Comments on the FY 2017 Behavioral Health Plan
1) Expansion of Pharmacological Treatment for SUD: Despite the fact that Objective 1.3. seeks to “Improve access and quality of services throughout the continuum of care” (p. 18), The Plan focuses only on Pharmacological treatments for SUD, without any mention of improved access and quality for ASAM 3.1 –3.7 levels of residential care for SUD patients. While DHMH talks about expanding access to pharmacological medications (p.13 1-1D); working to reduce stigma surrounding Medication-Assisted Treatment (MAT) (p.56 7-1F); updating educational materials regarding research around MAT (p.56 7-1F); promoting MAT via media outlets (p.56 7-1F); implementing a campaign to change public perception of MAT as “medical treatment vs. drug substitution” (p.56 7-1F); and gaining physicians’ support for MAT (p.56 7-1F); DHMH has hog-tied Abstinence-Based Residential Treatment (ABRT) programs by failing to resolve the IMD exclusion dilemma for 3.5—3.7 (detox) level of care until 2017, and for 3.1 (halfway house) level of care until 2019. ABRT programs typically use a finite buprenorphine taper and a structured therapeutic program which provides the patient with recovery supports to assist in abstinence maintenance.
WE PROPOSE THAT DHMH support “Consumer Choice” by ensuring that individuals are able to access ALL paths to recovery, rather than using public money to support one path to recovery over another. We also support an unbiased analysis of existing research and data by a consortium of stakeholders whose increased economic gain is in no way dependent upon the research outcomes.
2) Standards for Quality of Care: We wholeheartedly approve Goal IV. –“Utilize data and health information technology to evaluate, monitor, and improve the quality of service delivery and outcomes.” The problem is that there is no mention of the development of universal quality standards for SUD programs, or a mechanism for resolving grievances when service delivery does not meet even basic logical assumptions for what standards and outcomes should be. There are no enforcement provisions for sanctioning providers who do not provide even basic standards of care. Consumers of SUD services throughout the state continue to experience grievous obstacles to their successful recovery that consumers of mental health services do not experience due to regulated protections. This inequality is particularly obvious in the area of family engagement and support services, discharge planning, recovery support and housing, supportive recovery services in schools, involuntary commitment statutes, billable services, and program oversight.
Consumers continue to report a serious lack of family engagement and support services in SUD programs which often contributes to or exacerbates family disconnection; premature discharges which lead to death; unregulated and predatory halfway house programs which contribute to the physical, mental and emotional abuse and subsequent trauma of patients; lack of even basic recovery supports in schools which leads to the relapse of young people; lack of the mental health equivalent of involuntary commitment which contributes to preventable overdose death; lack of a rich treatment milieu of billable ancillary services which contribute to wellness; and a severe lack of anything resembling a formalized patient grievance process with oversight or remedy provisions. Additionally, patient referrals from one level of care to another level, based on an assessment per ASAM criteria, are haphazard and fractured at best. Fatal overdose is currently the most frequent cause of unexpected death in Maryland. The lack of a visible and formal plan, driven by stakeholder input, to raise quality of care in our treatment system continues to be increasingly irresponsible and unacceptable.
WE PROPOSE THAT DHMH must do more than simply monitor for infectious diseases (p.42 4-2B), medication diversion (p.42 4-2C), and overdose death (p.42 4-2C). These are very low standards. DHMH must meet with consumers of services, their families, and other stakeholders to remedy the very serious and life-threatening problems outlined above. In addition, we must work together to raise our program standards to ensure that those individuals with SUD have the supports they need to fully recover and engage in the same quality of life measures as anyone else. Those measures include job, housing, family, recreational pursuits, health and wellness, and basically –HAPPINESS!
3) Protecting Consumer Choice: While DHMH seeks to “enhance the role and responsibilities of the Health Departments, Core Service Agencies, Local Addiction Authorities, and Local Behavioral Health Authorities as system managers to assure access to quality services” (p.17 1-2D), that cannot at the same time limit Consumer Choice. While the only place in The Plan where County “referral agreements”, “Memorandum of Understanding (MOUs)”, and “collaboration with …community providers” is mentioned is in section (2-1G), SUD advocates are aware that many individuals with Medicaid, Medicare, or grant funding are told by local LAAs / LBHAs that they can only enter a “County-contracted” treatment program. By the same token, individuals seeking treatment in areas of the state outside of their home counties are denied access to programs when their County-of-residence does not contract with that specific provider –even though their method of payment is public state dollars. There is no other healthcare diagnosis where the County government is able to control or dictate which healthcare provider an individual chooses. This system of county contracting through referral agreements, limits or in some cases, entirely removes Consumer Choice.
WE PROPOSE THAT county LAAs/LBHAs are disallowed from developing referral agreements and MOUs with favored providers or else they develop these agreements with ALL providers in the state. LAAs and LBHAs should be able to provide Maryland residents with a complete list of all providers in the state and the services they offer. Furthermore, we suggest that Maryland enter into dialogs with surrounding states –particularly Pennsylvania, where there is an abundance of SUD programs without wait lists, and set up formal agreements to honor each other’s Medicaid and Medicare clients –similar to the pact entered into by several Northeast states in 2014. This would go far to expand capacity until such a time as Maryland is able to expand its own in-state capacity to meet the demand for SUD treatment.
4) Credentialing Family Peer Support: We applaud DHMH for implementing peer support credentialing in Maryland and hope this becomes a Medicaid billable service in the near future. We are especially supportive of DHMH focus on “the development of peer supports specifically for special populations”, including families (p.58 7-2A) and its acknowledgement of the important role of “family participation on policy and planning committees across the state” (p.58 7-2A).
In 2014, family peer support specialists affiliated with F.A.C.E. Addiction, provided thousands of Marylanders with parent-peer support and navigation services, as well as court advocacy and diversion support services. They held family-peer support and bereavement groups, as well as Naloxone trainings throughout their communities. They offered treatment scholarships, organized awareness and anti-stigma events, and served frequently as spokespeople for the media. The Directors of these non-profits developed, implemented, managed and supervised this work themselves. Since these volunteer leaders stepped in to fill a severe service gap in order to assist the state in quickly responding to the opioid dependence and overdose epidemic –there was no one to supervise them. However, the requirement that they now complete 500 additional hours of “supervised” work before they can become eligible for peer certification is short-sighted and unfair.
WE PROPOSE THAT DHMH work with family peer specialists to resolve this issue and accept proof of 500 hours of service regardless of that work being “supervised”.
5) Family Support Navigation System: Many Maryland SUD advocates are confused by (7-2E) on page 61, regarding DHMH plans for “developing and implementing a family support navigation system to empower and inform families caring for youth, adolescents, and young adults facing challenges related to substance-use disorders”, since (as outlined above) this system has already been developed and implemented for more than ten years.
Without any type of bid process, DHMH handed $350,000 to Maryland Coalition of Families for Children’s Mental Health (MCF), to “develop and implement” this system –which already exists. MCF was charged with collaborating, cooperating, partnering, and sharing ideas, in an open and transparent dialog, with the already existing network of organizations across Maryland that provide support services to families with children challenged by SUD, in order to build upon and expand the existing system. This collaborative process never occurred.
For an extraordinarily high cost, the MCF proposal delivers only a quarter of the services that are currently being provided by the existing network on a very limited and much lower budget. Based on their initial proposal (MCF was unwilling to share the final proposal), only 53% of public money was allocated for direct services provided by staff, while 47% was allocated to "infrastructure". According to Charity Watch and other standards for non-profit spending, those allocations would earn a score of zero in rankings for being a good, fiscally responsible charity. According to Charity Watch, 7 out of 10 charities spend 75% on services, and 9 out of 10 spend 65% on services.
We are concerned that while F.A.C.E. Addiction’s member organizations either do not have enough Naloxone to continue training families, have exhausted scholarship funds that ensure that clients without funding options get into halfway house beds, and are operating on such a shoestring budget that their continued work is jeopardized, that more than $156,000 dollars of public money is going to MCF “infrastructure”, regardless of service deliverables or cost. This was not the original intent of this grant.
Based on the MCF preliminary proposal, here is how they are electing to spend public money to support 6 part-time staffing positions working from home:
$1,792 for bank service charges $10,000 for printing
$8,961 for office supplies $7,706 for telephone
$7,800 for rent/occupancy $9,800 for equipment expenses
$2,160 for program supplies $28,436 for overhead
Many advocates view these costs as grossly inflated and therefore an egregious misallocation of public money. We need to see the existing proposal and discuss how best to deliver these services throughout the state in order for the Maryland taxpayer to maximize services. Since the assumption is that taxpayer dollars should be spent for the greatest good of all, we have a problem with the lack of transparency and open competition with which this grant was awarded. Competitive bidding in a market economy is the means by which costs are kept within reasonable bounds. When $350,000 dollar contracts are simply handed to a contractor who provides reduced outputs at inflated and exorbitant costs, our entire Maryland economy suffers.
WE PROPOSE THAT DHMH ensures that MCF honors the spirit of the agreement they made at the outset of this contract to:
- Partner with the existing incorporated non-profit network of F.A.C.E. Addiction Maryland members and affiliates (and any other family organizations) in a mutually collaborative process to expand upon a family support and navigation service delivery system that already exists across the state;
- Develop resource materials in collaboration with existing F.A.C.E. Addiction partners to promote services that are in the highest interest of families caring for children and young adults with SUD;
- Collaborate with F.A.C.E. Addiction members in dispersing the $350,000 public grant dollars in ways that will have the greatest impact on helping the greatest number of Maryland families who have been devastated by SUD.
6) Including “the Voice” for SUD in Public Policy: The Plan includes 77 Behavioral Health initiatives and lists the “involved parties” on each initiative. Of those 77 initiatives, independent organizations (OOMD, NAMI, MCF, MHAMD) and others were listed as an “involved party” only 33 times. “Other stakeholders” and/or “advocates”, including the Behavioral Health Advisory Council were listed as an “involved party” on only 12 initiatives. “Consumers” of services were listed as an “involved party” only 12 times. And “families” were listed as an “involved party” only 10 times. Not one of the incorporated non-profit SUD family organizations was listed. In order to understand how policy is working at the ground level, DHMH must support a feedback loop empowering the voice of those who actually utilize the services –directly, as patients, or indirectly as caregivers and/or family members of those patients.
Additionally, section 7—1B (p.54) specifies that DHMH will “continue to provide support, funding, and ongoing consultation to Maryland’s behavioral health advocacy groups,” and lists MCF, MHAMD, NAMI MD, OOOMD (all four of the traditional mental health organizations), but fails to list F.A.C.E. Addiction (an incorporated non-profit network of SUD member organizations throughout the state).
WE PROPOSE THAT DHMH include F.A.C.E. Addiction Maryland and/or any of its affiliated member organizations in all initiatives which impact them –so that a recovery peer or a family member impacted by SUD has the opportunity to participate in any policy which effects their lives –either directly as consumers or indirectly as caregivers of their consumer children. In addition, we must have a representative that we select to “participate in oversight of the Consumer Quality Team (CQT) project for statewide expansion”. (p.44, 4-2G)
WE ALSO PROPOSE that DHMH add “September is Recovery Month” to the bulleted list of initiatives to promote (perhaps following “May is Mental Health Month”) in section 7—1B (p.54).
7) Family Peer Support in Hospital ERs: We applaud DHMH’s provision for “peer support specialists and local outreach workers providing support, information, and referrals to treatment for individuals who are saved from an overdose …in hospital emergency departments.” (p.28, 2-2C) However, for teens and young adults –particularly those who live with their parents, it is the parent caregiver who is often instrumental in facilitating a young adult’s entry into treatment and also the most influential in supporting the teen or young adult in their recovery.
WE PROPOSE THAT family members in the Emergency Department assisting a loved one should also be offered the opportunity for family-peer support.
8) Striving for Fully Integrated Models: The Center for Mental Health Services reveals that nearly 43% of youth who receive mental health services have been diagnosed with a co-occurring substance use disorder. Some diagnoses have particularly high correlations, including post-traumatic stress disorder (85-90%), antisocial personality disorder (82%), bipolar disorder (71%), and schizophrenia (50%). Adolescents with a conduct disorder, oppositional defiant disorder or attention deficit disorder are up to 7 times more likely to have a substance use disorder, while adolescents with depression are 4 times more likely to use substances. Given the high prevalence of SUD among individuals with a mental health disorder, DHMH must ensure that the “First Episode Psychosis model” provides detox protocol for accepting “youth and young adults who are within two years of initial onset of psychotic symptoms” who also have a co-occurring SUD. (p.30, 2-3B)
WE PROPOSE THAT after approximately six years of integration planning, that any service, study, or model developed MUST be completely and fully integrated.
9) Justice System Diversion: We are in full support of DHMH efforts to “provide technical assistance and training to providers who serve individuals residing in the community who are in the court or corrections system,” particularly “judges, attorneys, law enforcement, and correctional professionals engaged with consumers of behavioral health services.” (p.51, 6-2A)
WE PROPOSE THAT mental health and SUD assessments are provided for all incarcerated offenders. We suggest that all justice system professionals are trained in diversion measures, in order to alleviate the severe backlog of inmates awaiting 8-507 placements, or sitting in jails as a result of an untreated SUD or other mental health disorder at the expense of Maryland taxpayers.
10) Referral Hotline: While “a statewide hotline to obtain a referral to treatment resources” is a great idea, when callers are given false or misleading information it is harmful to consumers or their caregivers who are likely in crisis due to their inability to locate treatment. Giving them inaccurate information adds to their distress and utilizes precious time that could have been spent seeking valid and accurate information. When advocates tested the hotline –repeating the test several times, we found that the information was accurate only 2 out of 11 times. To test the hotline, advocates posed as parents seeking detox for a chronic intravenous heroin-using adult-age child. They were given referrals to hospitals that did not provide opiate detox, to halfway houses that only accepted post-detox patients, to counseling centers without detox, and to residential housing providers.
WE PROPOSE THAT call center staff is better trained to provide valid information, or that they refer callers to trained peer support specialists who only provide accurate and credible information regarding treatment options to callers.
11) Oversight for LDAACs: While we applaud DHMH oversight of local Core Service Agencies and Behavioral Health Authorities via quarterly monitoring (p.43, 4-2D), DHMH must also have jurisdiction over the entire system of statewide information gathering in order to implement good policy that works. Oversight and monitoring must begin with the Local Mental Health Advisory Committees and the Local Drug & Alcohol Advisory Councils (LDAACs). Advocates and stakeholders in various counties report that LDAACs are easily hijacked by special interests, including specific providers or agency officers, and valuable stakeholder input is disallowed if it is perceived as reflecting negatively on the County Health Department or a specific contractor. Therefore, DHMH does not receive the information from the local level that is reflective of the needs of the community. When policy makers do not have the information they need to make good policy decisions, the Maryland constituency is ultimately harmed.
WE PROPOSE THAT DHMH must devise a process for resolving conflicts between groups of stakeholders and LDAACs to ensure that these Councils are welcoming and inclusive of all divergent interests and competing issues. In order to get accurate feedback regarding community needs, there must be an equal opportunity for community stakeholders to participate. Consumer issues that conflict with local providers or agency agendas must not only be allowed, but equally and impartially weighed. Stakeholder complaints involving the inability to bring valid and prove-able local issues to the table must be taken seriously by DHMH.