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Substance Use and Mental Health Services at a Crossroads

Behavioral health services must be strengthened to meet community needs. All too often, people with substance use and mental health disorders do not get the help they need. Behavioral health services are not available on-demand across New York State. A comprehensive continuum of prevention, treatment and recovery support services is not available in some communities.

Advocates maintain that resources for substance use and mental health disorders prevention, treatment, and recovery supports are inadequate, resulting in significant gaps in the service delivery system. Waiting lists with hundreds of persons seeking treatment for their opiate addiction exemplify the unfortunate reality that treatment is not available on-demand in New York State. Finding adequate mental health or substance use disorders services for children, adolescents, or young adults is extraordinarily difficult in many parts of the State. Unfortunately, as demand for services is increasing, the infrastructure for New York’s behavioral health system is experiencing troubling fiscal challenges; including the failure of some of our cornerstone service providers and a widespread lack of fiscal viability. These have been trying times for service providers and for individuals and families seeking help.

Community-based mental health and substance use disorders service providers are burdened by increased regulations, increased business costs, resources that do not keep pace with inflation, an under-paid workforce, and the limitations created by significant stigma. Persons and families with behavioral health needs are at wits-end when they cannot find services, are turned away because they have no insurance or inadequate insurance, or they experience some other barrier.

Because behavioral health services are under-funded and so many people never get the prevention, treatment, or recovery support services they need, New York State must strengthen its service delivery system if it wants to successfully achieve the goals of its new policy and program initiatives. Recent policy shifts and projects developed collaboratively by federal and New York State officials may be a cause for optimism.

Fragmentation of Services and Policy are Part of the Problem

It is a cause for significant concern that most people who are repeatedly hospitalized for physical health problems also suffer from substance use and mental health disorders. Especially alarming is the percentage of people who are frequently hospitalized for physical health concerns that also have a serious and persistent behavioral health need but are not engaged with any services or peer supports.

At the very first meeting of New York’s Medicaid Redesign Team, when it was noted that New York State had the highest rate of un-necessary hospitalization in the nation, participants were informed that 80% of the people who were un-necessarily hospitalized suffered from an untreated substance use or mental health disorder … or both. Because of the fragmentation that exists between primary healthcare and behavioral healthcare, many people presenting and re-presenting themselves at hospitals are never successfully referred to a substance use or mental health disorders service provider. Because of this failure, people with untreated (and sometimes un-diagnosed) behavioral health issues are likely to have difficulty taking care of their other chronic health conditions (heart disease, diabetes, hypertension, etc.) and see their health deteriorate unnecessarily.

More than 80% of persons incarcerated in New York State prisons and county jails, including Riker’s Island, suffer from substance use and mental health disorders. New York’s failure to integrate treatment more effectively into its public protection policy and program agenda has had numerous unintended consequences like unnecessary incarceration or hospitalization. Our prisons and jails have become the holding facilities for persons needing treatment, further stigmatizing them. Reforming drug laws or implementing I-STOP without strengthening community-based services leads to overdoses, deaths, poor health, stress on families, and wasted years in a cell. De-institutionalizing persons with mental health challenges, moving people out of substandard housing and adult homes back to the community without an adequate continuum of services results in a similar outcome. Fragmentation in policy development and implementation, where a meaningful role for behavioral health services providers and consumers is not included, produces costly, unacceptable health and social outcomes.

When we examine the challenges faced by persons working in a cross section of health and human service sectors or the consumers of services in the child welfare, domestic violence, social services, juvenile justice, homeless shelters, and countless other services, untreated substance use and mental health issues are a common denominator. To the extent that these service systems are not meaningfully connected with behavioral health prevention, treatment, and recovery support service providers, unnecessary suffering will be experienced by persons with behavioral health challenges and their families. This fragmentation is costly and damaging to individuals, families, and communities.

Integration and Adequate Resources are Part of the Solution

The Delivery System Reform Incentive Payment Program (DSRIP) is a new health initiative that could significantly change the value placed on behavioral health services as a critical driver in the achievement of New York’s public health goals. DSRIP has as its singular outcome target: reducing unnecessary hospitalizations by 25% over the next five years. One of the extraordinary dimensions of this innovative project is that it is supposed to rely heavily on behavioral health interventions and recovery supports. DSRIP will use 25 Performing Provider Systems, which are designed to be the new physical and behavioral health service delivery mechanisms for all New Yorkers on Medicaid, to reduce unnecessary hospitalizations. These new Performing Provider Systems will receive $6.42 billion over a five-year period to get the job done.

DSRIP is designed in a manner that requires each of the 25 Performing Provider Systems to have a strong behavioral health services component. In the early stages of development, behavioral health advocates are concerned that some Performing Provider Systems are not doing a good job of incorporating a strong behavioral health component while others are. If these new systems of services delivery do not stick to the DSRIP blueprint, they will not achieve their performance targets and New York State will lose. The behavioral health component of DSRIP has to be real, meaningful, and strong if we are to reduce unnecessary hospitalizations by 25% in 5 years.

The goals that drove passage of I-STOP, the data system put in place to reduce dangerous prescribing behaviors related to opiate pain medications and other potentially addicting medications, will only be achieved when prevention, treatment and recovery support services are strengthened. Unnecessary expense associated with the incarceration of persons with untreated mental health and substance use disorders will not decline until there is an investment made in community-based behavioral health services. It is only when behavioral health service providers are meaningfully engaged in policy development and corresponding services delivery reform that unnecessary confinement, unnecessary expense, unnecessary death, and poor health outcomes can be effectively addressed.

Behavioral health integration is imperative across health and human services sectors. An engaged behavioral health, substance use and mental health, services system can help to reduce homelessness, unemployment, child abuse and neglect, domestic violence, and a myriad of other health and social problems. When substance use and mental health disorders go untreated, the consequences impact the individual, their family, and the community. By fragmenting substance use and mental health prevention, treatment, and recovery supports and failing to integrate them across health and human service sectors, we continue to create a problem of unnecessary hospitalization, unnecessary, incarceration, and unnecessary pain and suffering.

When substance use and mental health services providers, consumers, and people in recovery are meaningfully incorporated into cross-systems policy conversations, meaningful change can occur leading to better health and social outcomes, increased integration, and better use of resources; three goals articulated by Governor Cuomo in his first State of the State address.

Funding should not be in a silo. Currently, for the most part, savings generated in one silo (health) by services providers paid from a different silo (behavioral health) is not reinvested in the system that created the savings. Where behavioral health programs achieve results that include savings, those savings should be reinvested in those behavioral health programs so that they can do more good work.

DSRIP has the right idea. Untreated substance use and mental health disorders are costly. They result in poor health and declining ability to address co-occurring health challenges like hypertension, diabetes, and heart disease. Integrating behavioral health services across systems of care is the answer.

Integration: Nuancing The OASAS – OMH Discussion

Community Forums are being convened this summer to get the input of individuals, families, community members, and services providers on the topic of the potential consolidation of the missions of the New York State Office of Alcoholism and Substance Abuse Services (OASAS) and the New York State Office of Mental Health (OMH). This inclusive conversation is an important conversation. The content of these Forums will be collected by OASAS and OMH with the help of a Steering Committee made of 20 stakeholders and communicated to the Governor’s staff as they consider what is best for New Yorkers.

Following the lead of the extraordinary policy work currently being done in New York State in the areas of healthcare, corrections and criminal justice, juvenile justice, and other sectors of the human services system, it might be a productive pursuit to broaden the conversation and examine integration of substance use and mental health services into the continuum of health and human services funded by New York State. This broader discussion could be rooted in better outcomes, better integration and better use of resources with emphasis on paying for performance; all priorities of Governor Cuomo.

Integration of competent and effective substance use and mental health disorders prevention, treatment, and recovery support services into other systems, especially where desired outcomes are not being achieved, would be a policy shift that could truly revolutionize New York’s health and human service delivery system. Let’s have the discussion about OASAS and OMH, but let’s contextualize the discussion in the best way to integrate both specialized services systems, substance use and mental health, across systems to dramatically improve outcomes, collaboration, and use of resources.

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