing assistance)

14. Housing • Consumers in the public mental health system want to move from a structured provider setting to the affordable and safe housing of their choice. • Regulation allows for variation in discharge policies amongst Residential Rehabilitation Program (RRP) providers. • When an individual is discharged from RRP without proper connection to services, continuity of care is disrupted.

15. Housing • Existing Programs • Mental Hygiene Administration: • RRP • Supported Housing • Crisis Beds • local housing voucher programs • Continuum of Care Programs • Therapeutic group homes • Group Homes for Adults with Mental Illness

16. Housing Recommendations • Expand Housing First statewide. Examples of programs in other states, such as programs established after Hurricane Katrina should be considered. • DHMH should sponsor legislation that prohibits discriminatory practices in the sale or rental of housing because of person’s source of income, including any government or housing assistance (Senate Bill 487 of 2013). • In the absence of affordable permanent housing, encourage the expansion of “safe havens.” • Initiate a comprehensive study of different models of housing programs in Maryland and continue to examine housing as a social barrier to continuity of care. • DHMH should ensure that continuity of care is not disrupted when individuals are discharged from RRPs. • Existing regulations should be amended to address variation in RRP discharge policies.

17. Gender, gender identity, and sexual orientation • Issue: Healthy People 2020, the nation’s health promotion and disease prevention program, noted that LGBT individuals face health disparities linked to social stigma, discrimination, and denial of their civil and human rights. • Among other things, LGBT youth are 2 to 3 times more likely to attempt suicide, more likely to experience homelessness. • Social determinants , such as a shortage of providers who are knowledgeable and culturally competent in LGBT issues, also affect an individual’s ability to access care.

18. Gender, gender identity, and sexual orientation • DHMH’s Office of Minority Health and Health Disparities is charged with addressing minority health disparities in Maryland. • Among other things the Office analyzes health disparities data, assists with local health disparities programs, conducts outreach, and conducts cultural competency and health literacy training.

19. Gender, gender identity, and sexual orientation recommendations • Encourage DHMH’s Office of Minority Health and Health Disparities to include LGBT issues in data analysis, local health disparities programs, outreach activities, and cultural competency and health literacy training. • Behavioral health providers should have to complete LGBT cultural competency training. DHMH should sponsor such training. • In addition to supporting statewide LGBT cultural competency efforts, DHMH should support the establishment of LGBT Health Centers.

20. Language • Issue: Patient-provider language barriers play a role in continuity of care and health disparities. • There aren’t enough foreign language interpreters or culturally competent providers. • There is no reimbursement for providers in instances where they need to provide foreign language translation services.

21. Language Recommendations • The state should include language services, as an administrative or optional covered service, in Maryland’s Medicaid Program and the Maryland Children's Health Insurance Program. • DHMH should provide mental health training for existing interpreters.

22. Race and Ethnicity • Issue: While health disparities exist for many minority groups, the workgroup focused largely on barriers to continuity of care facing African Americans. This was due to time constraints and the availability of data. • Disparities in mental health services for African Americans can lead to overrepresentation in involuntary treatment programs and underrepresentation in voluntary programs. Overrepresentation is a result of historical factors. • In 2004, African Americans were four times more likely to receive a schizophrenia diagnosis than whites of European ancestry (Barnes, 2004). • Controlling for all demographic variables, African Americans still received disproportionate diagnosis of schizophrenia compared to whites (Barnes, 2008).

23. Race and Ethnicity • Clinician bias against African Americans results in over-diagnosis and substandard treatment. (Loring, 1988) (Supplement to Mental Health Report of the Surgeon General, 2001). • Research has indicated African Americans metabolize psychotropic medications more slowly than whites. However, randomized clinical trials on efficacy of pharmaceutical treatment largely exclude minorities (A Report of the Surgeon General). • There is a lack of African American health care professionals. According to the Maryland Health Care Commission, in 2011, African Americans represented 10% of Maryland’s specialty physicians, but 29% of the state’s population.

24. Race and EthnicityInvoluntary Commitment • African Americans are more than twice as likely than whites to be involuntarily committed to state hospitals (Lewis, 2010). • A diagnosis of schizophrenia is most likely to lead to involuntary commitment in state hospitals (NASMHPD Research Institute). • Demographic variables increase the risk of involuntary treatment, including poverty, incarceration, and homelessness. African Americans are overrepresented within this context.

25. Implications of New York’s AOT Program • The New York State Assistant Outpatient Treatment (AOT) Program Evaluation noted that 34% of program participants were African American. • However, African Americans make up only 17% of the state’s population. • 67% of participants were male and 73% were diagnosed with schizophrenia. • Evaluators claimed no racial bias in selecting participants and cite upstream factors that lead to African American overrepresentation in the AOT program. Upstream factors included multiple hospital admissions, criminal incarceration, lack of stable housing, and poverty. • This ignores the historical factors that contribute to the overrepresentation of African Americans in the mental health system.

26. Race and Ethnicity Recommendations • Current demographic data of the public mental health system, including state hospitals, should be analyzed. • Behavioral health providers should have cultural competency training that addresses racial/ethnic health disparities. • The workgroup has grave concerns regarding racial implications of implementing an outpatient civil commitment program. These concerns are based on the outcomes of New York’s fully funded AOT program.

27. Comments from Workgroup Members and the Public