ISMICC Meeting Part 2 – Federal Advances to Address SMI and SED

Updated : Sep 12, 2019 in Articles

ISMICC Meeting Part 2 – Federal Advances to Address SMI and SED


>>Elinore McCance-Katz: Well, thank you all,
and I just have to say it’s so exciting to have you all here. And I’ll tell you why. Because, Dr. Minkoff, I will just say that
I don’t remember the Carter Commission. [laughter]>>Elinore McCance-Katz: I don’t know how
that was structured, and I actually don’t know how President Bush’s commission was structured
either. But — but — this is, I hope, going to be
different because now there is an Assistant Secretary, and what you can do is provide
that feedback and give me things to help me bring things forward and help me change things. You see all of our federal partners here. You’re going to hear more from them in just
a few minutes. But we’re all here because we want to change
all of the things you’ve been talking about. And so, we’re going to move on now to have
our federal partners make remarks for a few minutes. But as the day goes on, we’ll talk more and
more about how this counsel can make a difference. So, up first — so, I think the plan was to
go up to the podium — but I’ll just say since our federal partners are interspersed through
the room, I’ll leave it up to you. If you’d like to go to the podium, please
do so. If you’d rather speak from where you’re sitting,
that’s fine, too. Up to you. First, we have Associate Attorney General
Stephen Cox. Would you like to give some remarks for a
few minutes?>>Stephen Cox: I’ll just give some very high-level
remarks, but then I’d like to, if it’s possible, turn it over to my colleague, Tracey Trautman,
who might be able to give a little bit more detail. As I mentioned, I help oversee the Office
of Justice Programs as a number of subcomponents that do important work and provide important
assistance in the intersection of criminal justice and mental health. Tracey represents the Bureau of Justice Assistance,
which is multiple programs that involve training and providing tool kits to law enforcement
agencies and help them deal with folks suffering from mental disorders, and also to partner
with mental health and substance abuse service providers. And they also fund a number of publications
on strategies, recidivism, and recovery. Another component that she’ll talk a little
bit about is the Bureau of Justice Statistics that funds important national surveys and
studies on mental illness in jails, prisons, and the general population. The National Institute of Justice is also
within the Office of Justice Programs and they fund research and development, very interesting
and innovative research and development relating to the intersection of mental health and criminal
justice. And then there is, of course, the Office for
Victims of Crime that funds grants to improve, among many other things, mental health services
for victims of crime. But I’ll turn it over to Tracey. We can either do that now, or you can have
others go before, but it’s up to you.>>Tracey Trautman: Great. Thank you, Steve. As Steve mentioned, the Office of Justice
Programs is one of three grant-making components within DOJ and really our provision of services
is primarily through grants and other funding instruments that seeks to provide this facilitation
of services amongst all the communities. The Justice Department is committed to assisting
communities to improve their responses to the growing number of people with mental illnesses
and co-occurring substance abuse disorders who come into contact with our criminal justice
system. And some of you have talked about that in
your introductions. As I mentioned before, we do continue to hear
about the prevalence of those folks within the system and, as I think one of you mentioned,
that is often where they end up unfortunately. As Steve mentioned, the number of different
components within the Office of Justice Programs, I want to just highlight a couple things as
we go along. The National Institute of Justice, which is
our research arm, is doing work in this area, partnering with the National Institute of
Mental Health to pilot a jail suicide risk screening instrument and also to test an intervention
program through randomized control trial to reduce the likelihood of suicide post-release. Our Bureau of Justice Statistics, which is
one of the governmental statistical agencies, is monitoring the surveys about the prevalence
of serious mental illness in jails and prisons. And of course, as many of you know, those
rates far exceed those of the general population. Our Victims of Crime arm does have training
and technical assistance to assist victims’ assistance advocates, and a lot of those resources
do include providers who are serving crime victims who have serious mental illness as
well. My own agency, the Bureau of Justice Assistance,
has long worked in this space. We have a couple of programs I want to mention. We have, since 2006, administered the Justice
and Mental Health Collaboration Program, which is a grant program that has awarded roughly
70 million over the last several years. That is a grant for state, local, tribal entities
across the nation and really covers a broad spectrum of interventions that can occur,
either on the front end through diversion programs, certainly court-based programs,
and even potentially treatment within the walls. Through this program in particular, we fund
partnerships between criminal justice agencies like the police and sheriff’s departments,
courts, and corrections agencies. Over the years, we have learned through that
program that a collaborative response between mental health and criminal justice is the
best strategy to try and connect people to treatment. We also have a range of other resources that
we provide to folks. Last year, we actually funded a police and
mental health collaboration tool kit that you can find on our website, and it really
walks folks through this whole spectrum of building a program, but from building it — you
know, at a police department level — looking at the kind of training that folks should
have to sustaining that program as you move forward. And this year, we’re excited about getting
— we have 2.5 million appropriations in our budget that will allow us to really operationalize
that tool kit and go out to several sites and really kind of put that into practice. By early next year, we will have ready for
public release a National Crisis Intervention Team Curriculum that’ll be available to law
enforcement agencies. One of our sister entities, the COPS Office,
Community Oriented Policing, they are doing a number of publications looking at officer
safety and working with mental illness in the policing areas. BJA and the National Institute of Corrections
are also supporters of a stepping-up initiative — and I think we’re partnering with you,
Mary, on that — through which 384 counties to date have passed resolutions committing
to reduce the prevalence of people with serious mental illness in their jails, and we’re actually
making available some technical assistance for sites across the country to do that. So, at the Department of Justice we do have
a commitment, as I mentioned, to both officer safety on the one side as well as getting
folks with serious mental illness the treatment services they so desperately need, and we
appreciate our participation on this committee. Thank you.>>Elinore McCance-Katz: Thanks very much. And we’ll hear now from Deputy Assistant Secretary,
Jennifer Sheehy.>>Jennifer Sheehy: Hi. Good morning again, everyone. And I do want to say at the Department of
Labor, the Secretary believes that people with disabilities must be considered in all
labor policy because, of course, people with disabilities cut across every population and
every community in the U.S., no matter how you slice and dice it. But we also firmly believe that employment
is a key component of health recovery, mental health recovery, and that health outcomes
are improved when someone is working. We don’t really think of this as, you know,
another population. At the very least, one in five of us is going
to experience a serious mental health trauma in our working lifetime and it could be as
high as 50 percent, some reports say. I just want to talk today about two programs,
or two offices and programs that we have at the Department of Labor that serve people
with mental illness. I am the Acting Agency Head now for the Office
of Disability Employment Policy. We develop policy working with our federal
colleagues and look at programs and services, laws, regs that benefit people with disabilities
in employment. As such, we work with states, we work with
federal agencies, we work with Congress and the White House. But we also work with employers. And obviously employers drive our work opportunities;
so, we don’t want to leave our important customers out. We give technical assistance to employers
through an Employer Technical Assistance Center, and we take practices of employers and then
share them with other employers. We look for those promising practices. We have heard for so many years from employers
that helping employees when they have mental health conditions, mental illness, is something
that they feel was really the hardest of all disabilities. And it has been only recently that we see
progressive companies taking this on headfirst. And then we share those. We share practices of companies like Unilever
or EY, formerly Ernst & Young, or Aetna, who are driving their industry, driving leadership
in their industries by addressing mental health and wellness in their employees and offering
real supports that help someone sustain a job. We also operate the Job Accommodation Network. This center offers confidential one-on-one
advice on accommodations for employers, managers, and employees with all disabilities, but they
particularly have tools for people experiencing mental health conditions in the workplace. We have a promotional public outreach campaign
called the Campaign for Disability Employment. We’ve operated three PSAs. We’re developing our fourth now. All of them include a component of mental
health and really trying to dismiss some of those stereotypes and perceptions that people
falsely hold about people with disabilities, including those with serious mental illness. All of these are, of course, on our website,
dol.gov, and we operate a really critical initiative called our Employment First initiative,
and Richard Davis is our lead and he’s here and certainly will be talking a little bit
later after I have to leave, if the opportunity arises. This is — we fund technical assistance experts
that go into the state, work hand in hand with state agencies to show them how public
funds and their agencies, their infrastructure as it exists, can support integrated employment
for people with significant disabilities, including serious mental illness, support
integrated employment for people who may have been in sheltered workshops or who never worked
at all to make sure that they can work in meaningful careers. We have lots of really good examples in states
that have been successful doing so. And then I also want to mention our Employee
Benefits Security Administration. With other federal agencies, EBSA helps enforce
and administer the Mental Health Parity and Addiction Equity Act. EMBA enforces the law with respect to 2.2
million health plans that cover 131 million health conditions, or participants and beneficiaries. They work with employers’ insurance companies. They do enforcement. They have investigators that look at where
health plans may be not serving people with mental health conditions the way that they
serve other health conditions. And then they may levy penalties or sanctions,
make sure those disparities are corrected. They will be releasing new enforcement data
in January of 2018, and I will be happy to continue to be involved with this committee
and then share some of those findings with you at that point. Finally, I just want to mention that in the
President’s first budget he is supporting a very large state grants program for stay-at-work/return-to-work. Making sure that people that experience illness
or injury in the workplace have early intervention services coordinated between the employer
and the physician and the healthcare providers to make sure that person has every opportunity
to stay in their job or return to that job or another job rather than applying for Social
Security Disability Insurance. We are working with our partners at the Social
Security Administration — [laughter]>>Jennifer Sheehy:
— very, very closely to prepare for those grants should they be funded. Thank you.>>Elinore McCance-Katz: Thanks very much,
and now we’ll hear from Deputy Assistant Secretary Terry Adirim from Department of Defense.>>Terry Adirim: Great. Thank you very much. Good morning again. My name is Terry Adirim. I’m from the Department of Defense. Mental health is an important area of focus
for us, as it is for all of you, and therefore, DOD thanks Secretary Price and HHS for making
this a national priority, and for SAMHSA for leading this effort. Some of the areas as I was listening to what
everybody was saying, that we share with the civilian sector as being areas that we struggle
with, include improving access to care. Many of our beneficiaries, which I’ll give
you the numbers in a second, rely on the civilian sector for their healthcare. So, we struggle with that on a daily basis
in ensuring that they get the care that they need. And we also, because we are a reflection of
society, we also struggle with the social determinates of health and health disparities
which so greatly impact this particular issue. And another area of disparity that we struggle
with is with geographic disparities, and we find that there are places where we have difficulty
finding practitioners for beneficiaries. And lastly, another area that I think is really
important and a theme that I’ve heard around the room is reducing stigma. And for me personally, as a clinician, as
a physician, it’s not only reducing stigma of the public but also amongst providers. I’ve exposed quite frequently to my colleagues
who could use a little education and training around this issue. So, that’s just my own personal — So, what is the military health system? It’s one of the largest integrated healthcare
systems composed of what we call direct care, military hospitals and clinics, and a health
plan called Tricare. We serve 9.5 million beneficiaries, including
approximately 1.3 million active duty and over 2 million dependent children. We see a great number of our beneficiaries
for outpatient mental health visits. In 2016, there was over 1.2 million at military
treatment facilities and over 2.5 million at network facilities. Inpatient visits in 2016 included over 5,000
at military facilities and, as I had mentioned, we really rely on the civilian sector, over
32,000 at network facilities. We in DOD are proud of our efforts in identifying
and treating mental health conditions and our ongoing intensive efforts to improve and
encourage access to mental health services. We do a really good job at collecting data
and we work with — in fact, we’re working with SAMHSA on some projects involving our
data sets to understand our population with regard to mental health conditions. And we invite independent and public examination
of our work in order to benefit our servicemembers and families. But we’re aware that there are areas that
are in need of improvement, and we’re hoping to learn from you all how we could do that
and hopefully we could share with you what we’ve done that has been successful. And as Mr. McCaffery, our Assistant Secretary,
has said, “Mental health must be given the same attention as physical health.” And to that end, I’m proud to say that in
2016 DOD made Mental Health Parity a reality for DOD beneficiaries. We eliminated unnecessary quantitative and
nonquantitative treatment limitations on mental health and substance use disorder, we expanded
covered treatments to include intensive outpatient programs and venues for medication-assisted
treatment for opioid use disorder, and we streamlined requirements for institutional
mental health and substance use disorder care providers to become authorized providers for
DOD beneficiaries and to improve access in care. And our preliminary data suggests that by
implementing Mental Health Parity, it’s resulted in a 50 percent increase in outpatient psychotherapy
services provided to our beneficiaries. The nature of the men and woman who choose
to serve their country in uniform means that our efforts in the area of serious mental
illness are not identical to the civilian sector. We assess personnel primarily in the 18 to
25 age range, which is what all of you have identified as the age range where a number
of these mental health conditions appear, and it’s also an age range where other less
serious mental health conditions also crop up. Each of these conditions would be exacerbated
by the stresses of military service and would limit a future servicemember’s ability to
be deployed to austere environments in the nation’s service. So, anybody who presents to excess [spelled
phonetically] into military service who has any of these conditions would not necessarily
qualify for military service. And so, our patient population differs somewhat;
however, we are affected, as you all are well aware, by the mental health issues that all
of you are. When serious illness is identified in active
duty members after six months of service, personnel are referred to medical evaluation
boards. These boards examine all available evidence
to determine whether continued service would be in the best interest of the individual
and the nation. When a member separates from service in this
way, military benefits that include annuity payments and healthcare are awarded. So, we take care of our service members who
need to be separated because of their mental health conditions. DOD is informed by the epidemiology of serious
mental illness. For instance, psychiatrists are deployed in
boot camps and austere contingency areas specifically to triage serious mental illness in these
settings. And we’re happy to discuss that more if you
would like more information about that. We look forward to contributing to the efforts
of this committee and to sharing our experiences and the ongoing work at DOD in the area of
mental health. So, thank you.>>Elinore McCance-Katz: Thanks very much,
and now if we can hear from Director McCarthy from Veterans Affairs.>>John McCarthy: So, I’ll be presenting later,
so I’ll have more detail. In hearing the introductory comments, I was
struck by how affected we are by serious mental illness, by suicide. These really emphasize the communal nature
of human experience, and the impact that one person’s suffering has. And I’m going to leave that there. But veterans are a special subset of the U.S.
population who have served the country and participated as part of the American community. And the VA has long recognized the importance
of meeting the needs of vets, and as long as I’ve been with the VA, there’s been a focus
on those with serious mental illness. There was a deinstitutionalization movement,
grave concerns in the 80s about homelessness among veterans and serious mental illness,
and the VA has done a lot. We’ve heard about excess mortality and I’ll
just briefly say that it seems that among individuals with schizophrenia in the VA,
excess mortality is less than observed outside of the VA service. The VA is the largest integrated health system
in the United States, and there are a number of programs. There are enormous investments in scientists,
clinicians, to improve care for individuals with SMI. Suicide, of course, is a very high-profile
public concern. The rate of suicide among veterans is elevated;
among veterans coming to the VA for care, it’s elevated. These are tremendous public and VA concerns,
and there’s so much work going on. And yet, I think it’s just important to emphasize
that VA can’t do it alone. That the majority of veterans do not come
to the Veterans Health Administration for health services. And so, even if everything were just perfect
within the VHA, that wouldn’t be sufficient. And there’s so much more that needs to be
done. And so, this is an important meeting for going
forward. Thank you.>>Elinore McCance-Katz: Thanks very much,
and now we’ll hear from Deputy Assistant Commissioner Melissa Spencer from the Social Security Administration.>>Melissa Spencer: Thanks. So, I already talked to you about some significant
things going on in SSA, that we updated our mental listings and just kind of set the stage
with the percentage of applications that we get that represent individuals with mental
health issues. So, let me just kind of drill down in that
to a little bit more. Our process is complicated. As my husband is on retirement benefits and
he also worked for SSA, just being able to apply for benefits was still, just for retirement,
was a complicated process. It’s extremely complicated for those that
are our most vulnerable, especially if you are a person undergoing tremendous stress,
whatever your medical impairment is. And I think it’s even more so difficult for
a person with a mental impairment. It helps if there’s a family member or an
advocate who can help with the application process for SSI or Social Security. We’re doing a lot to move our services online,
and yet we want to ensure that we have a presence in the community for those individuals who
really need that face-to-face interaction to file for benefits to get information about
their claim. We’re doing a lot to move into the electronic
health environment. About over 10 percent of our claims now have
evidence that comes in as health information technology. Electronic medical evidence where we file
the claim, we know who the sources are, there’s a trigger that goes to that medical source,
and by the time the lay disability examiner and the medical consultant work on that claim,
there’s evidence already in the file as soon as they start working on it. So, that’s very helpful. Most people on the rolls for disability benefits
get approved fairly early in the process, at the initial level or the reconsideration
level or the first level of appeal. There are many who believe that, “Oh, you
need to go to the administrative law judge,” in order to get disability benefits, but 70
percent or more of our people on the rolls are on the rolls within just a few months
of application. So, the more we can do to encourage getting
evidence as early as possible, the better off we are. So, in terms of who gets allowed benefits
with a mental impairment, overall about 32 percent of those who apply for a mental impairment
get allowed. That’s about the average overall allowance
rate for all of our claims right now. For children, about 44 percent of children
who allege disability base are allowed for a mental impairment. So, as I said, 64 percent apply. About 44 percent of children on the rolls
get allowed for mental impairment. For schizophrenics, 51 percent of people who
allege schizophrenia are allowed. So, that’s a high number. So, we are paying attention. We are getting information. For depression and bipolar related, and that
is kind of a — that’s the gamut of severity for depression allegations to bipolar allegations
— 15 percent of those applications are allowed. A lot of individuals that we have who alleged
depression or an affective disorder generally have other impairments to go along with them;
generally, a musculoskeletal impairment. What we find is the longer somebody is waiting
for their claim to be adjudicated, they’re developing some other things as well, including
depression. Other life stressors are happening, and it’s
really impacting their overall health. So, that’s just kind of some basic information. For many children, most of them have comorbid
impairments. It’s not just simply intellectual disorders
that a child might allege. It’s ADHD. It’s obsessive-compulsive disorder. It’s speech language delay. A lot of impairments that combined to really
seriously impair a child and their ability to learn and to grow and thrive. We’re required by law to re-adjudicate every
child’s claim when they reach the age of 18. And what we learn is that when we do cease
child’s benefits at age 18, a young adult, the workout comes the return-to-work for those
young adults is not good. So, we’re excited by the partnership we have
with the Department of Labor to engage in any kind of activity that’s focusing on work
activity. A return-to-work for all adults, of preventing
disability applications. We also have demonstration projects specifically
geared at youth in transition. The Promise program is in effect in several
states. It’s focusing on children in school, older
teenagers, to start some work activity to get a taste of the work environment and success
in the work environment before the age-18 redetermination to get a child thinking, “Yes,
I can do this. There is work that I can do. I’d like to explore this further instead of
staying on benefits.” We also have several research partnerships
that we engage in, mostly with the National Academies of Sciences, where we ask them to
investigate significant issues that involve individuals with mental health issues. We’ve had some studies done in the past few
years on children with medical impairments. We’re having them assess and help us on how
we should assess someone’s ability to function in the workplace. All right, now what should we be paying attention
to and how can we accurately assess it to really get to the heart of whether someone
is disabled or not disabled. There’s been a lot of talk about homelessness
this morning. We have a partnership with the SOAR organization. Right now, we’re exploring ways that we can,
at the time of application, that the SOAR representative can have accumulated all the
information that we need to make a decision on that individual’s claim, and mostly it’s
schizophrenics that they work with us on. Homeless schizophrenics. And so how can we adjudicate that claim with
the evidence that we receive? How can we work together to better educate
ourselves to get information quickly? We’ve also changed some of our policy so that
we work more with non-medical sources, like parents, family members, community organizations,
non-physicians, that once we know there’s a medical problem we can use information from
wherever we can get it to help truly understand the severity of an individual’s medical condition. So, I’m anxious to continue to explore and
learn and see what other ideas we can explore to change our program.>>Elinore McCance-Katz: Thank you. We’ll hear from Principle Deputy Administrator
Kimberly Brandt from Centers for Medicare and Medicaid Services.>>Kimberly Brandt: Thank you. At CMS, as I mentioned before, we have over
130 million covered lives across our four programs. So, we have a wide array of programs under
way to address serious mental illnesses for both adults and for children. We’ve got a whole lot of them, so I’m going
to give you a high-level overview because I want to respectful of the time. But CMS has traditionally covered a lot of
these types of services, and thanks to the 21st Century Cures Act and other legislation,
we now are able to do even more innovative things. And so, our focus has been on innovative service
delivery. How can we think out of the box to better
provide these types of care in more innovative settings, and how can we also work to do more
community-based care? We’ve been working a lot with our state and
local partners to really try and figure out how to take the care to where people need
it in their communities rather than just thinking of it at the federal level. So, one of the things that is particularly
evident is in our Medicaid programs. We’re one of the largest payors for mental
health services in the United States for Medicaid and CHIP and so, as such, we play a really
important role in helping provide a lot of that behavioral healthcare. Some of the things that we have been doing
in the Medicaid space up until now have been working with states to make sure that they’re
implementing the Mental Health Parity requirements and then evaluating the impact of those requirements
on access to quality for Medicaid and CHIP. We want to make sure that people are playing
by the rules but also that the rules aren’t stopping services from being rendered. We’re also working to make sure that we’re
offering technical support to states so that they can start to use data analytics so that
they can assess the needs of their severe mental health population and develop work
plans to better be able to improve those service delivery systems. One of our biggest challenges at CMS, as such
a large payor, is that a lot of our computer systems are, quite frankly, stuck in the dark
ages. We’ve really been working to modernize our
technology. That’s something that’s near and dear to my
heart because it’s an issue I worked on before I came to this job — I’m now in week four
on this job [laughs] — but as a result, the states have not been very good at giving us
information and we don’t have reliable, consistent data across the states that allow us to get
that kind of information, and then to be able to work with them to provide that back so
that they can better target their services. So, that’s a big area that we’re working on
and that is a top priority of the Administrator. She has made that one of her top goals because
she feels it supports the Secretary’s goals, certainly not only with respect to this initiative,
but also to opioids and some of the other things as well. Moving forward, under the 21st Century Cures
Act, we were directed to issue a State Medicaid Director Letter – an SMD letter – regarding
opportunities to design innovative service delivery systems. That includes systems for providing community-based
services for adults with a serious mental illness or children with a serious emotional
disturbance. So, we have created a Medicaid innovation-accelerated
program — the IAP, if you will — where we’re working with states to plan a data intellectual
[spelled phonetically] that can be used by the states so that they can optimize their
ability to identify those beneficiaries who have serious mental illnesses. They can look at the types of services they’re
receiving and other analytics and really be able to drill down and help say, “Okay, these
people have had these types of issues. How can we better get their services to them?” It’ll provide technical support and tools
which will help support states to perform these data analytics on the characteristics
and distribution of opioid use disorder and medication-assisted treatment in their Medicaid
programs. So, we’ll be able to look at prescribing patterns
and things like that. It will also help us to be able to tell if
you have over-prescribers or some of the things that I was talking about earlier from a program
integrity fraud and abuse perspective. We’re also working with the states to make
sure that we get CMS-quality measure of core sets. We’re working to measure and improve the quality
of healthcare for children and adults by making sure those measures include five adult and
two child core set measures for behavioral health. The data for the state reporting for the last
fiscal year available in 2015 is now available on our website, and some of the things that
we were able to find as a result of those measures were that 72 percent of children
ages six to 20 years had a follow-up visit with a mental health provider within 30 days
of hospital discharge for a mental illness, and 34 states voluntarily reported on that
measure. We also were able to show that 74 percent
of adults age 18 and older were current smokers or tobacco users who were advised to quit,
and states were also reporting on that measure as well. We’ve also been working with SAMHSA, the Assistant
Secretary for Planning and Evaluation (ASPE) and other partners to award a total of $22.9
million to support 24 states throughout the nation in their efforts to improve the behavioral
health of citizens by providing community-based mental and substance use disorder treatment
grants, and those have been very helpful. The grantee states were eight different states,
and they’ve been participating in a two-year demonstration project, which just started
this year, and we’re anxious to see what the results are of that. A couple of other things that we have coming
up is that we are going to be, through our innovation center, doing a public meeting
on September 8th of this year. And while we don’t currently have a model
focused on behavioral health, what we’re hoping to do is have a public need to discuss ideas
for a potential behavioral healthcare and payment model to improve healthcare access
and quality while lowering the cost of care for our beneficiaries, particularly with behavioral
health conditions. So, more information will be coming on that
and we’ll share it with this committee, but in just in another week we’ll be having that
meeting and we would welcome public participation in that. And then lastly, I just want to talk a couple
of things in our Medicare, our more traditional fee-for-service space. We have a wide range of options for mental
health services in the Medicare program. Outpatient visits with mental healthcare professionals,
intensive outpatient care where multiple treatments are provided in a single day, and then we
also have the partial hospitalization program and inpatient care that are at various facilities. I think the biggest things that I want to
focus on there are that we really made a big effort in recent years to expand our access
to behavioral healthcare services by physicians and other practitioners. And so, one of the things that we put in place
as of January 1st of this year is that we now give a separate payment for physicians
for models of care that incorporate behavioral health treatment in the primary care setting. So, that’s something that now is reimbursed
separately that was not reimbursed before, and we’re promoting interprofessional collaboration
in treating mental illness and really start help foster that kind of collaboration. And then the last thing that I would point
out is that in our current proposed fee schedule that we have — and we promulgate a lot of
big rules that tell how we’re going to pay people at CMS –we’re proposing adding psychotherapy
for crisis to the list of eligible Medicare telehealth services, particularly in areas
— I heard Utah mentioned and a couple of others — in these rural areas being able
to do these types of services via telehealth is critical, and this is something that traditionally
we had not paid for. So, we’re now going to be able to add that
and have that covered. And then we’re also proposing to improve the
payment for office space behavioral health services that are the therapy and counseling
services, which are used to treat mental illness and emotional disturbance. Thank you.>>Elinore McCance-Katz: Thanks very much,
and we’ll hear from Acting Assistant Secretary for Elementary and Secondary Education, Jason
Botel.>>Jason Botel: Thank you. The Department of Education works closely
with other federal agencies, including many represented here, to maximize utilization
of evidence-based interventions that have been developed in whole or in part with federal
research investments. The Department has numerous programs and resources
that help school districts across the country to meet the needs of students with serious
mental illness. Because serious mental illness presents many
challenges to school staff through a number of its technical assistance centers, the Department
provides school districts with access to subject-matter experts with a system of implementing their
evidence-based interventions with fidelity. Some of the Department’s programs are resources
that address serious mental health issues include School Climate Transformation Grants. In 2014, five-year grant awards totally approximately
$180 million were made to 71 school districts in 23 states, Washington D.C., and the U.S.
Virgin Islands. The funds are being used by school districts
to develop, enhance, and expand systems of support for implementing evidence-based, multitiered
behavioral frameworks for improving behavioral outcomes and learning conditions for students. Many of these grantees are implementing their
programs in coordination with the Substance Abuse and Mental Health Services Administration’s
Safe and Healthy Students program, as well as with related activities under the Mental
Health First Aid program being funded by the SAMHSA under the Project AWARE State Educational
Agency Grants. We have a program called Project Serve. This program funds short- and long-term education-related
services for local educational agencies and institutions of higher education to help them
recover from and prevent a violent or traumatic event, such as student suicide clusters, in
which the learning environment has been severely disrupted. In fiscal year 2017, through the new Student
Support and Academic Enrichment Formula Grant program, $400 million in federal grants were
made to state education agencies to assist local school districts in the area of mental
health among other activity areas. Among the explicitly-mentioned allowable activities
in the statute are school-based mental health services and high-quality training for school
personnel in the areas of suicide prevention and trauma-informed practices in classroom
management. Within the Elementary and Secondary School
Counseling program, there are active grants through April 2019 that provide funding to
local educational agencies to establish or expand elementary and secondary school counseling
programs. These projects use a developmental preventive
approach, expand the inventory of effective counseling programs, include in-service training,
and involve parents and community groups. And finally, Youth Suicide Prevention Fact
Sheet, a resource for schools, is something we’ve developed. Teen suicide is a major public health issue
that affects people of all ages, backgrounds, and racial and ethnic groups throughout the
country. We all know when a student commits suicide,
it’s not only a tragedy for his or her family, but can also significantly affect other students
and disrupt school-learning environments. To assist schools in addressing this issue,
the Department created and published this fact sheet for schools with links to numerous
resources. Thank you>>Elinore McCance-Katz: Thanks very much,
and I’ll just finish up by saying something about SAMHSA and posing some questions to
this group. I think you all know that SAMHSA has a number
of programs, the majority of its programs do fund services and programs for those with
serious mental illness and/or children with serious emotional disturbances, ranging from
our mental health block grants to a wide range of discretionary grants that support programs
for the homeless, jail diversion, and supported employment. Looking forward, however, there’s much more
we can do, and that SAMHSA should be doing. So, I want to mention a few areas that I hope
I’ll hear things about today. A major concern that I have is keeping people
with serious mental illness out of our jails and prisons. Far too many people enter treatment as a result
of criminal charges, which to a great extent could be avoided had a person with a serious
mental illness received effective psychiatric medical care and other recovery supports. I believe that part of considering these issues
includes a better understanding of how to facilitate entry into services. So, how do we move medical treatment of serious
mental illness out of jails and prisons and back to communities and community mental health
programs? A discussion of how to encourage development
of therapeutic relationships that include shared decision making and advance directives,
where a person and their clinician work together to determine care to be rendered should the
person become incapacitated by mental illness, would very helpful. I hope to hear a discussion of how we can
make better use of evidence-based treatment, such as Assertive Community Treatment, Assisted
Outpatient Treatment, and linkages with peers to support recovery. Discussion of how civil commitment laws might
be appropriately used to assist a person with preventing relapse to psychosis and whether
there are ways the federal government can assist. For example, by compensating physicians and
other clinicians for time spent in such processes. These kinds of suggestions could help the
federal government in thinking through whether there are ways to assist persons with serious
mental illness that are not currently available to us. Access to care and recovery support services
are an ongoing challenge. NSDUH estimates that 35 percent of Americans
with serious mental illness get no treatment at all. This is a terrible disservice to those with
great needs, and we have to address it. Further, too often people experiencing mental
disorders spend long times waiting in emergency departments which are not equipped to provide
dated [spelled phonetically] care and are not appropriate placements for those with
serious mental illness. Hopefully, there will be some discussion of
current needs in the United States for resources to address mental health needs. We’ll be looking to you for suggestions around
issues like hospital beds, acute care versus longer term needs, crisis intervention services,
and additional levels of caring communities. For example, group homes and recovery housing. Committee input regarding what we need to
be doing to more effectively engage people in care is also needed. I hope committee members will provide input
regarding issues surrounding the use of psychotropic medications, particularly for those who experience
psychosis. I hope I’ll hear some discussion around effectiveness
of medication treatments, including expansion of the use of long-acting formulations which
have been shown to be effective, the use of clozapine for treatment-resistant schizophrenia,
as well as monitoring for and addressing side effects of psychotropic medications. A discussion of recovery supports and the
evidence base for these. Are there areas where federal agencies could
better collaborate and what guidance would council members offer to us? Issues related to how we can protect privacy
rights while considering the concerns of family are ongoing and input from committee members
would be helpful around this issue. We have major issues with workforce, in terms
of numbers of behavioral healthcare staff, geographic distribution of those staff, and
preparation of providers to provide evidence-based interventions. Integration of behavioral and physical healthcare
and the ability of behavioral health clinicians to address co-occurring mental and substance
use disorders remain challenges. I hope there might be some discussion of these
kinds of issues and mechanisms by which we can extend the reach of providers through
innovative approaches, as the current status results in too many not being able to access
needed services. This committee can provide input that can
help to guide us in the government to more effective partnerships at the federal level
so services and systems will be less disjointed for individuals, families, and providers at
the local level. This is a lot to ask, but I am grateful to
be here today, as I begin my time with HHS and to work with all of you in improving behavioral
health of the nation. So, we have a lot of work to do, and we have
really a short amount of time to do it. We’re a little off schedule now, and what
we’re going to do is move into the federal panel, and I will introduce that
in a moment but will say that we will ask the panel members to stick to 10 minutes — we
need you to do that — and the discussant will be speak for five minutes. And we’ll see where we are at the end of this. I’m really very interested in getting comments
and so we may have to do some adjustments around lunch. You’ll also notice that there’s not breaks
in the day. So, if you need a break, please just feel
free to do whatever you need to do. My apologies, but we need a lot from you today. So, I’m pleased to introduce our first panel
of the day entitled Federal Advances to Challenges in SMI and SED. This panel will provide a summary of federal
advances, challenges, and recommendations in SMI and SED research, and we are honored
to have the following presenters: Dr. Gordon from NIMH; Mr. Paolo del Vecchio from the
Center for Mental Health Services at SAMHSA; Dr. John McCarthy, Director of the Serious
Mental Illness Treatment Resource and Evaluation Center, Department of Veterans Affairs and
the Office of Mental Health Operations; and Ms. Ruby Qazilbash, who is the Associate Deputy
Director in the Bureau of Justice Assistance at the Department of Justice. Our discussant for this panel, who is also
an ISMICC council member, is Ms. Melissa Spencer who is the Deputy Associate Commissioner for
the Social Security Administration’s Office of Disability Policy. So, if we can have the panel speakers come
up here, give their 10-minute talk, return to their seats and just have the next person
come up thereafter. So, Dr. Gordon, thank you, if you can go ahead
and start us off.>>Joshua A. Gordon: Thank you, Dr. McCance-Katz,
and thank you, members of the committee, for the opportunity to briefly address you about
NIMH efforts in the serious mental illness sphere. As Dr. McCance-Katz mentioned, I am the Director
of the National Institute of Mental Health, which is the primary federal agency responsible
for mental health research, and we take a broad view of our responsibilities in mental
health research. In particular, it’s very important for us
to make sure that we balance our research portfolio to take care of the needs now so
that we have research which has potential near-term impact, as well as the needs in
the future so that we have research portfolios that have potential medium- and long-term
impacts in order to make sure that we take care of those who need help today, but also
provide the basis for a dramatically better future for them with transformative treatments
that take time to develop. The work I’m going to tell you today is really
just a sampling of our efforts in the recent past and in the near future around serious
mental illness. A lot of what I’m going to talk about today
is focused on schizophrenia, but that’s really just a matter of convenience; of course, we
have similar programs in other disease areas as well. And at the end, I’ll talk a little bit about
a particularly high-priority area for us at NIMH, as well as many around the table, which
is suicide prevention. So, if we’re going to take a long-term view
of serious mental illness, we need to understand it across the entire cycle of development,
and that means we need to understand disease origins. We need to understand how the disease progresses,
typically through pre-symptomatic periods, prodromal periods in the disease states and
then of course understand how to maximize recovery. There are four principles or four areas that
we focus on. Which is to identify risk and enhance our
ability to predict the development of serious mental illness, to identify biomarkers that
help us predict that risk but also that follow the course of the disease, to chart that illness
across development. And that’s very important because those of
you around the table will know that all serious mental illness, including those affecting
adults, primarily have their origins early in development. And so, it’s important to chart the illness
course throughout development. And then of course, to develop personalized
interventions. In terms of predicting risk, one of the greatest
clues that we have now is the emergence of tremendous genetic information and genetic
knowledge. This is a chart that’s already four years
old, but that was published in Nature showing the first large-scale genetic study in schizophrenia
identifying 108 places in the genome that confer risk for schizophrenia. Now there’s over 180. We understand, of course, that genetic risk
is only part of the story. And we need to understand that environmental
factors, as well as developmental factors that play a role in the development of serious
mental illness. But we are making progress in these areas. In terms of defining the biomarkers that will
allow us to chart the course of the illness, again we’re making substantial progress through
the combination of a change in our approach as well as developments of new technologies. So, at the NIMH, we really try to avoid studying
simple individual diagnoses, and rather pool individuals who suffer from serious mental
illness across diagnostic domains, according to symptoms. And this is an example of a study that took
individuals who suffer from psychosis, regardless of which diagnosis, pooled them together,
put them through a number of different what we call “deep phenotyping.” So, measure their behavior, measure their
brain activity, measure their symptoms, and try to figure out if we can group them according
to types that may have better predictive capability as far as better understanding their course. As well as to develop biomarkers, like here,
indicated electrophysiological measurements from the brain that can predict course. Another effort is really to try to study individuals
longitudinally over time. And this data I’m showing you here is rather
pretty. It’s neuroimaging data that comes from studies
of individuals at high-risk for schizophrenia showing how their brain changes over time,
particularly highlighting areas that change in the structure as individuals progress from
a prodromal stage to a psychosis stage. I’m showing you this neuroimaging study because
it’s rather pretty, but you can also demonstrate this with behavior neuropsychological measures. So, we have multiple modalities by which we
can try to develop predictive tools, and that we can chart the course of individuals as
their illnesses progress. So, what can we then do for individuals, and
why is it so important to predict them? I want to highlight one more past study before
I go into the future. And this particular highlights a collaboration
between SAMHSA and NIMH in studying integrated care as a model for care for first episode
psychosis patients. Integrated care includes psychosis — sorry,
psychotherapy, family education and support, supported employment and education as well
as, of course, medication for the individuals. And we had shown — NIMH had shown in laboratory
settings that this case can really improve care for first episode psychosis. But it was really in collaboration with SAMHSA
that we were able to demonstrate that this is implementable. And some of you around the table had important
roles to play in this. And the important message that came here,
as illustrated on this right-hand side of the graph where you see two divergent curves,
both in red. And these are the effects of this integrated
care in patients who either were seen early in the course of their illness, or people
who were delayed in receiving this integrated care. And what you can see is it matters if you
get patients into treatment early, they can get better. And so that’s the state of the art right now. We can develop methods to predict progression,
we can get individuals into treatment. And when we get them into treatment — at
least when we get them into the state of the art treatment, integrated care focusing on
all aspects of recovery — we can help them get better. And we can help them get better faster. But of course, getting them into care is a
challenge, and so that’s now where we go into the future. And so now I’m going to briefly run through
some areas that we are supporting research in right now, or that we’re soliciting applications
in, so that you can understand what we hope to know five years from now. And, so, example of that is we have several
efforts that were aimed at trying to reduce treatment delays in first episode psychosis. Here again, we’re going to be partnering with
SAMHSA to try to develop ways of making sure that individuals get identified. Not once they have psychosis, but when they’re
at risk for psychosis in that early period so that they can be followed in community
mental health centers and treated the moment that they show evidence of frank psychosis. We similarly have researched to improve the
care of individuals at clinical high-risk. Because, even if they don’t go on — even
if such individuals don’t go on to a full psychosis illness, they nonetheless have needs,
mental healthcare needs. And so, while we are watching them for progression,
we want to make sure to also meet their needs. And finally, we have established some research
centers that are aimed at really develop — in the communities that are aimed at developing
novel approaches to treating youth and adults and, importantly mentioned by panel members,
transition age youth so that we can really try to improve things in general for people
of all categories of illness in this age group. A major effort of ours at NIMH is to realize,
as I said before, that our diagnoses aren’t necessarily good predictors of treatment,
and we really need to develop a more individualized approach. If you think about the history of psychiatry
and psychology, individualized approach is what we’re all about. But, as we move into the medication era, often
medications are thrown at diagnoses and symptoms without real knowledge about which individuals
would best benefit from those approaches. And so, we have several different efforts,
including one that’s aimed at trying to understand the relationship between patterns of brain
activity and treatment, and really develop actual novel treatments aimed at patterns
of dysfunctional brain activity. And I show you here just at the bottom a quick
graphic to demonstrate what we’re talking about. The brain is a dynamic organ, which changes
over time, and neural activity in the brain is coordinated according to these activities’
changes over time. And we actually have methods now that we can
intervene dynamically with brain activity in real-time. And those approaches may — may I should say
— have ability to individualize treatment. In other words, find out particularly what’s
wrong in an individual’s dynamic activity and then attempt to address that dysfunction
directly through intervening in those patterns of brain activity. And I would categorize these kinds of research
as “medium-term” payoffs. If we can identify what makes individuals
susceptible to particular treatments, we can make a difference in the medium-term. Finally, I want to close with a focus on one
aspect of serious mental illness which, as you know, is of rising concern in the United
States. Suicide rates are rising across all population
groups, although particularly in middle-aged men and in youth. And this rise has been inexorable despite
numerous efforts to counter it and to understand it. And, at the NIMH we’ve taken this head-on
by trying to understand one, how do we again predict those individuals who are at high-risk
of suicide? And of course, included in high-risk groups
are those who suffer from serious mental illness. And number two, what to do once we identify
those who are at highest risk, how can we help them? It was mentioned already some zero suicide
efforts today, we — as well as efforts that we’ve made in collaboration with the Justice
Department and others to study individuals involved in the criminal justice system who
are particularly at high-risk. Not actually so much while they’re in jail
or prison, but actually in the year following release from prison. And then, we have particularly efforts aimed
at gaps in our knowledge, particularly in understanding mortality outcomes and in trying
to use existing data sets to improve our ability to identify those at risk and counter that
risk. So, thank you for this opportunity again to
present an overview of research. I’m happy to answer questions later on, and
only — enthusiastic about learning more from this group about what the needs are for future
research efforts, so that we can help you achieve your goals of improving care for individuals
with serious mental illness.

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