The American Psychological Association was pleased to have Arthur C. Evans, Jr., PhD, as a witness March 25, 2014 at a hearing of the U.S. House Subcommittee on Oversight of the Committee on Energy and Commerce. Below is a shortened version of Dr. Evans’ full testimony, with full video of the hearing on the Committee’s website.
Dr. Evans serves as Commissioner of the Department of Behavioral Health and disAbility Services (DBHIDS), which deploys resources to address the needs of the 1.5 million people in the city of Philadelphia. This involves assessing the needs of individuals living in the community and developing a comprehensive strategy to prevent, treat, and rehabilitate individuals with varied and diverse problems, including serious mental illness and substance use. His department developed and uses an innovative approach that includes a full range of services, from prevention and early intervention to rehabilitation and peer services. This approach stems from the following principles.
1. People can and do recover from mental health and substance use disorders.
This recovery is facilitated when individuals live in an environment with the early intervention, treatment, and support services they need. Behavioral health providers know how to treat these individuals, and ensuring the availability of an array of community-based resources may make more intensive interventions, such as inpatient hospitalization, less necessary.
2. We should address the need for a comprehensive lifespan strategy to promote mental health and prevent behavioral health disorders.
No discussion of the needs of those in acute distress should focus solely on increasing inpatient beds or lowering the threshold for commitment. It is counterintuitive that the solution to a perceived inpatient bed shortage is to build a strong community-based service system. However, experience consistently bears this out. An overemphasis on inpatient beds can drain needed resources away from other critical areas that prevent people from needing crisis services.
Philadelphia engages several low-cost and potentially high-impact approaches to prevention and early intervention. For instance, Philadelphia is widely implementing mental health first aid, in perhaps the most ambitious program in the country. The city aims to train 10 percent of the city’s population, including teachers, first responders, parents, law enforcement, and others. So far, an enthusiastic public response shows a thirst for this kind of information. DBHIDS’ collaboration with the Philadelphia Police Department serves as another example. Since 2006, DBHIDS has trained 1,600 police officers in crisis intervention, so as to defuse conflicts with individuals living in the community with serious mental illness.
3. Our behavioral health systems must rethink their current means of assessing the number of needed inpatient beds.
The scope of outpatient and community-based resources that exist in the community drives the need for inpatient beds.
4. We need to develop post-inpatient treatment approaches and strategies that stabilize patients and permit them to develop the skills they need to function in the community.
DBHIDS invests in programs that build the skills of individuals with serious mental illness. In 2006, it started a Certified Peer Specialist (CPS) Initiative. This allows individuals who recovered from serious mental illness to work in competitively paid jobs and serve as models of recovery for behavioral health program staff and participants. Philadelphia succeeded in training over 580 Certified Peer Specialists and, through this program, successfully integrated individuals with significant behavioral health challenges into the community. Peer specialists in these settings play an important stabilizing role for individuals and provide a critical factor for people in crisis – hope that things will get better.
To fund this initiative, Pennsylvania successfully rewrote the State Medicaid plan, allowing Pennsylvania to pay for peer support services for individuals with serious mental illness using Medicaid dollars. Access to Medicaid funding allowed Philadelphia and other counties to implement and expand this resource.
5. Initiatives to address psychiatric inpatient bed capacity should include efforts to improve the efficiency of existing resources and use data-driven approaches to inform practice and policy.
For example, Philadelphia utilizes evidence-based treatment approaches to shorten lengths of stay for individuals who historically had very long hospitalizations. Additionally, working with our inpatient providers, DBHIDS implemented a pay-for-performance system for the past six years, which resulted in practice improvement and system efficiencies. This data-driven approach reduced readmissions, improved continuity of care, resulted in cost savings, and, most importantly, improved clinical outcomes.
6. Finally, we should increase the flexibility of our payment system for behavioral health.
Our payment structure restricts the majority of resources to services for those already diagnosed with serious problems or for those with acute symptomatology. This means mental health agencies typically devote less than 3% of their budgets to prevention and early intervention. That leaves families and communities to fend for themselves in the early stages of behavioral health conditions, and then to navigate the system, often in times of acute distress. Instead, systems should spend a greater proportion of their budgets on prevention and early-intervention services.
In conclusion, any discussion of the needs of those with serious mental illness and substance use problems must address the need for a comprehensive, culturally appropriate strategy to promote mental health and prevent behavioral health disorders across the lifespan. They must broaden our range of services beyond the health care system, to build on strategic local partnerships to build community resources necessary to respond and heal — for instance, training our first responders, partnering with community organizations and faith-based groups, and investing in our children and youth to support healthy starts to their lives. Most importantly, governments must become effective allies of people with behavioral health needs and their families — giving them the tools necessary to raise healthy children and then providing them with comprehensive services and supports, when they turn to us for help when in need.