Reviews of SMI Coordination Committee's First Meeting; Talk with ISMICC Member Elena Kravitz at NYAPRS Conference

Monday, September 11, 2017

NYAPRS Note: The following 3 accounts of the recently convened first meeting of the new Interdepartmental Serious Mental Illness Coordinating Committee (ISMICC) demonstrate the diversity of issues that will be explored and the variety of points of view that will help inform the committee’s preliminary recommendations in October and final ones 5 years from now.
I’ve highlighted a number of comments that underscore the important of a recovery point of view in these discussions.
Committee member Elena Kravitz, who works at Collaborative Support Programs of New Jersey will represent that point of view and advance the role of peer support in improving and humanizing care.
Elena will be joining NAMI’s Jay Yudorf in this Friday’s presentation at this week’s NYAPRS Annual Conference entitled ‘Collaboration for Recovery’ which will describe local efforts to advance “a strong, and growing collaboration between peer support, Government, traditional providers, and law enforcement.”
Elena will be sitting down with conference attendees at lunch Friday: please hear her thoughts and share your own!
Last chance to register! See https://rms.nyaprs.org/event/?page=CiviCRM&q=civicrm/event/info&reset=1&id=24 and/or contact NYAPRS Office Manager Eileen Crosby at eileenc@nyaprs.org

Inaugural Federal Committee Meeting Confirms HHS’s Efforts to Address SMI
Mental Health Weekly September 11, 2017

Prevention and intervention and criminal justice were among the topics discussed during the inaugural meeting of the U.S. Department of Health and Human Services’ (HHS’s) federal committee established by law to address the needs of adults with serious mental illness and children with serious emotional disturbance. The committee intends to deliver its first report to Congress Dec. 13.

The Interdepartmental Serious Mental Illness Coordinating Committee (ISMICC) held its inaugural meeting on Aug. 31. Members of the public were invited to attend the all-day meeting via telephone or webcast.

The committee was established to improve federal coordination of efforts that address the pressing needs of adults with serious mental illness and youth with serious emotional disturbance. The ISMICC was a mandate of the 21st Century Cures Act signed into law December 2016. The bipartisan legislation also created the position of assistant secretary for mental health and substance abuse in HHS. Elinore McCance-Katz, M.D., was sworn in last month as the first to hold this position.

HHS announced Aug. 16 the appointment of 14 public members to ISMICC with the current mental health serious mental illness.

The nonfederal committee members are serving a three-year term. The 10 federal agencies include such departments as the Department of Labor, the Department of Education and the Centers for Medicare & Medicaid Services.

During the meeting’s onset, HHS Secretary Tom Price, M.D., charged the committee with three goals to address the challenge of serious mental illness:
• Expanding evidence-based prevention, detection and intervention, including more effective early treatment of psychosis, as well as aggressive work on suicide prevention.
• Improving the quality of care in all settings, both inpatient and community-based, by supporting the integration of mental and physical health and expanding the capacity to offer treatment.
• Improving outcomes for all Americans struggling with these diseases, by helping them find rewarding work and a stable place in their community.

Range of Concerns
During the meeting led by Mc-Cance-Katz, Kenneth Minkoff, M.D., of Zia Partners, noted the challenges of the current system.

“We acknowledge that the system of care for people with serious mental illness and [for children] with serious emotional disturbance is not acceptable the way it is,” he said.

“We believe that people in need with these issues should get the help that is available in every single community.”

Minkoff noted that it’s “inappropriate” that program officials would say they can only help someone with a mental health condition when they’ve hurt someone.

“I make sure that people who run a crisis center would never say that to people,” he said. “We can come to your home, we can follow up with you and we’re not going to let you drop.” Minkoff said he is excited about the committee’s commitment to work collaboratively with stakeholders.

One of the public comments focused on people who are languishing in jails. A psychiatric nurse addressing the panel said she didn’t feel a sense of urgency regarding individuals with serious mental illness. She said she worked with other psychiatric nurses in jails and in the ER. “The urgency there is just as terrible,” she said. “I would encourage everyone to make some changes.”

Committee member and author Pete Early discussed the barriers his son faced in seeking help for his serious mental illness.

“Not you going to need to identify the problem, you have to figure out who’s going to pay for it.” he noted. In Virginia, resources such as housing and assertive community treatment can be made available, he said, but who is going to foot the bill? “You’ve got to keep that in mind. The ideas sound great, but you’re hit with reality in the system,” he said.

Mary Giliberti, J.D., CEO of the National Alliance on Mental Illness, discussed the importance of prevention. “If you intervene early, you can get better outcomes,” she noted. “It’s important to be there for young people,” she said.

“Consumers are hearing such comments as ‘We can’t help you,’ rather than ‘How can I help?’”

Committee member Linda S. Beeber, Ph.D., PMHCNS-BC, FAAN, distinguished professor at the University of North Carolina at Chapel Hill School of Nursing, noted that it is important to think beyond treatment to prevention as a means to cut across silos.

The issue of violence was also discussed. Maryann Davis, Ph.D., research associate professor in the Department of Psychiatry at the University of Massachusetts Medical School, noted that while there may be an increase in violence among the population with serious mental illness, it is a small one.

“The vast majority are not engaged in violence with others,” she said. The presence of substance abuse may accelerate violence, she said.

“What we should talk about is ensuring people get the treatment they need so that violence isn’t an issue,” said John Snook of the Treatment Advocacy Center.

Optimism
The inaugural meeting and the committee’s call to address consumers with the most significant care needs, such as schizophrenia and bipolar disorder, represented a “clear signal that mental health is a priority for the U.S. government and our health system,” ISMICC member David W. Covington, CEO and president of RI International, a crisis mental health service provider, told MHW. Covington said he was encouraged and optimistic about the government’s efforts to address serious mental illness.

HHS Secretary Price led with an inspirational charge to the group, said Covington. “I was very encouraged by the manner in which he approached the topic,” he said. Price spoke about the challenges con fronting the 10 million people with serious mental illness, including the lifespan, homelessness and incarceration disparities, Covington said.

Price noted that “recovery is the expectation,” said Covington. Price also said that efforts to address serious mental illness require the same expertise that is brought to cancer and heart disease, Covington said.

Covington noted there was mention of two prior reports commissioned by previous administrations. On Feb. 17, 1977, President Jimmy Carter, through an executive order, established the Presidential Commission on Mental Health. In April 2002, President George W. Bush established the New Freedom Commission on Mental Health to conduct a comprehensive study of the U.S. mental health service delivery system and to make recommendations based on its findings.

The two prior efforts yielded reports within a year’s timeframe, said Covington. The current effort will include a report to Congress, which will become part of an ongoing effort over the next five years, he said. The creation of the new federal committee “demonstrates an ongoing and elevating commitment to serious mental illness — even stronger than Bush and Carter’s efforts,” Covington added.

A blog prepared by Covington about the meeting highlights the key dates for a planned first report to Congress by December 13 to evaluate the effect of federal programs and recommendations for action.

Gaining Input
McCance-Katz told the panel and attendees that “the goal of the federal effort is to do the best job we can to try to hear what the public wants and needs and make adjustments in the infrastructure to serve people. The goal is to get a lot of input and ensure that people feel heard.”

McCance-Katz discussed the upcoming report to Congress. The first draft of the report is expected in mid-October, she said. Committee members should break into work groups and take a couple of days to review it, she noted.

Although there is no specific date set yet for the second ISMICC meeting, it will likely be virtual, she said. The committee may also decide to go on site visits, such as to HUD or the Department of Labor, Mc-Cance-Katz noted.

Opportunities will also be available for the public to provide more commentary, she said. The committee will try to reconvene around the time the report is released, she noted. They would also like to conduct a few listening sessions, although they are not planned yet.

McCance-Katz thanked committee members and federal partners. “I think we will get a good product out of this that we can use as a blueprint going forward,” she said. •
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Serious Mental Illness Committee Has Its Work Cut Out
Challenges in collecting data, improving diagnosis highlighted
By Joyce Frieden Medpage Today September 1, 2017

WASHINGTON -- The federal government's new committee on serious mental illness certainly has no shortage of issues to sort through, if its first meeting is any indication.

The group, officially known as the Interdepartmental Serious Mental Illness Coordinating Committee, met on Thursday for the first time. In welcoming members, Health and Human Services Secretary Tom Price, MD, called the committee "historic" and its purpose "significant".

"There is no time like now for work of this committee to begin. We are badly in need of a fresh examination of how we treat serious mental illness in America," he said. "Each of our priorities presents a complicated challenge, one where our policies are coming up short, and one where real progress would be a truly meaningful victory for the health and well-being of Americans."

Price also shared the story of a family friend named Charles. "He got to be 18, 19, 20 and struggled with schizophrenia, was in and out of institutions, in prison, and he lived homeless for a long period of time. Charles woke up one morning and decided he needed to kill his father and himself, and he did ... We are deeply committed to understanding why we failed Charles and his family."

The 24-member committee also heard from Ben Carson, MD, Secretary of Housing and Urban Development. "As we help people find housing, we must be aware of additional mental health issues. We must look for places of intersection, places for intervention. Homelessness, for instance," said Carson. "One estimate is that 26% of all sheltered homeless persons have a severe mental illness. So the shelter is an important point of contact. Staff must be trained to recognize mental health issues and mental disabilities."

"At HUD, I can assure you we'll be strong advocates for mental health [diagnosis] and treatment," he said.

Committee members each gave their own brief introductions; many of them either struggled with mental illness or substance abuse themselves, or had family members who did. "I have a brother who never survived his addiction," said Ralph Gaines, Principal Deputy Assistant Secretary for Community Planning and Development at HUD.

"The only people that recognized my mental illness were my children," said Elena Kravitz, a peer support provider and manager with Collaborative Support Programs of New Jersey.

"I have schizophrenia; I have been ill since 1977," said Elyn Saks, JD, PhD, law professor and legal scholar at the University of Southern California.

Committee chair Eleanor McCance-Katz, MD, PhD, assistant secretary for mental health and substance use at the Substance Abuse and Mental Health Services Administration (SAMHSA), laid out some of the committee's charges. "A major concern I have is keeping people with serious mental illness out of our prisons ... How do we move medical treatment of serious mental illness out of prisons and back to communities? I also hope to hear discussion of how we can make better use of evidence-based treatments ... and linkages with peers to support recovery."

She also said she wanted to hear "a discussion of how civil commitment laws might be appropriately used to assist a person with preventing relapse to psychosis ... I also want to know whether there are ways federal agencies can assist -- for example, by compensating physicians for their time spent in such processes."

Access to care and recovery support services are an ongoing challenge, McCance-Katz continued. "The estimates are that 35% of people with mental illness get no treatment at all. This is a terrible disservice. Emergency departments are not an appropriate place to provide needed care ... I am looking to you for suggestions around issues like hospital beds and acute care versus longer term needs." Other issues she mentioned included:
•Use of psychotropic medications
•Medication effectiveness
•Use of clozapine for resistant schizophrenia
•Protecting privacy rights
•Behavioral healthcare workforce including numbers of people and geographic distribution
•Integration of behavioral and physical healthcare
•Addressing concurrent substance use disorders

Other government members of the panel also discussed the challenges they face. "How are we defining serious mental illness itself?" said Paolo del Vecchio, director of SAMHSA's Center for Mental Health Services. "Across the federal government we're defining it differently, so the need for standardized data collection is critical."

Over at the Department of Veterans Affairs (VA), "Despite substantial VA investment ... [suicide] rates have stayed high," said John McCarthy, PhD, MPH, director of the VA's Serious Mental Illness Treatment Resource and Evaluation Center. "The VA has prioritized suicide prevention and put an emphasis on everyone being responsible, and on partnerships," but challenges remain.

Overall, "suicide rates rising across all population groups, particularly in middle-aged men and in youth," said Joshua Gordon, MD, PhD, director of the National Institute of Mental Health. "How do we predict individuals at high risk of suicide and, once we've identified them, how can we help them? That [especially] includes those not only in jail or prison but also in the year after release from prison."

Then it was the non-government panelists' turn. For youths transitioning to adulthood, "there is extremely little evidence of what works in that age group," said Maryann Davis, PhD, research associate professor of psychiatry at the University of Massachusetts Medical Center. She noted that a National Academy of Medicine report issued in 2015 called for establishing an evidence base for mental health among young adults.

"I think a lot more emphasis could be placed on the need to develop that evidence base," said Davis. "The second aspect is the ... need for much more research on how to deliver services in a manner appealing to young people. I know SAMHSA has had a few programs on how to better support transition-age youth, and it would certainly be beneficial to see those continue and expand."

Panelists also raised the issue of social connections. "This issue of friends I think we diminish," said David Covington, MBA, president and CEO of RI International, an organization that assists mentally ill patients with housing, employment, and other needs. He mentioned a study showing that loneliness was a 30% contributor to early mortality, "and we find almost no data [on that] in the serious mental illness community." Helping mentally ill patients find jobs is also important to their well-being, he continued; until that is dealt with, "we are going to miss out on a huge opportunity."

Cognitive deficits are another problem, said Joe Parks, a practicing psychiatrist and medical director of the National Council for Behavioral Health.

"The majority of these people see 15-20 different providers, they're taking 16 different medications, they have deficits in executive ability and the ability to organize information -- and we expect them to keep track of that and figure out what they need and when they need it. We shouldn't be surprised because they don't have the wherewithal to get all that straight."

"We don't require the supports to help them with cognitive deficits," he said to the federal officials on the panel. "Unfortunately, you're going to be the ones to require and regulate that it be done. This is an area where the private sector is failing and it requires more regulation, not less."

Katz noted that the committee's first report to Congress is due in December of this year, and will include sections on advances in dealing with serious mental illness, federal programs in place, as well as their outcomes, and recommendations agencies can take to better coordinate services for adults and children with serious mental illness. An outline of the report will be circulated to the committee in mid-September, followed by a first draft in mid-October and a second draft in mid-November.

The committee's second report is due in 5 years, she said.

https://www.medpagetoday.com/psychiatry/generalpsychiatry/67678
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A Huge Step Forward
by davidwcovington September 1, 2017

Yesterday was the inaugural meeting of the federal Interdepartmental Serious Mental Illness Coordinating Committee (ISMICC). While the acronym is a mouthful, the meeting is an important step to better health and quality of life to members of our community with the most significant needs; individuals with schizophrenia, bipolar disorder and major depressive disorder. Health and Human Services (HHS) has prioritized mental health alongside two other top priorities: opioid abuse and childhood obesity.

I’ve attended many government meetings on mental health and suicide prevention in Washington DC over the past decade but this represents my first mental health meeting next to the Capital at the HHS offices Hubert Humphrey Building. It’s a clear signal that mental health is a priority to the US government and our healthcare system.

HHS Secretary Dr. Tom Price began with the challenges for the 10 million people with serious mental illness; including lifespan, homelessness and incarceration disparities. “Recovery is the expectation” with employment and social connectedness being mentioned during the discussion. According to Price, prejudice and apathy have weakened the way we address these issues but they require the same expertise and commitment as cancer or heart disease treatment. Secretary Price also called out the importance of family support and inclusion in the collaborative process to evolve our health care system.

There were prior mental health initiatives under Presidents Jimmy Carter and George W. Bush, but Secretary Price explained that the ISMICC is the first to report to Congress and he expressed strong confidence in the newly appointed Assistant Secretary for Mental Health Dr. Elinore McCance-Katz. This new role reports directly to the Secretary of HHS and Dr. McCance-Katz is the first psychiatrist to lead SAMHSA.

The charge of the ISMICC is three-fold:
· Report on advances in treatment, recovery and prevention;
· Provide rigorous assessment that is candid and sober; and
· Make specific recommendations on policy reform.

“I firmly believe mental health care does not receive the emphasis or resources it needs,” Secretary Price stated, adding “We need a true continuum of care from outpatient to inpatient.” Lisa Dixon from Columbia University shared her feelings on the inspirational opening: “My heart is in my hands with the promise for what this group might achieve.”

All branches of government were represented. Department of Housing and Urban Development Secretary Dr. Ben Carson spoke next sharing his lifelong interest in psychology. He explained that his mother struggled with major depression when he was growing up and was hospitalized.

One of the highlights for me personally was the active participation of the Center for Medicare and Medicaid Services. Kimberly Brandt described the largest health insurer in the world with 130 million covered lives and $1 trillion in spending. She identified several key CMS initiatives; including states reporting on outpatient follow-up to psychiatric inpatient services, the prevalence of smoking for individuals with serious mental illness, and expanded telehealth opportunities for delivering crisis psychiatry services. She also pointed to an upcoming CMS meeting on September 8 which will lay the groundwork for innovations in behavioral healthcare payment models.

Dr. McCance-Katz shared with the ISMICC ten key areas that she hopes to hear addressed in the dialogue:
· How do we move treatment back to community supports and services for those in jail or prison?
· How do we improve therapeutic relationships and what role might advanced directives play?
· How do we increase evidence-based practices like Assertive Community Treatment, Assisted Outpatient Treatment, and linkages to peers?
· How do we improve civil commitment laws?
· How do we improve access to care, especially given that 35% of people with serious mental illness receive no treatment at all?
· How do we address the long waits frequently experienced in hospital emergency departments, ensuring adequate acute care, crisis intervention and additional levels of care?
· How do we improve recovery supports and ensure better evidence for these approaches?
· How do we protect privacy rights?
· How do we address workforce deficits, including the numbers and geographic distribution?
· How do we incorporate co-occurring substance use services?

Next, four panelists presented on federal advances to address challenges in SMI and SED.

Dr. Joshua Gordon from the National Institute of Mental Health offered a strategic framework for SMI and SED research that would deliver personalized interventions. He presented RAISE as an example of success using this approach (RAISE stands for Recovery After an Initial Schizophrenia Episode).

Gordon also prioritized suicide prevention and described the NIMH RFA on applied research to evaluate the effectiveness of the Zero Suicide in Healthcare systems model.

SAMHSA’s Paolo del Vecchio leads the Center for Mental Health Services and started with the stark disparity between people with SMI/SED related to receipt of evidence-based practices. For example, unemployment rates for individuals with serious mental illness are extraordinarily high. 70% of individuals express a desire to work but only 2% receive evidence-based supported employment services.

Del Vecchio surveyed the principles of coordinated care: medications, therapy and recovery supports while highlighting approaches that integrate all three components. Great emphasis on the need for a coordinated continuum of crisis care and the Zero Suicide in healthcare. “We prepare people for a life of recovery, not a life of disability.”

Dr. John McCarthy with the Department of Veterans Affairs, Office of Mental Health Operations, described the advances in treatment and access. While the overall number of veterans in the US has declined since 2005, the penetration for those receiving treatment with the VA has increased 24%. The growth in outpatient mental healthcare is up 85% over the same time period.

McCarthy reported on the substantially increased hazard ratio of suicide for individuals with serious mental illness and the July 2017 findings from Dr. Mark Olfson related to the very significant suicide risks for individuals in the immediate aftermath of a psychiatric hospitalization. He described several VA initiatives to address these risks; including the Veterans Crisis Line, 400 suicide prevention coordinator staff nationwide and the REACH vet program, which uses predictive analytics to determine those at highest risk.

Finally, the Bureau of Justice Assistance’s Ruby Qazilbash shined a light on the prevalence of people with SMI in the criminal justice system. She cited data that approximately 4% of the general population has a serious mental illness, but 17% of the 11 million annually incarcerated in the jail population has a serious mental illness. She also described the frustrations of local law enforcement, whose experience can find one in ten calls involve mental health, contacts which require twice as long to resolve as other police activities.

After the lunch break, a second panel presented non-federal advances.

Lynda Gargan with the National Federation of Families for Children’s Mental Health shared her own powerful personal journey of challenges and successes regarding her son.

Columbia University Medical Center’s Dr. Lisa Dixon reviewed the evidence for Coordinated Specialty Care for individuals experiencing a first psychosis, which demonstrates dramatic reductions in inpatient hospitalization and strong improvements in school and/or work progress. She asserted that “being productive equals a basic human need.” People want to work. It’s an essential part of recovery. And… Individual Placement and Support (IPS) is very effective, creating employment rates as high as 78%.

Dixon also reviewed the impacts of peer supports strategies; concluding that they reduce the use of acute services, result in decreased depression and substance use and increase engagement and hopefulness (Bellamy et al, 2017, “An update on the growing evidence base for peer support,” Mental Health and Social Inclusion).

Dr. Sergio Aguilar-Gaxiola from the University of California encouraged a focus on a comprehensive view of the non-medical determinants of health, including co-morbid medical diseases, smoking, obesity, physical inactivity, poverty, trauma, poor social connectedness and homelessness.

Formerly medical director for the state of Missouri, Dr. Joseph Parks is the lead psychiatrist at the National Council for Behavioral Health. Parks discussed the challenges of access to care; including a psychiatry workforce shortage, psychiatric boarding with people waiting in hospital emergency departments for mental health services and insurance gaps. He also encouraged the enforcement of parity requirements to appropriately resource services.

Using a data driven approach, Parks recommended a framework for strengthening community treatments and crisis services. He stated that standard definitions of levels of care (using placement criteria like the LOCUS and CALOCUS) will ensure better matching to needed supports and ultimately decrease the shortage of psychiatric inpatient beds.

Committee member Elyn Saks summarized the four presentations stating the most important element is access to care. She also encouraged a thoughtful analysis of the use of coercion and force in behavioral healthcare treatment, and suggested we create more engaging treatment.

There was generous and passionate input from everyone in the room. One of the most memorable threads related to the word “Interdepartmental.” Dr. Ken Minkoff with ZiaPartners, Dr. Clayton Chau of the Institute for Mental Health and Wellness St. Joseph Hoag Health System and author Pete Earley, among others, encouraged the ISMICC to action around the central importance of integrated solutions across federal departments. Minkoff shared his involvement in both the prior Presidential mental health initiatives and stated this is the first-time integrated solutions have been the goal.

What an amazing day… an amazing opportunity… an amazing mission… and an amazing group of people. I am truly honored!

Key Timeline
December 13, 2017 – First report to Congress with a summary of advances in SMI and SED, evaluation of the effect of federal programs and impact on public health and specific recommendations for actions that the departments can take to better coordinate.

October 15, 2017 – First draft of the report with a seven-day turn around for feedback from the ISMICC.

November 15, 2017 – Second draft modified with comments with another seven-day turn around for further feedback.

ISMICC Non-federal committee members are serving a three-year term.

A second report to Congress is required by the 21st Century Cures Act in 2022.

https://davidwcovington.com/2017/09/01/a-huge-step-forward/