Milwaukee Journal Sentinel: A public health approach for mental health
by Walter Laux
October 5, 2013
Ealier this year, the State of Wisconsin released a Mental Health and Substance Abuse Needs Assessment. This report estimated that one in five Wisconsinites has a mental illness, and one-fourth of those individuals have a serious mental illness. This means most of us know someone affected by mental illness, whether we realize it or not, and mental illness is pervasive in our communities.
As extensive community discussion and data collection have shown, the Milwaukee County Behavioral Health Division regularly experiences demands that exceed its capacity, which translates into escalating emergency detentions and crisis contacts. Mental health crisis services can serve as a bellwether of capacity in other parts of the BHD system.
For instance, insufficient capacity for longer-term community services that foster recovery leads to a vicious cycle of individuals accessing crisis services for short-term stabilization. The result for many individuals is ever-increasing crises year after year, especially for those with the most complex problems, such as poor health, poverty, substance use and homelessness. Despite the seemingly intractable nature of these challenges, new opportunities lie ahead if Milwaukee is poised to capitalize on them.
Beginning Jan. 1, many people who were previously uninsured will gain access to insurance thanks to the Affordable Care Act. About 44,000 Milwaukee County residents who are uninsured will be eligible for BadgerCare. Another 77,000 residents will be able to access affordable insurance through the marketplace established by the ACA.
Mental health and substance use treatment are covered benefits for both Medicaid and the individual and small group insurance markets, along with other essential health benefits. Since currently uninsured people will have access to mental health coverage through insurance, it could lessen the strain on BHD to provide uncompensated care and free up resources to take a proactive approach, with long-term goals of reducing the overreliance on emergency crisis services.
Employing a public health approach, Milwaukee County has a unique opportunity within the context of the ACA's implementation to affect community mental health services.
An environmental scan across the country reveals new innovations in the field of mental health.
In Oregon, Lane County administrators engaged insurance plans, hospitals, physician groups, behavioral health providers, specialty care and community partners to develop a Coordinated Care Organization that improves care and access by allowing patients to have one point of contact for most of their health care needs.
In Camden, N.J., a hospital emergency room physician used street-level data to determine where referrals were coming from, and then facilitated the opening of a community clinic in a public housing project. This clinic cut costs in half because it was able to address problems before patients showed up in more-costly emergency rooms.
And in Philadelphia, behavioral health providers are deployed to medical hospitals and community vigils to provide education and early intervention for victims of violence and trauma to mitigate development of post-traumatic stress disorder.
These are just a few examples of the initiatives happening right now in the United States. A public health approach to community mental health care shifts the focus to keeping people well through prevention, rather than waiting for people to become ill enough to treat. It also includes promoting education about mental illness and strategies to reduce stigma so that individuals can connect to treatment before a crisis occurs.
Examples of a public health approach that leverage BHD's knowledge and expertise could include providing technical assistance and education to primary care physicians on mental health screenings. It could also include helping Qualified Health Plans in the Milwaukee market assess the adequacy of their behavioral health capacity.
Assessing for adequacy could include questions such as, do the QHP's networks provide timely access, including walk-in hours? Are network providers located in areas accessible by people without transportation? Are providers using evidence-based practices that include both medication and therapy? Are providers equipped to address all of the individual's needs that affect mental health?
Mental health should not be treated in isolation from basic needs, housing, education, employment or social support. These elements are often referred to as social determinants of health and can have a profound effect not only on one's physical health but also on one's mental health.
Just last month, a presentation at the Wisconsin Prevention Conference found that 40% of health outcomes can be traced to social determinants. Milwaukee County funds a modest amount of activities that address these determinants, such as limited peer-operated services and housing for low income individuals with serious mental illness.
Most people will have insurance in 2014 and beyond that will cover the cost of mental health treatment. So it may be prudent for the county to fund additional, expanded basic needs such as housing, education, employment and social support services outside the realm of traditional treatment that help keep individuals with serious mental illness stable in the community. Certainly, the county is uniquely qualified to consult and partner with QHPs and providers on how to ameliorate conditions such as homelessness and concurrent substance use to affect health outcomes.
A prevention-focused approach along with funding of non-traditional services that affect social determinants of health for individuals with serious mental illness may be a natural fit for BHD in the new health care landscape. Ultimately, a public health model would relieve the overburdened system. By employing a proactive methodology to mental health care, one can envision a robust, community-based mental health system that is less reliant on costly county-funded crisis services, has fewer emergency detentions and results in reduced hospitalizations.
Such an approach would allow BHD to focus its attention on providing adequate support for those with the greatest impairments to live successfully in the community while continuing to fulfill its role as a safety net for the much smaller uninsured population.
Walter Laux is director of behavioral health services at Community Advocates in Milwaukee.
Please click here to view this op-ed on the Journal Sentinel website.