Experts Divided Over Reform Plan's Prospects

Recognizing that years of change and turmoil have left them with a seriously flawed mental health system, Michigan government officials and mental health experts have announced several steps they will take to reform that system. The reviews of the recommendations are decidedly mixed.

Earlier this year the Michigan Department of Community Health (MDCH) released a list of 17 priority issues to begin the process of transforming mental health services over the next year or so. They are part of a road map the state needs to follow for the next two or three decades.

The commission that devised the plan was appointed in December 2003, by Gov. Jennifer Granholm (D) and headed by Janet Olszewski, Ph.D., director of the MDCH. It focused on seven core areas—stigma; public information; access to care; juvenile and adult criminal justice; suicide; organizing, financing and performance and measurement of the system; and connection with other health services and related concerns.

Michigan's mental health system has changed dramatically over the years from an institutional model to a community-based one. The result has been an expensive, unwieldy system that provides inadequate care and fails to move people toward recovery.

The system underwent a vast transformation from 1991 to 1997 when six adult psychiatric hospitals and five children's hospitals closed. The state moved to a Medicaid managed care carveout for public mental health services, which became complicated due to changing federal regulations followed by funding stagnation.

Psychiatric News asked representatives from the mental health community their views on Michigan's 12-month plan. All agreed that a daunting challenge is finding ways to begin changing the mental health system within current funding constraints.

Michelle Reid, M.D., medical director of the Detroit-Wayne County Community Mental Health Agency, an organization larger than many state systems, was a member of the commission, along with two other psychiatrists. “I am excited about the 12-month implementation plan, and if we do only one of the many things addressed, it would make a big difference in people's lives,” she said. She noted that in Michigan about 1,000 people commit suicide each year, and the majority of them had not received mental health services. To address this problem the Michigan Suicide Prevention Coalition is promoting and supporting implementation of a comprehensive, statewide suicide-prevention plan, which the state has approved. Michigan's surgeon general will add suicide prevention to goals for a healthy Michigan, and the MDCH will require suicide prevention plans to be submitted with annual needs assessment by each community mental health services program in November. A statewide public-education campaign will be developed.

As Michigan's mental health system changed over the years to concentrate more on individuals with severe and persistent mental illness, population-based activities such as suicide awareness and intervention programs were forced to take a back seat.

Mark Reinstein, Ph.D., CEO of the Mental Health Association in Michigan, found that the 12-month plan addressed much more than he expected, though in some areas he characterized it as timid.

He praised the report's attempts to develop statewide uniformity in determining eligibility for public mental health services, because before this, eligibility was often neither clearly defined nor uniform. And he commended the call to use the state's Mental Illness Advisory Council to assist with carrying out the commission's recommendations. He agreed with Reid that the new suicide prevention plan is a much needed improvement,

But he faulted the MDCH plan for taking strong consensus recommendations of the commission, then saying they will have to be subjected to reexamination by outside parties before the commission decides if they are advisable or feasible.

The commission also recommends that Michigan develop a system of mental health courts, though it is not yet clear whether the MDCH is in favor of this idea and thus ready to move forward on it.

While the commission did not have time to confront two important issues—financial support for the remaining state psychiatric hospitals and the fact that these hospitals and the community services are dealing with ever-growing numbers of people with past forensic involvement—he said they were at least able to add these to the list of problems that need to be attacked.

Susan McParland, director of Michigan's Association for Children With Emotional Disorders, said the plan needed to set forth ultimate goals. She called the plan lackluster and said it would be better for the public to see a longer-range plan.

She was especially distressed about the recommendations for reforming the juvenile-justice system, which she said were inadequate. “Many of our children who have emotional disorders are becoming enmeshed in the criminal justice system and have been sent to horrible facilities without the mental health care or educational support they need, and this plan does nothing to address this crisis,” she said.

In addition, she was surprised to find that none of the commission's recommendations for planning, outreach, assessment, and physician communication regarding mental health services for the elderly were addressed in the follow-up plan.

She mentioned that other gaps in the plan will stifle its implementation. The plan suggests, for example, that many issues will be referred to the Advisory Council on Mental Illness, and unfortunately only one person has been appointed to that council, so it is not yet a working council.

McParland also agreed with Reinstein that in too many areas the MDCH plan requires further stakeholder meetings, which seem unnecessary since the mental health commission was appointed by the governor and has already made the recommendations.

Patrick Barrie, deputy director of the state's Mental Health and Substance Abuse Administration, is optimistic about the plan. The way he explained its implementation answers some of the questions and objections others raised. He commended plans to reduce variance in the system and standardize eligibility and access criteria, service activities, costing methods, and appeals mechanisms. All of this will require working with stakeholder groups and pooling the expertise of consumers, families, mental health boards, state hospital officials, and advocacy organizations. We have always done that with costing and quality issues, and we are going to implement that in terms of eligibility and access issues and coordinate this with evidence-based practice, which has already been started, he said.

Funding is another big challenge in implementing the recommendations. Michigan has a complex system driven by multiple funding sources, such as Medicaid, SCHIP, general fund dollars, block grants, and other programs.

In an interview with the Detroit News, Olzewski, the MDCH director, said mental health system reform is a continuing campaign. “I think the reason we are going to continue to bring some people to the table is that we know they should have some concerns, so we need to address everybody's concerns.”

“Transforming Mental Health Care in Michigan: A Plan for Implementing Recommendations of the Michigan Mental Health Commission” is posted at<http://www.michigan.gov/documents/DCH_Implementation_Plan_April_2005_122025_7.pdf>.▪