Thursday, October 16, 2014


Where are Integrated Regulations to Guide Maryland's New Behavioral Health 'Services and Systems'?

According to the Maryland Department of Health and Mental Hygiene's website, there are "ongoing efforts to integrate the State’s mental health and substance use disorder services and systems". In order for these "services and systems" to become integrated, the regulations --which guide the activities of those regulated by the Department (DHMH), must also be integrated --otherwise, they have no real reason to change what they currently do and adopt the state's new system of integrated care.  Family advocates have no expectation that treatment providers will make changes to existing programs simply on a voluntary basis.

Even though DHMH plans to contract with a national accreditation organization --either the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) or the Commission on Accreditation of Rehabilitation Facilities (CARF), to provide "new" standards for treatment providers and to ensure that treatment facilities comply with these standards, the consumers who will potentially utilize these services want to ensure that SUD treatment standards are comparable to mental health treatment standards.  Consumers of SUD treatment services have not yet been given the opportunity to review the new accreditation standards, and therefore, cannot logically be expected to comment on something which they have not yet seen.

Currently, there are eight regulations for the delivery of substance abuse treatment services compared to thirty for the delivery of mental health treatment services.  If Substance Use Disorder (SUD) is now recognized as the neurologically-based mental health disorder that science has proven it to be, then individuals struggling with SUD should get the same protections and receive the same quality of care that Maryland currently provides to individuals struggling with all other mental health disorders.  Unfortunately, this is currently not the case.

Marylanders have been waiting for true integration, and hence, comparable and equitable regulations, for years.  Now that DHMH is reviewing and changing these regulations, consumers of SUD services and their families are expecting that SUD service providers will be held to the same high standards that have guided mental health service providers for decades.

With the epidemic rate of overdose death in the state, and the Governor's promise to lower overdose death by 20% in the next year --delivering anything less to consumers of SUD services will not be acceptable.  It is time for SUD patients and their families to receive their fair share of protections and standards.


Below are just a few regulations governing mental health treatment, which are currently NOT applied equally to substance use disorder treatment.  Consumers of the newly integrated "services and systems" need to know how the "new" regulations will be applied to ensure that they receive the same high quality care that consumers of mental health services already have.

INVOLUNTARY ADMISSION:  10.21.01 outlines involuntary admission to an inpatient treatment facility if the individual has a mental illness that "substantially impairs the mental or emotional functioning of the individual so as to make care or treatment necessary or advisable for the welfare of the individual or for the safety of the person or property of another".  It currently excludes a diagnosis of substance use disorder.  RESULT: Parents are able to petition the courts to have their child admitted to a hospital against their will if they are cutting themselves, but not if they are shooting heroin --even though the death rate is much higher for overdoses than suicides.  

CONSUMER PARTICIPATION IN TREATMENT POLICY:  10.21.02 mandates that treatment programs must include community and consumer participation in establishing policies and procedures and for reviewing and evaluating these policies.  There is no equal standard for SUD treatment.  RESULT: Consumer input shapes treatment policy at mental health facilities, but not at substance abuse facilities.

GROUP HOUSING:  10.21.04 outlines regulations for "Group Homes for Adults with Mental Illness" but excludes individuals with a substance use disorder.  In the SUD "Continuum of Care" we have "Sober Living Homes" for Adults with a Mental Illness (SUD), which are regulated by housing laws --not DHMH.  RESULT: Currently, there is nothing to prevent our children from being referred by a residential treatment provider into substandard housing, run by a violent unstable drug-using sexual predator, where they share a bedroom with three other drinking or drugging men or women, and where they are required to pay hundreds of nonrefundable dollars prior to moving in. Even when the housing environment is not as overtly harmful as this example, many sober living environments inadvertently undermine the recovery of these individuals --diagnosed with a chronic, severely debilitating, and often fatal mental health disorder, when they fail to provide essential links to the support services that these individuals desperately need to regain their mental health.

FAMILY INVOLVEMENT:  10.21.05 charges staff to "assist individuals in aftercare soon as possible after acceptance, in collaboration with the individual" and "community-based service providers", "family members", "others who have a personal interest in the individual"... (with proper consent).  No equivalent regulation for substance use treatment providers exists.  RESULT: In many SUD treatment facilities, family members are typically disallowed or strongly discouraged from participating in aftercare planning.  "Proper consent" is neither explained nor sought by facility staff.  "Community-based service providers" are rarely, if ever, permitted to have contact with the individual while in treatment, much less in planning for discharge. The individual recovering from a severely debilitating mental health issue (SUD) is often coerced into making important life-altering decisions without the benefit of those whom they rely on for insight and wisdom.

NOTICE TO NEXT-OF-KIN:  10.21.05 also ensures that notification of discharge or release must be provided to next-of-kin (with proper consent).  No equivalent regulation for substance use treatment exists.  RESULT: In SUD treatment, young adults are routinely kicked out of treatment without a phone, money or transporation, for infractions that are unrelated to either their own health and safety or the health and safety of others.  Under current practices, there is no way for a parent to find out whether their child has left treatment other than to call police and report them missing.  Presumably, the provider is required to tell police that the individual has left treatment (as opposed to dying or being kidnapped).  Then, the police can let the next-of-kin know that their family member was last seen alive by the facility staff, but is no longer at the facility.

ADOLESCENT PROGRAMS:  10.21.06 outlines regulations for Regional Institutes for Children and Adolescents (RICAs) for adolescents with "a long-term and severe mental disorder" with "treatment needs that cannot be met through community-based programs" and where residential treatment can be "expected to improve the individual's condition or prevent further regression so that the individual can return to the community" --except adolescents with a substance use disorder.  RESULT: Many parents are so desperate for help for a child with a substance use disorder, that they rely on individuals without any licensing or training to handcuff their sleeping kids in the middle of the night, drag them out of their beds, and transport them across the country to unregulated facilities in rural states where withholding of food, sleep deprivation, or isolation without clothing are among the negative reinforcements used as a means of control.  These horrific tortures are implemented under the guise of "therapy".

Similarly, 10.21.07 outlines regulations for Therapeutic Group Homes (TGHs), which also exclude kids with a substance use disorder.

FAMILY SUPPORT ORGANIZATION: allows a Psychiatric Residential Treatment Facility (PRTF) to bill Medicaid for a) caregiver (parents) peer-to-peer support; b) youth peer-to-peer support (through 26 years old); and c) family and youth training.  A FAMILY SUPPORT ORGANIZATION may provide these services to PRTFs and get paid for them if: 1) they are non-profit; 2) their board and staff are caregivers with lived experience.  No equivalent regulation for SUD treatment exists.  RESULT: Family Support Organizations providing these same services for SUD to caregivers and transition-age youth are NOT paid and their services are rarely even acknowledged by SUD Residential Treatment Facilities.

EXPRESSIVE AND EXPERIENTIAL THERAPIES: allows a PRTF to bill Medicaid for "Expressive and Experiential Behavioral Services", including art; dance/movement; horse-back riding; horticulture; music; drama; etc.  Presumably, if PRTFs are able to get reimbursed for these services, they are more motivated to provide these services. RESULT: Since these waivers do not apply to SUD providers, SUD facilities are not motivated to provide these therapies to their patients.

CRISIS AND STABILIZATION SERVICES: allows a PRTF to bill Medicaid for Crisis and Stabilization Services, therefore providing them with an incentive to provide these services.  No equivalent regulation for SUD providers exists.  RESULT: Unless an individual suffering with SUD is "in crisis" to the point where they are unconscious and in need of emergency medical services, caregivers are fully responsible for providing crisis and stabilization services.  It is not uncommon for caregivers to set alarms throughout the night so they can frequently check on a loved one who is "in crisis" and "in need of stabilization" to ensure that they continue breathing.

GRIEVANCE SYSTEM:  10.21.14 outlines a very detailed resident grievance process with four stages, including mandatory meetings, time parameters for responses, written responses from treatment directors, remedy and appeal guidelines, reviews by Resident's Rights and Central Review Committees, reporting requirements, etc. in order to provide a "fair, efficient, and complete remedy for allegations of rights violations".  RESULT: As there is no similar regulation for SUD treatment providers, patients whose rights have been violated may feel lucky to have a "complaint box" where violations are reviewed by a low level staff prior to being filed in the waste basket.

SIGNED RELEASES FOR HIPAA COMPLIANCE: mandates that a "Community Mental Health Program" must ensure that an individual "receives information, verbally and in writing, regarding making an Advance Directive for Mental Health Services" --a document designed to give authority to a representative whom the patient trusts to make decisions concerning his or her treatment.  The Mental Health community recognizes that a patient's ability to make rational decisions may be compromised by their debilitating disorder, and they may need assistance from someone whom they trust and respect to assist them in making life and death decisions.  No equivalent regulation for substance use treatment providers exists.  RESULT: Many SUD facilities do not provide any information to admitted clients regarding HIPAA releases to allow a similarly trusted advocate or family member to assist them in making treatment decisions.  In fact, without a signed release, staff at treatment facilities commonly tell family members --husbands, wives, parents, children that they "cannot confirm or deny" that their loved one is in treatment --even when the family member dropped them off and signed an agreement to pay for treatment an hour before.  This archaic practice not only fails to recognize the vitally important role of the family in supporting their loved one's treatment and recovery, but actually undermines primary ties and normal healthy relationships between parent and child or husband and wife.

COMMUNITY ADVISORY COMMITTEES: stipulates that a "Community Mental Health Program" must have an Advisory Committee comprised of individuals currently or previously served by a mental health program, family members of those served, or members of a mental health advocacy organization.  Mental Health programs provide better quality services with a higher rate of successful outcomes when they have the benefit of feedback from those with "lived experience" and first-hand insights into the treatment experience.  No equivalent regulation for SUD treatment providers exists.  RESULT: SUD programs fail to seek input or feedback from family members and fail to recognize existing substance abuse advocacy organizations, hence they fail to benefit from the lived experience or first-hand insights of their clients, and their programs are weaker and less effective because of it.

LOCAL RESOLUTION OF CONFLICTS: outlines collaboration between a "Community Mental Health Program" and a County Core Service Agency.  It addresses "protocol for resolution of conflict between the program and an individual served", thereby providing local oversight for programs within a local community.  There is no equivalent for SUD treatment providers.  RESULT: Currently, there is no person, agency, or office that resolves conflicts between a SUD program and the individual served.  Individuals with a valid and documented grievance against a SUD provider have absolutely no avenue for complaint or resolution.

CULTURAL SENSITIVITY: ensures that information and services are provided in a "culturally sensitive manner" and at a "suitable reading comprehension level".  No equivalent regulation exists for SUD treatment providers.  RESULT: Patients are likely to become anxious and intimidated when they find themselves in treatment situations which alienate them, either due to cultural differences, language comprehension issues, learning deficits, physical impairments or any other barrier which would cause them to feel threatened or isolated by the treatment environment.

NOTICE PRIOR TO DISCHARGE: stipulates that "except in the case of imminent danger" notice of the discontinuation of treatment services must be given.  This gives the patient time to find another facility or to appeal the decision.  RESULT:  Since SUD providers have no equivalent regulation, they are at liberty to discharge any patient without warning, based on the whims of the staff in charge at the time.  Premature discharge is common and occurs regularly at many SUD treatment facilities.

LINKS TO SUPPORT SERVICES: specifies that a "rehabilitation assessment" will be conducted for each patient in order to assess their need for housing and employment, mobility and transportation, social relationships and leisure activities, education and vocational training, etc.  Links to these types of "Rehabilitation and Support Services" are provided in order to support the patient's recovery.  No equivalent regulation for SUD treatment providers exists.  RESULT: Without this focus on the 'whole person', many SUD providers simply offer addiction education without addressing any other significant areas of their patient's lives.  It is as if they can simply educate them out of their addiction without spending time or effort rebuilding lost lives and replacing old patterns with new habits.  Service providers don't seem to understand that a patient who has engaged in negative and defeating habits for many years, with no experience or memory of how to access links to successful recovery, will somehow miraculously make these connections.  Thus, an individual new to recovery with only 28 days of residential treatment is returned to homelessness and joblessness with absolutely no awareness of how to live a "normal" life, and without the assistance or training necessary for accomplishing it.

HOUSING ASSISTANCE: directs the "Community Mental Health Program" Director to attempt to develop financial resources to assist an individual temporarily to maintain housing within the community.  No equivalent regulation for SUD treatment exists.  RESULT:  Patients with a SUD are commonly discharged to homeless shelters.  Programs, like Access To Recovery, that were effective in ensuring that patients released from a detox facility had a minimum of funding to cover one month of rent in a step down level of care have been cut, regardless of how promising or effective the program's outcomes were.

GROUP HOUSING STANDARDS:  10.21.22 requires all areas of a Residential Rehab to be "safe and clean and free from clutter and have furnishings, supplies and utensils comparable to those found in residences of nondisabled residences" --requires "hot and cold running water and adequate light, heat and ventilation".  Ensures that a resident has "access to food"; "an adequate supply of soap, towels, and toilet tissue"; "access to transportation" and to a telephone; and a "bed with a clean mattress, pillow, and linens".  It stipulates that no more than two people will share a room and that there will be at least one bathroom for every four residents.  No equivalent regulation for SUD treatment facilities exists.  RESULT: SUD patients who need an ASAM 3.1 level of care are commonly discharged to housing which is currently governed by housing laws.  As such, this very vulnerable population has been readily preyed upon by landlords --often motivated by greed, and eager to make money off of individuals trying to get back on their feet, perhaps after years of battling an often fatal and severely debilitating neurological disorder.


Below are the "new" regulations proposed by the "new" Behavioral Health Administration, governing the "new" integrated treatment "services and systems".  Consumers are concerned that the "new" regulations are simply a rewritten version of the "old" regulations.  We are concerned that the vast gap between SUD treatment services and mental health services will not be bridged and the needs of consumers and families of SUD treatment services will continue to be ignored by service providers, government agencies and elected leaders.  This is simply an intolerable and unacceptable option.

We were promised integration!  Our tax dollars paid for integration!  We deserve integration!  And we will not rest until we have integration! "provides, at a minimum, individual, group, and family therapy..." under licensing regulations for MENTAL HEALTH TREATMENT without having an equivalent provision under SUBSTANCE USE DISORDER TREATMENT.  Consumers of SUD services will benefit equally when this licensing provision is applied to SUD treatment. "provides community-based comprehensive rehabilitation services and supports, including, but not limited to: (i) community living skills; (ii) activities of daily living; (iii) family and peer support," under licensing regulations for MENTAL HEALTH TREATMENT without an equivalent provision for SUBSTANCE USE DISORDER TREATMENT.  Consumers of SUD services will benefit equally when this licensing provision is applied to SUD treatment. provides similar "services and supports designed to promote resiliency and facilitate the development or restoration of a minor's age appropriate skills...(i) self-care skills; (ii) social, peer, family, and teacher interactions; and (iii) semi-independent living skills," for MENTAL HEALTH patients without the equivalent for SUBSTANCE USE DISORDER patients.  Consumers of SUD services will benefit equally when this licensing provision is applied to SUD treatment. "promotes the individual's ability to engage and participate in appropriate community activities" for individuals receiving MENTAL HEALTH TREATMENT but not for those receiving SUBSTANCE USE DISORDER TREATMENT.  Consumers of SUD services will benefit equally when this licensing provision is applied to SUD treatment. provides for a "Supported Employment Program" for MENTAL HEALTH patients without an any equivalent provision for SUD patients.  Consumers of SUD services will benefit equally when this licensing provision is applied to SUD treatment.

.05.A.(1) Mental health has licensing regs for "group homes for adults with mental illness", which exclude persons with substance use disorders.  Individuals suffering with a substance use disorder are stuck with unregulated sober living homes --currently used as step-down programs in the continuum of care when detox facilities refer unsuspecting clients into them.  While individuals recovering from any other mental health crisis get to live in homes with light, heat and hot water; with appropriate furnishings; with access to food; with soap, towels and toilet tissue; with access to telephone and transportation; with curtains and a clean mattress and pillow and bedding --our unsuspecting, barely adult, children are referred by treatment providers into unregulated sober living homes with absolutely no oversight --or even the promise that the residents are remotely drug-free.  Many sober living houses are enormously harmful to the recovery of individuals, particularly transition age adults who may have very little experience living independently.  When treatment providers are allowed to discharge clients to unlicensed and unregulated "sober-living homes" under the guise of "continuum of care", very vulnerable and fragile individuals are placed at enormous risk.  SUD advocates do not have a problem with housing laws pertaining to housing --but when providers refer clients who meet ASAM criteria for a level 3.1 facility into a HOUSE --governed by housing laws --and pretend that this is our contiuum of care --it is nothing less than a breach of public trust.  Consumers of SUD services will benefit equally when this licensing provision is applied to SUD treatment.

.05.A.(2)  makes a provision for mobile treatment services for individuals needing mental health services, but not for those needing SUD services.  Consumers of SUD services will benefit equally when this licensing provision is applied to SUD treatment.

.05.A.(9)  makes a provision for respite care services in mental health treatment but not in substance use disorder treatment.  Consumers of SUD services will benefit equally when this licensing provision is applied to SUD treatment.

Section C:  The fact that a third section of COMAR 10.21.11 exists --Section C: Integrated Behavioral Health Programs, seems to suggest that facilities that are regulated under Section A: Mental Health Programs and under Section B: Substance Use Disorder Programs WILL NOT BE REQUIRED TO INTEGRATE MENTAL HEALTH AND SUD TREATMENT SERVICES.  Consumers were lead to believe that this was the point of Behavioral Health Integration in the first place.  Isn't this what is promised to consumers on the DHMH website --inherent in the statement "ongoing efforts to integrate the State’s mental health and substance use disorder services and systems"? With the overdose death rate at epidemic levels, can we afford anything less?


The American Society of Addiction Medicine (ASAM) developed criteria for "placement, continued stay and transfer/discharge of patients with addiction and co-occurring conditions".  While DHMH requires treatment providers operating in Maryland to follow these guidelines when determining the appropriate level of care for patients --they DO NOT require insurance companies doing business in the state to recognize these same guidelines.  As a result, Maryland has a disjointed and inconsistent treatment system because some providers follow ASAM criteria for determining level of care, while others do not.  Those that do, either charge families for whatever portion of their treatment program is not paid by insurance or provide services for which they are not paid.  Other programs discard ASAM criteria altogether, allowing insurance companies or a client's ability to pay, to determine their level of care.

Consumers of services are wondering if Maryland's Behavioral Health administrators are in denial when they fail to acknowlege this blatant and flagrant inconsistency.  Agency administrators repeatedly insist that Maryland treatment providers are required to follow ASAM criteria, when it is painfully obvious to anyone who has used the state's treatment system that placement, length of stay, and transfer/discharge plans are more often based on an individual's ability to pay and the availability of beds (often limited to a single county) than on ASAM criteria when determining 'level of care'.  Consumers can certainly vouch for the fact that SUD treatment providers use ASAM criteria inconsistently at best.

Consumers expect and deserve basic honesty from appointed agency representatives.  Regardless of whether DHMH chooses to resolve the fact that our Maryland treatment system is NOT guided by ASAM criteria, they should, at the very least, be honest about that fact.  Trying to convince consumers that placement, length of stay, or transfer/discharge is based on a standardized medical criteria when they have consistently experienced otherwise is like trying to convince someone it is safe to cross a wooden bridge when it is on fire.  If our elected and appointed leaders do not care enough to fix the problem, at least they should not cover up their lack of care with misrepresentations and falsehoods.

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