Behavioral Health Action Report

Action, Advocacy, and Assessment



 

Introduction

 
The Behavioral Health Action Team found that a “scorecard approach” was the method that many communities utilized to review the status of their behavioral health performance. At a basic level, scorecards usually present comparisons of each area being measured to best practice standards to assess current performance and determine areas that need to be addressed. Toward that end, this report utilized a Behavioral Health Scorecard to compare Kansas City trends and statistics to national trends in three areas:  mental health treatment, safety, and housing. (Scorecard:  Attachment 1). The subcategories in each area of focus are consistent with attempts by other cities or states that have measured the status of behavioral health for their locale.
 
The Behavioral Health Scorecard indicates that Kansas City is “worse” than the national average in several areas however shows progress where collaborative effort is used. Regional studies were used to document Kansas City’s rankings along with research supported best-practice approaches that provide the underpinning for the scorecard findings. As a result of this comprehensive analysis, the recommendations in this report focus on three areas that require community-wide action and have the greatest likelihood for success in improving Greater Kansas City’s behavioral health scores.

 

Strategies to Improve Capacity

 
The Mid American Regional Council convened a study in 2014 to assess behavioral health capacity for children, youth, and young families across the metropolitan area. The study, conducted by The University of Missouri Institute for Public Policy with funding from the Greater Kansas City Healthcare Foundation and the REACH Healthcare Foundation, identified an annual short-fall of $148 million needed to cover the cost of basic behavioral health services for children, youth and young families. The chart in Attachment 2 clearly documents the need for more behavioral health capacity. In addition, statistics from the adult homeless shelters and the community’s domestic violence agencies indicate that 3 adults are turned away for every one person taken into care. The Behavioral Health Action Team also reviewed a variety of local and regional studies conducted to assess adult mental health services and found similar gaps in behavioral health capacity. Some of these are referenced in Attachment 3 and Attachment 4.
 
In addition, there is extraordinary data to indicate to our community that behavioral health services are essential. Employers throughout the community report antidepressant medications as one of the top 5 most costly aspects for their health plans. The Healthcare Foundation has documented the costs of untreated mental illnesses in the hundreds of millions of dollars (http://hcfgkc.org/resources/mental-health). Providers who rely on public funds report long waiting lists for people to access treatment. People with mental health issues and insurance also report problems accessing services and confusion about selecting providers. Finally, most medications prescribed for people with mental illnesses come from primary care physicians due to the shortage of psychiatrists. In short, the systems of care that are designed to provide services are overwhelmed, complex and inadequate.
 
Despite the complexity, it is important to note that every dollar invested in behavioral health capacity results in an estimated cost savings of $8 to $10. This return on investment factors in the cost of lost productivity, school drop-out rates, emergency room visits, and incarceration. A cost analysis completed by Kim Wilson Housing in Kansas in 2014 in regard to inadequate housing notes that “unnecessary and inflated costs are shifted to tax payers because individuals/families that are homeless fall into more expensive systems of care, and they do so more frequently than those who are not homeless.”
 
It is clear that additional dollars are needed across the metropolitan area to fulfill the goals of sufficient treatment capacity, adequate and safe housing, and prevention education, but it also has been found that the investment of additional resources in behavioral health has a significant return for the community as well as for the individuals benefitted.
 

Best Practice Approaches to insure a healthier KC

 
The Behavioral Health Action Team seeks to draw attention to evidence-based approaches to behavioral health care that are changing outcomes and lowering costs for both mental and physical healthcare. The approaches are “trauma-informed care” and “integrated health care.” Both of these approaches have unique definitions and are associated with standards in practice and policy that are promoted by SAMHSA and the Agency for Healthcare Research and Quality (AHRQ). These approaches are discussed in more detail later in this report.
 
The Behavioral Health Action Team also recognizes that addressing mental health and substance abuse services can be complex especially since there are many systems involved in providing treatment. The team, therefore, recommends that it would be of significance to highlight defined best practices that are essential to achieve a healthier KC. Toward that end, in addition to encouraging increased investment in behavioral health capacity, the team recommends a focus on building a community that is trauma informed, promotes integrated primary physical and behavioral health care and assures coordination of care across systems. These form the foundation for a Healthy KC and are explained as follows with recommended actions to consider.
 
Trauma-Informed Care:
Trauma is defined as any adverse event that overwhelms one's ability to cope. Unlike “Trauma Specific” services that are rendered by professionals for people who have demonstrated a need for clinical interventions, “Trauma Informed” practices can be used in any setting, home, school, business, recreational activities, etc. These practices recognize the prevalence of trauma in our community and support every person by understanding the changes in the brain associated with adverse events. While the Behavioral Health Action Team recommendations focus on trauma informed practices for service providers, it seems especially important when serving children and families impacted by homelessness. The study by the National Child Traumatic Stress Network (Attachment 5) provides recommendations for agencies and providers across the community.
 
During the 1990s a major study was conducted by Kaiser Permanente, the Adverse Childhood Experience study (ACE’s). This study validated the fact that when a child experienced multiple adverse experiences there was a high probability that the person would experience major medical and behavioral health diseases as an adult. The impact to the community can be seen in high rates of absenteeism, under performing at work and school, high healthcare costs, etc. The research has been validated now across the country. In addition, best practices have emerged for communities, businesses, schools and families that can be implemented, are cost effective and result in improved health. The process to become a trauma informed community starts with education and information sharing, assessment, adopting practices that are trauma sensitive and recognizing when the person needs professional trauma specific interventions and referral to such services. The education and information sharing occurs in multiple settings and requires ongoing support to create behavior change. Examples of organizations that are adopting trauma informed practices in Kansas City include the Independence and Kansas City Public Schools, Kansas City Police Department, and area community mental health centers.
 
Any discussion about improving behavioral health should include an understanding of resiliency. Several states have adopted resiliency-based approaches in tandem with trauma-informed care to encourage victims of trauma to engage in activities that break the intergenerational cycle of trauma and strengthen the communities in which they live.
 
Recommendation: The Healthy KC Commissioners and KC Chamber encourage their member organizations and communities of influence to become trauma informed. The expected benefits include increased employee productivity, improved retention rates, increased skill acquisition and a healthier KC. Resources are available from a community collective, Trauma Matters KC. This group has been meeting for 3 years and is poised to support a community wide initiative. There are more than 30 organizations participating and over 100 individuals who have the knowledge and skill to provide the information and to support organizations to become trauma informed.
 
Integrated Care:
For more than a century, behavioral health services have been separated from primary care or physical healthcare. Today there is wide recognition that medical problems and mental illnesses, including substance use, are inter-related. As noted in the trauma informed section, there is conclusive evidence that traumatic experiences affect the entire body resulting in physical health consequences. There is also evidence that diseases have an impact on one's mental health. In addition to the individual factors that promote the need for integrated care, there is the reality that the way care is delivered today is not as efficient or as effective as it could be. Finally, the number of doctors is insufficient to meet the needs of communities. Clearly, a better approach must be developed and implemented.
 
An integrated care system includes same day access, no wrong door for services, patient access to his or her own medical record, a simple and efficient referral process, single clinical record and a team-based approach to care. It is generally expected that the clinical team leader will be the primary care physician. Others work together with the primary care physician within their specialties. The specialists provide consultation when needed or direct services for complex or treatment resistant diseases. The results from an integrated system are positive and cost effective. A number of healthcare systems across the country have adopted integrated care and report improved patient outcomes, reduction in costs and improvement in access to care.
 
Recommendation: The Healthy KC initiative undertakes to promote integrated care through local healthcare systems and insurance companies to improve the well-being of behavioral and physical health in Kansas City. Best practice training is available from the American Hospital Association and the National Council for Community Behavioral Healthcare.
 
Coordinated Care:
Anyone who has received care from multiple doctors has experienced the need for coordinated care. Treatment can be disconnected, conflicting and confusing when the patient's records are not readily accessible. A person's care is even more disconnected between primary care doctors and behavioral health providers. There is no easy way to access medical records because the person is treated by different systems with different medical records. While there is progress in this area by way of the health information exchange, there still exists barriers to coordinated care. A critical barrier is the stigma associated with receiving behavioral health services. People express concern that there will be negative employment consequences for receiving behavioral health treatment. These consequences may be passed over for a promotion, increased scrutiny about work performance or termination. Further, doctors don't always understand the interactions of the medications or treatment or they underestimate the severity of the diseases the person has.
 
The solutions are multifaceted. Continued advocacy to promote and enforce laws that guarantee access to care, continued efforts to assure that systems "talk" to each other and promotion of patient portals to access their records are just a few.
 
Recommendation: The Healthy KC initiative support health information systems, to make sure that behavioral health services are included in the health information exchange and to assure that employers support comprehensive care and treatment. It is critical that employers provide information to their employees about the need to communicate with their doctors about the care they receive and to use patient portals as they are available. All efforts to assure that systems "talk" to each other are critical.


Prevention and early intervention to reduce risk

 
Half of all lifetime cases of mental health disorders start by age 14 and three-fourths start by age 24. The average age of onset of anxiety disorders, the most common category of diagnoses, is 11 years. Because the majority of adult mental illness begins in childhood, intervening early is a critically important and powerful strategy with significant potential long-term impact.
 
Prevention and Early Intervention (PEI) programs are given priority by many other states as a key strategy to “prevent mental illness from becoming severe and disabling” and improve “timely access for underserved populations.” PEI programs emphasize strategies to reduce negative outcomes that may result from untreated mental illness: suicide, incarcerations, school failure or dropout, unemployment, prolonged suffering, homelessness, and removal of children from their homes. PEI is a “help-first” instead of a “fail first” strategy and identifies individuals at risk of or indicating early signs of mental illness or emotional disturbance and links them to treatment and other resources. PEI creates partnerships with schools, justice systems, primary care, and a wide range of social services and community groups and locates services in convenient places where people go for other routine activities.
 
The essential principles of PEI are identified in research literature as follows:
  • Embrace and implement culturally diverse definitions of and approaches to mental health.
  • Prioritize ongoing learning and communication at all levels to increase mutual understanding and respect among diverse communities involved in mental health prevention.
  • Combat stigma, using a range of direct and indirect approaches.
  • Enhance positive relationships and opportunities for peer support.
  • Create comprehensive, multi-faceted community-based and family-based approaches.
  • Collaborate, as a priority strategy, with systems, organizations, and individuals who have not traditionally been considered part of the mental health delivery system.
  • Educate a wide range of people to recognize and respond to early indications of mental health challenges.
  • Intervene at key transitions in which the combination of vulnerability and openness to support creates enhanced opportunities for growth and positive change.
  • Reduce risk and increase protective factors that foster resilience. Prevention: Children, Youth, and Families
  •  Recognize and work to combat the negative impact for mental health of trauma and social injustice.
  • Assess the impact of prevention efforts, using a variety of methods, with a focus on client-led definitions of goals and outcomes.
  • Create and modify public policies to support prevention and early intervention.