Chapter 2
Highlights of Initiatives under Way

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This chapter provides a snapshot of policy, programmatic, fiscal and evaluative activities under way within OMH. By its nature, the chapter it is not intended to provide an exhaustive examination of agency operations. Rather, it gives a picture of initiatives that reflect core values consonant with a recovery-oriented approach and framed by inclusive strategic planning and performance measurement processes.

Society’s Role in Promoting Mental Health and Well-Being

Scientific evidence shows that just as we can do much to promote and maintain our overall health regardless of age, there is much that can be done to promote and strengthen mental health at every stage of life.

Mental illnesses are prevalent and their impact on individuals and families can be profound, as noted in Figures 2.1 and 2.2.^{1,2,3,4,5,6,7,8,9,10,11} The effects of mental illness manifest themselves across the lifespan, among all ethnic, racial and cultural groups, and at every socioeconomic level. In any given year, an estimated 23.9 percent of American adults have a diagnosable mental disorder; 5.4 percent have serious mental illness (mental disorder and substantial functional impairment), and 2.6 percent have serious and persistent mental illness (a serious mental illness of prolonged duration).¹²

Of the estimated 3.5 million New Yorkers with mental illness, 800,000 have serious mental illness, of which 380,000 have serious and persistent mental illness. In the United States, an estimated 12 percent of children from ages 9 to 17 have a serious emotional disturbance and functional impairment in any 12 months; in New York State, this translates to approximately 500,000 children with serious mental illness.¹³ Populations of priority in the State public mental health system are persons with the most serious mental illnesses and the greatest need, children with severe emotional disturbances who are or may be at risk for out-of-home placement, victims of trauma, and persons who are at risk for or have co-morbid health illnesses.

Without early intervention, mental disorders can become more difficult and costly to treat. The consequences of untreated mental illness can be lethal. Suicide related to depression, for example, costs our nation $5.4 billion annually.¹⁴ In addition, untreated mental illness is associated with school failure, teenage childbearing, unstable employment, marital instability and violence.¹⁵

Serious mental illness is also associated with other critical public health challenges. Modifiable factors such as smoking, alcohol use, poor nutrition, obesity, and lack of exercise play an important role in elevating the cost of care and leading to premature death and lost productivity.¹⁶ Additionally, the economic and social burden of mental illness is evident by overuse of more costly emergency psychiatric services and underutilization of less expensive preventive services, such as nutritional counseling and smoking cessation programs.

Recovery from serious mental illness was once thought not possible. Because research demonstrates that recovery from serious mental illness is possible with the right services and supports, OMH places high priority on a recovery-oriented approach to services. Children and adults who suffer from serious mental illnesses do regain valued social roles with proper treatment and supports that promote stable housing, meaningful work, and education. This does not mean people with serious mental illness are “cured,” but rather that they are managing chronic illnesses successfully, while living in their communities and carrying out normal activities of daily living.

OMH’s Role in Promoting Quality

In promoting the overall public mental health of all New Yorkers through education and advocacy and ensuring access to quality services for adults with serious mental illness and children with serious emotional disturbances, OMH has taken a prominent role nationally.

Since the formal introduction of its “Winds of Change” education and awareness campaign in June 2001, OMH has endeavored to promote scientifically based practices, better known as evidence-based practices, into clinical care. The campaign has served as a catalyst to closing the gap between what has been learned through research and the incorporation of this scientific knowledge into clinical practice. Moreover, the campaign has been contributing to the agency’s quality agenda, one that rests upon the achievement of positive outcomes through the adoption of evidence-based practices, enhanced accountability resulting from data-driven performance management, use of technology to improve services, effective State and local collaborations, and population-based planning methodologies.

As noted in Chapter 1, guiding the agency’s daily work is the Strategic Plan Framework, which serves as the foundation for a well-planned, integrated, and executed set of initiatives and programs aimed at comprehensively and effectively achieving the agency’s mission.

Important Policy and Program Initiatives

OMH primarily directs resources toward assuring continued access to services and supports essential to the well-being of individuals with serious mental illnesses or serious emotional disturbance. According to the scientific evidence base, the need for services by persons with serious mental illnesses is supported by our understanding that these illnesses:

• Are often chronic and disabling
• Have effects that are frequently compounded by the presence of co-morbid physical illnesses
• Are responsive to effective, recovery-oriented treatments and supports, which enable successful community integration
• Require costly economic and social investments, as with other major chronic conditions

Within this overall context, OMH has identified critical policy and program initiatives related to the mental health needs of children and adults with serious mental illnesses. Framed by the ABCD’s of Mental Health Care, these principles provide the underlying structure for ensuring accountability for the quality and outcomes of services, the incorporation of best practices to foster recovery and wellness, coordinated and integrated care, and the elimination of disparities.

The policy and program initiatives adopted by OMH reflect several strategic areas of emphasis closely aligned to the Strategic Plan Framework. These strategic areas currently focus on several key areas:

• Providing access to preventive care and evidence-based treatment
• Conducting basic, clinical and services research
• Providing access to safe and affordable housing
• Providing care coordination for persons with co-morbid disorders
• Enhancing accountability through data-driven performance management
• Using technology to improve services
• Preserving access to necessary psychiatric care
• Recruiting and retaining a qualified workforce

Providing Access to Preventive Care and Evidence-based Treatment

Individuals and families experience large and significant disruptions in their lives because of mental illness. Unlike most disabling physical diseases, mental illness begins very early in life. Half of all lifetime cases begin by age 14, and three-quarters have begun by age 24, making mental disorders the chronic diseases of the young.¹⁷ Anxiety disorders, for example, often begin in late childhood, impulse disorders in early adolescence, and substance abuse in the early 20’s. Unlike heart disease or most cancers, young people with mental disorders suffer disability when they are in the prime of their lives, typically years during which they would be their most productive.¹⁸

Despite effective treatments, there are long delays – sometimes decades – from the first onset of symptoms to when people seek and receive treatment. Critical needs include:

• Identifying mental illness early and providing access to treatment and supports that keep our children’s development on track, while they are at home with their families
• Creating new mechanisms to engage treatment programs in performing community-based screening, comprehensive assessments and in-home services for children
• Increasing access to evidence-based, community-based services for vulnerable children.

Moreover, children need access to appropriate and effective services for co-morbid mental illness and physical illnesses, such as asthma, obesity, diabetes and epilepsy. This requires ongoing attention to eliminating disparities in access to routine preventive health among poor nonwhite communities, where youth are more vulnerable to these conditions.

The “Achieving the Promise” initiative currently under way is addressing such needs. Additionally, children’s services have been bolstered with the introduction of the Children’s Mental Health Act in 2006, requiring the Commissioner of Mental Health to develop and monitor a plan for children, youth and their families. Moreover, in 2006 the National Institute of Mental Health funded a Children’s Services Research Center under the direction of Dr. Kimberly Hoagwood, to advance the science of implementing evidence-based practices for children, provide data for clinical and policy decision making, improve community mental health practice, and improve outcomes for children, adolescents and their families. Findings generated by the research center are expected to have broad national relevance.

With respect to adults, a number of evidence-based practices are being employed in New York State. A promising model for promoting evidence-based treatments in the early phase of implementation is the Personalized Recovery Oriented Services (PROS) program, a comprehensive recovery-oriented approach to services for adults with serious mental illness. PROS is designed to integrate a broad array of treatment, support, and rehabilitation services, which formerly were not able to be offered under one program auspice. Such services have been proven to be most effective when offered in an integrated, combined approach. PROS also allows existing State-funded rehabilitation programs, such as psychosocial clubs, vocational support programs and on-site rehabilitation programs, to benefit from participation in the federal Medicaid program; promotes accountability through licensing of mental health rehabilitation service providers; and advances the adoption of scientifically proven practices that produce positive outcomes for individuals with serious mental illness.

Other examples of initiatives aimed at increasing access to preventive care include:

Saving Lives in New York: Suicide Prevention and Public Health

• This three-volume publication serves as the foundation for suicide public awareness and prevention efforts in New York. This comprehensive, data-driven report is the result of a collaboration with the New York State Suicide Prevention Council.
• All three volumes of the report are available online at http://www.omh.state.ny.us/omhweb/savinglives/.
• The current focus of the suicide initiative is on intervention, including depression education to primary care physicians, an increase in gate-keeping capacity in communities, means restriction education for emergency department staff, screening of adolescents for suicide risk, and depression screening in communities.
• The publication is complemented by the statewide public education and awareness (SPEAK) campaign (see http://www.omh.state.ny.us/omhweb/speak/), which is designed to raise awareness of suicide facts, risks and warning signs, and steps to take when someone considers suicide; and to reduce the stigma associated with seeking and obtaining mental health services.

Geriatric Mental Illness Initiatives

• A cross-systems approach is being taken to respond to shifts in population trends and major social changes facing older New Yorkers, many of whom have complex mental and physical health needs.
• The Commissioners of Mental Health and the Office of the Aging co-chair the State Interagency Geriatric Mental Health Planning Council, which is providing leadership in meeting the mental health needs of older New Yorkers.
• The Council has recommended demonstration projects, which are being funded under the Geriatric Mental Health Act; one is focused on enabling community members to identify older persons at risk for mental illness and link them to services and the other seeks to integrate mental health and physical health care in primary health care settings.

Talk, Listen, Connect: Helping Families during Military Deployment

• This public education initiative is aimed at helping young children and their families to cope with the feelings, challenges, and concerns experienced during various phases of pre-deployment, deployment and homecoming. It is aiding parents and caregivers to identify signs of stress and is fostering healthy communications.
• The initiative is a partnership of OMH, Sesame Workshop, Wal-Mart, and the Military Child Education Coalition.
• Bilingual, multiple-media outreach kits, including DVD and materials for parents/caregivers and children, are being employed to help families in all branches of the military (see http://www.sesameworkshop.org/initiatives/emotion/tlc ).

Project Recovery Crisis Counseling Program for Victims of June 2006 Flooding

• FEMA and the Center for Mental Health Services awarded funding and support in August 2006 for the immediate response to the traumatic effects of severe flooding in the Southern Tier, including Tioga, Broome, Otsego and Chenango counties.
• Additional FEMA funding was awarded to continue the disaster mental health response to the flooding and its aftereffects, for the four counties as well as Delaware and Montgomery counties, two other highly affected counties.
• Outreach, public education, and crisis counseling are being offered to residents to ameliorate stress symptoms and assist victims in returning to their pre-disaster level of functioning.

Conducting Basic, Clinical and Services Research

Extraordinary gains have been made in mental health care, some of them based on advances in our understanding of the human brain and some based on a better understanding of how to deliver care to those who suffer from mental disorders. Despite gains, however, substantial gaps exist in basic and clinical scientific knowledge related to the treatment and prevention of mental diseases and in services research related to the translation of state-of-the-art treatments into mainstream practice.

As a national and international leader in mental health research, the State is committed to reducing the burden of mental illness and improving access to effective care. OMH research is conducted by its Research Division and within the Center for Information Technology and Evaluation Research. The Research Division performs basic, clinical and services research primarily at two locations: the Nathan S. Kline Institute for Psychiatric Research (NKI) in Orangeburg and the New York State Psychiatric Institute (NYSPI) in New York City.

NKI has earned a national and international reputation for its pioneering contributions in psychiatric research, especially in the areas of psychopharmacological treatments for schizophrenia and major mood disorders, and in the application of computer technology to mental health services. NKI researchers are responsible for reporting the first case-control study of its kind confirming an association between second-generation (atypical) antipsychotic medication use and the development of diabetes mellitus. They are also breaking ground on the modeling of Alzheimer’s disease and identifying key therapeutic approaches for initiating clinical trials.

NYSPI is among the nation’s top recipients of federal funds and research grants, fueling innovation and discoveries into the cause and treatment of mental illness. Some examples include Nobel Laureate Eric Kandel’s work on the cellular processes that underlie learning and memory that have implications for major psychiatric disorders; a major study of the effects of 9/11 on New York City schoolchildren that helped in securing substantial federal grant funding to the State to meet post-9/11 mental health needs of schoolchildren; acceptance of Ritalin as the treatment for ADHD in school-age children due in large part to a national study led by Dr. Larry Greenhill; innovative research by Dr. John Mann that has isolated an area of the brain implicated in suicide; and Dr. Madelyn Gould’s work in youth suicide that has helped illuminate the concept of “suicide contagion” and shaped guidelines for suicide reporting by the news media.

Providing Access to Safe and Affordable Housing

Reductions in homelessness and hospitalization are linked to the availability of safe and affordable housing. When lacking, secure and reasonably priced housing deters persons with mental illnesses from being meaningfully involved in the community.

Research and demonstration programs have documented the effectiveness of the supportive housing model for people with serious mental illness. Moreover, research has also found that permanent supportive housing can be cost-effective when compared to the cost of homelessness. A University of Pennsylvania study, for example, found that homeless persons in New York City with mental illness who were placed in permanent supportive housing cost the public $16,282 less per person per year compared to their previous costs for mental health, corrections, Medicaid, and public institutions and shelters.¹⁹

One important area of concentration within OMH has also been to enhance the quality of housing for persons living in adult homes who have been or are recipients of mental health services. Through an assessment process conducted by OMH, approximately 300 persons residing in adult homes were determined to be capable of or expressed an interest in other community housing. Since April 2005, approximately 220 residents of adult homes have been placed into community housing funded by OMH. Additionally, their recovery is being fostered through participation in a supportive case management program that includes teams of case managers and peer specialists.

As noted by the President’s New Freedom Commission, the lack of decent, secure, affordable, and integrated housing is one of the most significant barriers to full participation in community life for people with mental illness. Examples of housing initiatives in progress include:

New York / New York III Supportive Housing Agreement

• This City-State agreement provides 9,000 units of supportive housing for individuals and families with special needs who are homeless or at risk of homelessness
• The initiative targets 5,500 of the units to individuals and families with mental illness; the remaining units will be serving persons with HIV/AIDS, youth leaving foster care, and persons and families with substance abuse disorders.

Enhanced Community-Based Residential Models

• This 2006-2007 Executive Budget initiative enabled Supported Housing programs to appropriately address the rehabilitation and support needs of residents, respond to inflationary pressures, and maintain existing capacity.
• It included a three-year, annual cost-of-living adjustment tied to the consumer price index for targeted OMH non-trended programs.
• It maintained support for 31,100 housing units (exclusive of NY/NY III) supported by prior-year budgets.
• An important aim was to retain and recruit culturally competent, qualified clinical staff.

More details on these and other enhancements to housing appear in Chapter 4.

Providing Care Coordination for Persons with Co-morbid Disorders

Co-morbidity, which signifies the simultaneous occurrence of two or more disorders, is important to understanding the disease burden of mental illness. Co-morbid mental disorders affecting individuals with serious physical illnesses are often under-recognized; yet, if not effectively treated, they can result in lower adherence to medical treatment, an increase in disability and mortality, and higher health care costs.² Conversely, compared to the general population, people with serious mental illness have higher rates of mortality for the same diseases.²¹ Schizophrenia, major depression and bipolar disorder are all associated with medical causes of death often two to three times that of the public.²²

Children and adults with mental illnesses served by Medicaid are also affected by common physical illnesses. A reflection of the complexity of treating co-morbid conditions is the rise in per person costs. Moreover, treatment costs tend to rise substantially by adulthood, making a strong argument for early intervention and integrated care.²³

Research also suggests that an estimated 40-65 percent of persons with a lifetime substance use disorder have at least one mental disorder; about one-half of persons with one or more lifetime mental disorders also have lifetime histories of at least one substance use disorder.^{24, 25} Increases in accidents, suicide and aggressive actions are also seen among persons with co-occurring substance abuse and mental disorders. Studies of health care service utilization have found that persons who are high users of physical health services often suffer from co-occurring disorders. Moreover, clinical and general population studies show a high prevalence of co-morbidity among persons with mental disorders.^{26, 27, 28, 29, 30, 31, 32}

When care is not received, persons with complex needs will enter the health system later, with the likelihood of substantially higher treatment costs. Coordination of care – whereby a balanced array of physical health and mental health treatment, self-help, social and rehabilitative services is made available – is seen as essential for persons with co-occurring disorders. These services require a focus on rehabilitation and recovery, and are most effective when combined with individualized service plans designed around the needs and desires of the individual.

Examples of active programs addressing the care coordination needs of persons with co-morbid disorders include:

Assertive Community Treatment

• Well established and effective, this intervention employs a multidisciplinary team that provides flexible integrated treatment, support, and rehabilitation services to individuals in their natural living settings.
• Services are provided 24 hours a day, seven days a week, for as long as they are needed and delivered using a small staff-to-recipient ratio (i.e., one clinician for every 10 recipients).
• This intervention uses assertive engagement to engage and maintain individuals in treatment. It reduces the need for hospitalization.
• Treatment is especially effective for persons with the most serious mental illnesses when it is combined with supported housing.

Assisted Outpatient Treatment

• Based on Kendra’s Law, this court-ordered treatment serves persons likely to have difficulty living safely in the community without close monitoring and mandatory participation in treatment.
• Evaluation shows significantly reduced rates of harmful consequences such as arrests, incarcerations, homelessness and hospitalizations.
• The AOT Quality Improvement Panel is studying quality improvement strategies, including standardizing AOT processes statewide, enhancing AOT treatment planning, ensuring cultural sensitivity, and reducing stigma through public education and outreach.

Forensic Mental Health Services

• Two major areas of activity have been in expanding services and ensuring that corrections officers, police, and others in the forensics system are well prepared to assess and respond therapeutically and appropriately to the mental health needs of inmates, persons transitioning back to the community or other persons who have contact with the criminal justice system.
• Corrections-based mental health services are being expanded, in partnership with the Department of Correctional Services, to include Special Treatment Programs, Behavioral Health Units, and Satellite Mental Health Units. Intermediate Care Programs are slated to open in 2007 and additional capacity is being implement using tele-psychiatry.
• Through a collaboration with the Division of Forensic Services, the New York State Unified Court System’s Office of Court Administration and the Center for Court Innovation, additional mental health courts are being developed as an alternative to incarceration; the Bronx Mental Health Court was awarded the distinction as a national model for mental health courts in June 2006 by the U.S. Department of Justice’s Bureau of Justice Assistance and the Council of State Governments.

Enhancing Accountability through Data-driven Performance Management

Government and health care leaders are increasingly focused on the importance of performance management in advancing service quality and accountability. For OMH, performance management is central to advancing a science-to-practice agenda and ultimately in achieving person-centered recovery. The essential elements of the OMH performance management system include a focused mission, vision and values; using performance measures, standards and targets to align resources with the agency’s strategic goals and objectives; promoting ownership of and accountability for results; ensuring that timely and reliable data concerning performance are widely available to enable data-informed decision-making; continuous input from stakeholders on agency direction and performance; and transparency to enforce accountability and foster trust. OMH staff recently developed an electronic balanced scorecard to provide at-a-glance hard data concerning organizational performance. The OMH Balanced Scorecard is used internally to assess agency progress, but is also available to the public on the agency’s website (http://scorecard.omh.state.ny.us). Management indicators and targets highlight how data are being used to manage care for children and adults with complex mental health needs.

Using Technology to Improve Services

OMH is a leader in using information technology to improve clinical care. Recent innovations pioneered by OMH include the Psychiatric Services and Clinical Knowledge Enhancement System (PSYCKES), an award-winning application that supports prescribing practices and enables physicians to analyze up to 15 years of patient medication history to determine whether past medication trials have been adequate and whether current treatment reflects evidence-based standards of care. PSYCKES also identifies pharmacy administrative cost-savings opportunities that do not compromise quality of care. Using this system over the last year, OMH has achieved a statewide reduction of 90 percent in poly-pharmaceutical practices that are not supported by scientific evidence.

OMH has also leveraged information technology to improve mental health services outside of the State-operated system. More than 2,500 local mental health agencies statewide rely on web-based applications developed by OMH; these offer many benefits to local agencies, including ad-hoc reporting capabilities and care coordination modules agencies can use to manage referrals, admissions and discharges, assessments, and treatment planning.

To maximize performance management, OMH has developed a robust business intelligence infrastructure. At the core is an enterprise data warehouse that integrates data collected from OMH applications and external sources. The data warehouse makes it easy to query large amounts of data and supports ad-hoc analyses, data mining, and real-time reports including the agency’s Balanced Scorecard. With this infrastructure, OMH is uniquely positioned to analyze, identify and execute initiatives to promote accountability and efficient use of Medicaid and other public mental health funding. More details on these resources are outlined in Chapter 5.

Preserving Necessary Access to Psychiatric Care

While effective outpatient, community-based treatment and support services are essential for persons with mental illnesses, inpatient psychiatric care remains an important component of the public mental health system. A substantial portion of mental health services delivery occurs in New York State hospitals.

Acute care mental health inpatient services are primarily delivered through psychiatric departments of general hospitals, with intermediate and long-term inpatient care provided primarily by the OMH State-operated psychiatric center network. Along with acute inpatient care, Article 28 hospitals provide a substantial portion of outpatient mental health services. Two-thirds of Article 28 hospitals with inpatient psychiatric units also provide licensed outpatient services. In the children’s system, however, State psychiatric centers serve as a safety net; typically these centers provide acute care in rural settings and more intermediate care in urban areas.

OMH supported the work of the 21st Century Commission. “Rightsizing” of the hospital system can be a catalyst for positive change. Such change, however, demands a careful examination of current specialty mental health services and assurances that they will continue to be available to meet treatment needs within communities. In a meeting with the Commission in July 2006, OMH urged the Commission to take care to maintain sufficient levels of specialty services, to adequately meet community needs.

In discussing the Commission’s mission to eliminate excess health care capacity, OMH provided an overview of the recent closure of Middletown Psychiatric Center, suggesting that it serve as one model for hospital rightsizing. Inpatient services were preserved but consolidated at nearby Rockland Psychiatric Center, and resulting annual operating savings of nearly $7 million are being reinvested to expand community-based outpatient services that were in short supply in Orange and Sullivan Counties.

Recruiting and Retaining a Qualified Workforce

The successful implementation of a science to practice agenda requires the ability to recruit and retain staff with the education, skills and credentials necessary to deliver evidence-based care. It has become increasingly challenging for public mental health providers to recruit skilled, licensed professionals such as child psychiatrists, registered nurses and pharmacists. These professionals are in short supply and high demand nationally. In the United States, for example, while millions of children suffer from serious emotional disturbance, there are approximately 6,300 child and adolescent psychiatrists and their availability is severely limited in rural and in poor, urban areas.³³ In addition, the salaries commanded by child psychiatrists further diminish the availability of these physicians in publicly funded programs.

Echoing national trends, recruitment and retention of nonprofessional staff in the locally operated public mental health system is challenging, with voluntary providers reporting unacceptable levels of turnover in some programs.³⁴ Salary levels need to keep pace with inflation and competitive with other employment opportunities.

Looking toward the 2007-2008 Fiscal Year

The balanced scorecard approach is employed constantly in building upon the policy, programmatic, fiscal and evaluative activities under way within OMH. The trends and challenges examined by the agency in preparation for the selection of initiatives to address gaps in the system of care are noted in Chapter 3.

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Comments or questions about the information on this page can be directed to the Office of Planning.