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A New Approach To Mental Health Care, Imported From Abroad

2020; Project HOPE; Volume: 39; Issue: 3 Linguagem: Inglês

10.1377/hlthaff.2020.00047

2694-233X

Rob Waters,

Global Health and Surgery

Leading To HealthBehavioral Health Care Health AffairsVol. 39, No. 3: The Affordable Care Act Turns 10 A New Approach To Mental Health Care, Imported From AbroadRob Waters AffiliationsThis is the second part of a two-part article. The first appeared in the February 2020 issue of Health Affairs. It is part of a series on transforming health systems published with support from The Robert Wood Johnson Foundation. This is an open access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY 4.0) license, which permits others to distribute, remix, adapt, and build upon this work, for commercial use, provided the original work is properly cited. See https://creativecommons.org/licenses/by/4.0/. Rob Waters ([email protected]) is an independent journalist in Oakland, California, who writes about health and science and has contributed to Kaiser Health News, STAT, Mother Jones, and Psychotherapy Networker, among other publications. Photograph ©2019 Los Angeles Times. Used with permission.PUBLISHED:March 2020Open Accesshttps://doi.org/10.1377/hlthaff.2020.00047AboutSectionsView PDFPermissions ShareShare onFacebookTwitterLinked InRedditEmail ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsDownload Exhibits AbstractCan a transformative care strategy, tested and proven in Trieste, Italy, work in Los Angeles, California?TOPICSBehavioral health careMental healthMental health servicesMental disordersMedicaidCosts and spendingCase managementHospital costsNursesPsychiatristsHope: Kerry Morrison, right, former director of the Hollywood Property Owners Alliance, talks to George Cooper, 60, who is homeless, at an encampment on El Centro Avenue in Hollywood. A trip to Trieste, in northern Italy, turned Morrison’s despair about homelessness into hope.Photograph by Mel Melcon/Los Angeles TimesWalk south down Vine Street in Los Angeles, California, along the Hollywood Walk of Fame, past the stars embedded in the sidewalk for the likes of Dean Martin, Bing Crosby, and Cyd Charisse, and past homeless people sleeping in front of the Trader Joe’s or sitting at bus stops with their possessions. You’ll come to a squat, featureless concrete building that looks like a fortified bunker. The first and second floors of the building are devoid of windows, but high above the entrance on La Mirada Avenue, a row of small windows looks like portholes on a cruise ship.Through that entrance, a uniformed guard stands at the top of the stairs. Visitors who enter the building must submit to a bag search and allow a metal-detecting wand to be passed over their limbs and torso. They can then proceed to a window and push their paperwork under a pane of thick glass to a clerk. Welcome to the Hollywood Mental Health Center, Los Angeles County’s principal clinical program for people who struggle with mental health problems.Nathan Sheets, executive director of the Center in Hollywood, a drop-in program for homeless people less than a mile away, has spent hours at this building with clients, trying desperately to help them get the assistance they need. “You walk in, they pat you down, they search your bags. For a person experiencing psychosis, that in itself is a problem,” he says.Then the wait in a windowless room begins—for an eligibility worker to conduct an intake; for a nurse to take vital signs; and ultimately, Sheets says, for a brief meeting with a psychiatrist, who most likely will write a prescription for a thirty-day supply of medication. If clients step out for a cigarette at any point, they may give up and disappear. And since the clients are homeless and there’s no easy way for Sheets’s team to find or remind them, there’s a good chance they’ll miss the next appointment, get disenrolled, and have to go through the process all over again.“If a person is in immediate need for mental health services, the Hollywood mental health building might as well not exist,” Sheets says. “It doesn’t even cross my mind as an option.”This building is just one piece of a broken mental health system in Los Angeles—a system that largely continues to fail the tens of thousands of people in the city who are grappling with homelessness and mental illness. It’s the antithesis of the community-based mental health system that the city of Trieste, Italy, has built over the past forty years, a system that LA County would like to replicate in Hollywood at the urging of a woman named Kerry Morrison.Morrison served for twenty-two years as director of the Hollywood Property Owners Alliance, one of the oldest business improvement districts in the country. She has witnessed with a growing sense of outrage the city’s failure to adequately respond to the increasing misery of homeless and mentally ill people sleeping on Hollywood’s sidewalks. In a city of fabulous wealth, she couldn’t accept that so many people were living in squalor and that the systems to help them were so fractured.Several years ago Morrison began an effort to get help for some of the most vulnerable and disturbed homeless people in Hollywood, a group she dubbed the Hollywood Top 14. She pushed to get them into treatment, using court-ordered conservatorships if necessary. She also helped form a coalition, Hollywood 4WRD, that has pushed to create new shelters, and she began hunting for broader solutions. Her search led her to Trieste in 2017, where she found herself awed by the city’s inclusive, humane, and highly effective community mental health and wellness system. (Health Affairs explored Trieste’s mental health system in the February 2020 issue.)1Morrison, who left her leadership post with the business district early in 2019 to focus on the mental health effort, returned to Trieste four more times, and with support from the Durfee Foundation of Los Angeles, she brought local leaders to get a firsthand look. The delegations have included Los Angeles County District Attorney Jackie Lacey; Superior Court Judge James Bianco; and Jonathan Sherin, the psychiatrist who has served as the county’s director of mental health services for the past three years. At Morrison’s urging, Sherin and his staff developed a proposal to build a Trieste-style system of community-based care in Hollywood.It’s difficult to overstate just how audacious—some would say impossible—an aspiration that is.Los Angeles may be more affected by the twin crises of homelessness and mental health neglect than any other US city.Los Angeles may be more affected by the twin crises of homelessness and mental health neglect than any other US city. At last count, more than 36,000 people were homeless in the city (population: 4.0 million), as were 59,000 across the county (population: 10.1 million), according to the county’s homeless services agency. A staggering three-quarters of the county’s homeless residents are unsheltered, with 11,000 living in tents and makeshift shelters and 16,000 living in cars. More than 30 percent of the unsheltered suffer from mental illness or have a substance use disorder.2‘Blissfully Unaware’In May 2019 California’s Mental Health Services Oversight and Accountability Commission voted to provide $117 million over five years to fund a Trieste-style pilot in Hollywood, where 103,000 people live.3 The money comes from the Mental Health Services Act (MHSA), a measure approved by California voters in 2004 that levies a 1 percent tax on millionaires and raises about $2 billion a year for mental health services.Perhaps the most important feature of the proposed pilot is that funds from the MHSA are unrestricted, and the services they pay for don’t need to follow the federal rules that govern Medicaid, the joint federal-state program that pays for nearly all public mental health programs. With few exceptions, Medicaid dollars must be spent on clinical measures instead of supportive services such as housing, socialization, and job readiness. Sherin says that these rules force mental health clinicians to spend a third of their time or more doing paperwork to justify the medical necessity of their treatment.“Our system has been driven almost entirely by medically oriented approaches and funded based on allowable services with cumbersome bureaucratic requirements,” Sherin says. “We spend our time making sure that we’re compliant and that we’re taking care of the auditor, instead of engaging people as human beings, identifying what they need, and addressing the other issues in their lives.”By contrast, Trieste’s mental health system gives people who grapple with mental illness help with all aspects of their lives by ensuring that their physical needs for food, clothing, and shelter are met; helping them forge connections with other community members; and supporting them in their pursuit of meaningful activities and employment. Staff members in Trieste “are blissfully unaware” of how the services they provide are paid for, Sherin says, and they spend little time documenting their work with patients.Can what happens in Trieste work in Los Angeles, a city twenty times larger and a place where the county jail has become the largest de facto mental health facility in the US? Can the kind of mutual support that occurs in a country with a famously collectivist culture be replicated in a city and country that are just as well known for their ethos of individualism, self-actualization, and privacy?Morrison and Sherin hope so, and they believe that this project can be a turning point and push Los Angeles on a path of transforming a mental health system described by users and clinicians alike as unfriendly and bureaucratic.“We know we don’t have enough treatment options, and when we do have options, they’re often not customer friendly because the facilities and the culture of service are not welcoming,” Sherin says. “We have a broken culture, and I’m reorganizing the entire thing.”If the pilot shows success, Sherin hopes to expand it throughout LA County and, in the process, convince both the state and federal governments to change how they pay for mental health services. It’s a daunting goal.Learning From The PastLast summer, after spending a week in Trieste and getting a firsthand look at the renowned mental health system there, I spent a few days in Los Angeles. I examined how the crises of homelessness and mental illness were affecting the city and learned more about the mental health department’s plan for the pilot in Hollywood. My first stop was the county’s two-year-old Peer Resource Center, in the Koreatown district.Located four miles from the Hollywood Mental Health Center, the Peer Resource Center embodies the kind of environment that the new pilot program will aim to create. It is “kind of like Trieste in one little center,” says Keris Myrick, the county mental health department’s chief of peer services. She says that the center is a welcoming place for people who need to get off their feet; hang out; connect with peers; and take advantage of support groups, job counseling, and mutual support services provided by people who—like Myrick—have their own histories of using the mental health system.She and psychologist Dave Pilon chose the peer center as the site for an interview to tell me more about the department’s plans. Pilon, who used to run mental health programs in Long Beach, LA County’s second-largest city, was recruited out of retirement to help develop and write the sixty-four-page proposal for the Hollywood pilot.“I was reluctant,” Pilon told me, “because I’ve been involved in a lot of these system-change programs,” and he knew all too well that most run out of steam when they run out of funding. What roped him in, he says, were these magic words from Sherin: “We really need to blow up the financing of the way we run mental health.”That got Pilon interested. “I know where we need to plant the explosives,” he says.Pilon led a similar experiment in the early 1990s at a Long Beach program called the Village Integrated Service Agency. It provided intensive case management and a full range of services to patients who struggled with severe mental illness, most of whom were receiving disability benefits. The key innovation was the ability of the Village to spend money on all kinds of services, not just clinical ones. Using general funds, not Medicaid dollars, the state paid the Village a flat rate ($15,000 a year per person) to provide all care, including hospitalization if needed, for the 102 people randomly selected to get Village care. Another 108 people with similar needs continued to get standard care from local mental health providers.4The Village devoted most of its money to nonclinical services, spending 40 percent of its budget on case management, 25 percent on employment services, 12 percent on socialization, and just 6 percent on hospitalization. By contrast, more than half of the costs generated by people in the comparison group were for hospital stays, with just 10 percent spent on case management and 2 percent on employment and socialization services combined.4After two years an independent evaluation found that compared to members of the comparison group, Village clients had spent less time in the hospital; were less likely to live in institutional settings; and were more likely to have worked at jobs, to be engaged in leisure activities, and to say that they were satisfied with their services. The program was “able to change the usual hospital-heavy pattern of service distribution and develop new and effective services,” the evaluators found.4(pX)At the end of the project, a final unpublished report by the evaluation team found that—relative to the comparison group—Village clients were more connected to their therapists; spent more time in leisure and social activities; had more income, and thus more money at their disposal; and were more satisfied with their services. Family members of Village clients also reported feeling better about their loved ones’ situation.5But providing these extra services cost more: The small savings on hospitalization and general health care costs for Village clients didn’t make up for the extra money spent on social and rehabilitative services. In the program’s second year, total public costs, including non–mental health services, were $29,000 for each Village client and $19,000 for each member of the comparison group. The “more favorable outcomes for the demonstration groups…came at a high price,” in the words of the evaluation.4(p182)The final evaluation added one ominous note about the surprisingly large difference in costs: “We are only now getting good data on how minimal public services are to many seriously mentally ill clients. Consequently, designers of the demonstration seriously overestimated the ‘usual system’ costs against which” the Village program’s costs were being compared.5(p7)California ended the experiment in 1996. “The state said, you guys are a success, we’re done,” Pilon says. “Now we’re transferring you over to the usual system of care. Welcome to the world of Medicaid.”The Village continued to care for patients for the next twenty years, using a standard fee-for-service model and billing Medicaid. But it had less success, Pilon says: “My biggest challenge was to maintain the welcoming, do-whatever-it-takes culture that we had created in the face of billing requirements that got stricter and stricter and stricter every year.”Pilon argues that compared to the 1990s, it’s easier to save money now because the huge increases in homelessness and substance abuse have exploded the costs of the most expensive interventions: hospitalization and incarceration. In that sense, he contends, the pilot’s plan to shift funding priorities and invest in a richer mix of social and rehabilitative services stands a good chance of at least being revenue-neutral.The overall philosophy of the proposed Hollywood pilot is simple: Consider people who grapple with mental illness as whole human beings, not just a collection of symptoms to be diagnosed and treated. Connect with these people, learn what they need, and organize an array of compassionate services aimed at helping them recover and gain agency over their lives. Pilon says that the ultimate goal, a combination of the practical and the spiritual, is for people to have “somewhere to live, something to do, and someone to love.”Follow The MoneyThe reform starts with money. The total budget for the effort is pegged at slightly below the amount the county currently spends on mental health and health services for 4,000 clients using services at seven mental health, drop-in, and wellness programs in Hollywood. The cost of serving these users in fiscal year 2017 was about $27.3 million. The proposal envisions spending $11.9 million in a first year of planning and then $26.2 million a year for the next four years actually running the program.Instead of billing for and documenting the specific clinical services provided, the pilot proposes to create global budgets for four or five categories of users, each with its own per capita case rate. People with the least ability to function independently and the greatest level of need would be in a tier with the highest per capita budget (perhaps $25,000 a year), while those most able to function on their own would be in the lowest-cost tier (perhaps $3,000 a year).The program would begin by evaluating the needs and ability to function of each mental health service user based on two rating scales, the Milestones of Recovery Scale and the Determinants of Care, and assigning users to a tier. The funds allocated to that tier could be used by the program for whatever a person needs—whether that’s a rent subsidy or psychotherapy session, food voucher or prescription, bus fare or yoga class. Users would be reevaluated monthly, and if their condition or ability to function changed for the better or worse, they could be assigned to a different tier.This approach would discard the system now used under Medicaid to classify each clinical interaction with a client as the basis for a fee. Instead, staff members would list which of thirteen activities they did with a client (from initial engagement to crisis intervention) and what area of the client’s life the work was focused on (such as housing, employment, family relationships, or substance use). Pilon says that the Hollywood team also plans to develop a phone-based app that would allow staff members to record simple statements about their activities, such as “driving by car to an encampment.” The goal, he says, is to push the share of time staff members spend documenting their activities down to 5 percent.The pilot proposal also calls for flipping the existing ratio of services “by making the psychosocial services ‘primary’ and the clinical services ‘ancillary.’”3(p6) It would establish “health homes” for every user at a wellness center, peer center, or outpatient clinic, where case managers would coordinate the user’s health and mental health care, helping them navigate the systems and get the help they need. The managers would also work with users to improve their ability to manage their own money, medications, and lives.Outreach teams composed of nurses, social workers, and peer specialists would work 24/7. When appropriate, they’d act as first responders, replacing police officers or paramedics and bringing people who experience manageable crises to places where they could rest and decompress. According to the proposal, these new facilities would include a ten-bed peer respite center, a home-like place where people could stay in the company of peers for up to two weeks; a ten-bed crisis residential center with professional staffing, where people could also stay for up to two weeks; and an urgent care unit with ten slots, where people could spend up to twenty-three hours. The goal of all of these elements is to reduce the use of emergency departments and psychiatric emergency facilities and the burden on police and paramedics.As in Trieste, the program would make extensive use of a peer-support model, with increased recruitment and training of paid peer-support workers. “We’re going to have a very significant role,” Myrick says.‘Striking Contradictions’Roberto Mezzina, who retired in October 2019 as Trieste’s director of mental health after working there for four decades, hosted the delegations that Morrison brought from Los Angeles and visited Hollywood to learn what Sherin and his team hope to do there. He says that California’s history of remaking itself and “the mobile nature of American society” make him optimistic about the Hollywood pilot. The fact that key decision makers and community leaders such as Morrison “embrace the idea of change—that’s a good start,” he says.On the other hand, he says, “American society has the most striking contradictions—especially Los Angeles,” where the richest and the poorest live right next to each other. “The system is very complicated—patchy and fragmented and existing in chaos. The jails became like hospitals, and the hospitals can become like jails. In this situation, to create a new experience and new pathway for care is not easy. It’s not enough to create a good community mental health center and then scale it up. You have to change the imbalance of power between service providers and service users.”A key difference, of course, is that Italy has virtually no homelessness, a comparatively robust social safety net, and a forty-year history of both deinstitutionalization and providing community-based mental health services. Another big difference is the role of involuntary treatment. For Mezzina and his colleagues, compelling someone into treatment represents a failure and is vanishingly rare. In 2018, he told me, only eighteen patients were forcibly treated in Trieste out of almost 5,000 served.When Mezzina visited Los Angeles, Sherin says, he was “morally injured” to see the vast numbers of people living in squalor on the streets. The Italian also disagreed with Sherin’s thoughts on forced treatment.“He and I would probably argue about this for the rest of our lives,” Sherin says. “I would say that our communities are so divided and disconnected, and our systems are so broken and bureaucratic, that we have more sick people [than there are in Italy], and they’re sicker. And until we can have the flexibility, be driven by outcomes, and develop collective sensibility, we’re going to have to have more compelled treatment [and hospitalization].”“I would say our involuntary treatment laws need to be reformed,” Sherin adds. “We need to look at involuntary treatment as a first step toward recovery for certain individuals. We need more hospital beds, because they’re going to be replacing the open-air asylum of the street, and we need to close the asylum of the jail. That’s where we are now.”The proposed Hollywood pilot must still be approved by the five-member Los Angeles County Board of Supervisors. It hasn’t yet come before the board because Sherin and his staff are still working to nail down agreements with unions and other partners. Sherin says he is “far down the road” in negotiations with an intermediary organization that could lease and manage the property for the facilities the project will need. Once that is done, Sherin will bring the project and contracts to the county supervisors for official approval—which he hopes will happen in the coming months. Then will come a year of planning and “stakeholder engagement,” with the program expected to begin operations in early 2021.“When I say ‘stakeholders,’ I mean the people being served and their families, the communities, the business sector, other county departments, the city, the state—everyone that has a stake,” Sherin says. The process will include community forums and a direct appeal to businesses, employers, landlords, and “all people who have assets in the community. We’ll be asking: ‘What can we use? What can you do? What do you need to rent an apartment to someone with mental illness or a meth addiction?’”Hollywood is a logical place to try this experiment because it has the second-highest concentration of homeless people in the city.Supervisor Sheila Kuehl, whose district includes Hollywood, is an enthusiastic supporter. “I think it’s bold, and I’m very excited about it,” she told me. Kuehl argues that Hollywood is a logical place to try this experiment because it has the second-highest concentration of homeless people in the city, after Skid Row, but with far fewer services. She also believes that Morrison’s coalition building among Hollywood business leaders and service providers has helped make the community a more receptive and hospitable place, one that notably isn’t taking a not-in-my-backyard stance toward new programs that seek to address homelessness and mental illness.For her part, Morrison keeps working and walking the neighborhood, talking to people she sees on the street. She began doing that several years ago, when she helped organize interviews with homeless people to try to understand their histories and needs. We walk together along Vine Street as Morrison looks for a man named Caleb, whom she saw earlier in the day. He uses meth and has been on the street for five years, and Morrison considers him extremely vulnerable. We don’t find him, but she talks to another man named Dwayne and a woman she thinks is named Kelly. She approaches each compassionately, crouching down to speak softly and find out if they need anything.Morrison is frustrated. She feels that almost no one from the county is doing this kind of outreach in the way it needs to happen. She was in a meeting recently with a Department of Mental Health outreach team and learned that two weeks earlier, a county worker had spotted a homeless woman named Sally—a longtime member of the Hollywood Top 14—whom local agencies had been worrying about and looking for. But the worker didn’t engage her because his shift was about to end. Morrison hopes that when the Trieste-style pilot begins, outreach workers will act with more urgency and fewer constraints. Then they might be able to convince someone like Caleb to go to an urgent care center and get off the street for a while.“You would do daily engagement with him, and say, ‘Hey buddy, why don’t you come with me? I can get you something to eat. You can get out of the heat for a couple hours, take a shower.’ He might not agree the first or second time, but we’ll see that people will agree once they trust you,” Morrison says. “And then you can start the process of helping them take the next step.”This kind of transformation will require broader efforts as well, says Myrick. Creating change “is not incumbent on just the staff, the providers, and the peers that are doing all of this work in support of people. It’s incumbent on the community. When you come through the door of the Peer Resource Center, everybody who’s in this building has a responsibility to help that person. And I think that’s where we kind of miss the boat in America.”NOTES1 Waters R. The old asylum is gone: today a mental health system serves all. Health Aff (Millwood). 2020;39(2):186–91. Go to the article, Google Scholar 2 Los Angeles Homeless Services Authority. 2019 Greater Los Angeles homeless count presentation [Internet]. Los Angeles (CA): LAHSA; [last updated 2019 Aug 5; cited 2020 Jan 29]. Available from: https://www.lahsa.org/documents?id=3437-2019-greater-los-angeles-homeless-count-presentation.pdf Google Scholar 3 Los Angeles County Department of Mental Health. The TRIESTE* project: *true recovery innovation embraces systems that empower [Internet]. Sacramento (CA): Mental Health Services Oversight and Accountability Commission; [updated 2019 Apr 30; cited 2020 Jan 29]. Available from: https://mhsoac.ca.gov/sites/default/files/documents/2019-05/1054552_TriesteConceptPaper-4-18-2019FINAL.pdf Google Scholar 4 Chandler D, Hu TW, Meisel J, McGowen M, Madison K. Mental health costs, other public costs, and family burden among mental health clients in capitated integrated service agencies. J Ment Health Adm. 1997;24(2):178–88. Crossref, Medline, Google Scholar 5 Chandler D, Hu T, Meisel J, McGowen M, Madison K. Client outcomes in a three-year controlled study of two model integrated service agencies. Unpublished. Google Scholar Loading Comments... Please enable JavaScript to view the comments powered by Disqus. DetailsExhibitsReferencesRelated Article Metrics History Published online 2 March 2020 InformationThis open access article is distributed in accordance with the terms of the Creative Commons Attribution (CC BY 4.0) license.