March 29, 2011 Caroline Buck David Lumbert

1. Assessing the Consequences of a Decade of Funding Cuts to New Hampshire State Mental Health Services March 29, 2011 Caroline Buck David Lumbert

2. Project Goal & Method • Examine impacts of recent budget cuts on mental health services in New Hampshire. • Contacted health professionals at all ten Community Mental Health Centers (CMHCs). • Analyzed past reports on NH mental health system services from the last decade.

3. Presentation Overview • CMHC organization & funding structure. • Internal effects of funding changes. • External effects of funding changes. • Other state examples & policy options.

4. History • In the 1980s, New Hampshire boasted a model U.S. community-based mental health care system. • In 2008,  $4.6 million in Medicaid payments was cut. • In 2009, $3 million was cut. • NH mental-health centers were forced to choose between cutting services or reducing the quality of services.

5. Organizational Structure of the Mental Health Care System • Community mental health centers (CMHCs) are private not-for-profit facilities that have been contracted out by the government. • NH Department of Health and Human Services (Bureau of Behavioral Health). • There are ten centers located in New Hampshire • Each serves a specific region in NH.

6. Community Mental Health Care Centers The centers combined serve 47,000 patients annually. Required to be open 24 hours a day, seven days a week for emergency psychiatric care.

7. Funding Structures • CMHCs are private, non-profit organizations. • 85% of funding comes from consumer fees. About ¾ of these fees are paid by federal Medicaid money. • State of NH provides very little Medicaid funding to CMHCs.

8. River Bend CMHC – Funding Example Fiscal Year 2008, Source: River Bend 2008 Annual Report

9. Where Money Is Being Lost • Serving uninsured and underinsured patients. • Mandate to be open 24 hours/day. • Staffing costs increased 24% from 2004-2009, while overall expenses increased by 26%. (Kane 2010) • Current proposal to amend legislation.

10. Internal Impacts of Funding Changes • Number of beds available – 236 in 1990, 186 in 2008. • Increasing demand for services. • Burdens on staff availability and quality. • Reduction in types of services offered.

11. Impact on Patients • Increase in patients over the past decade. • 1 in 5 children and 26% of adults in NH have a mental health disorder. • Reduction in beds leads to longer wait times. • Less time with patients, fewer resources directed toward substance abuse, and less communication with parents. (UNH Survey)

12. Impact on Staff • Layoffs – 10% of workforce at Riverbend. • Increase in caseload – 50-80 at Seacoast. • Salary freezes and benefit reductions. • Loss of paid vacation. • High turnover rate – 20% statewide.

13. Impact on Programs • Examples of programs that have been eliminated due to budget cuts: • 13-bed, 24 hour residential program at Riverbend. • Assertive Community Treatment team at Riverbend. • Child Respite Program at West Central. • Several satellite clinics and residential facilities.

14. External Impacts of Funding Changes • Emergency room mental health care. • Correctional facilities. • Increase in homeless population.

15. Impact on Emergency Rooms • Overcrowding of CMHCs has increased the burden (and cost) on Emergency Rooms. • Wait times have gone from 8 hrs to almost one week. • Community-based treatment could cost $200 per patient day vs. $600 to $2,000 per day in the ER.

16. Impact on Correctional Facilities • Prison population has increased by 31% and spending on correctional facilities has doubled. • 65% of inmates in state prison are diagnosed with mental health issues. • Lack of care can lead to recidivism.

17. Impact on Homeless Shelters • Studies show a direct correlation between a shortage of psychiatric beds and high homelessness rates. • 50% of clients in New Hampshire homeless shelters have some kind of mental illness.

18. How New Hampshire Stacks Up • In 2006, NH received a "D" rating from NAMI. • In the 2009 NAMI state mental-health ratings, New Hampshire was among 18 states who earned a "C" grade. • Top states for mental health: NY, MA, CT, ME, MD, and OK.

19. Massachusetts • NAMI “B” grade. • Forefront of mental health care for over a century. • Community-Based Flexible Support Program. • Independent living skills training and support for discharged patients and their families.

20. New York • NAMI “B” grade. • Innovative “Housing First” project. • New York pledged 9,000 new housing units over a ten-year time span & costs the state $62 per day. • More cost effective than hospital care ($479), treatment in correctional facilities ($233) or treatment in homeless shelters ($74).

21. Connecticut • NAMI “B” grade. • Very forward-thinking vision for programs. • Electronic monitoring system for recovery of patients & collaboration between CHMCs and jails. • Jay Couture (Seacoast MHC) cited the value for mental health centers having better electronic health records.

22. Policy Options • Maintain current system. • Allocate more state Medicaid funding into the mental health system. • Institute Community-Based, Transitional Housing Programs (follow example of New York and Massachusetts). • Eliminate 24-hour service mandate. • State pay for care of uninsured/underinsured patients.

23. Questions.