Public Hearing to examine the impact of
the NYS Office of Mental Health’s plan to establish Regional Centers of
Excellence on affected communities
September 19, 2013, Middletown Common,
Middletown, New York
By Andrew Malekoff, Executive Director
and CEO, North Shore Child and Family Guidance Center, Roslyn Heights, New York,
11577
In the past
25 years, the mental health system has seen many changes. From a system in New York State that
consisted primarily of outpatient clinics, community hospitals, state
hospitals, and residential treatment facilities, a continuum has evolved which
now also includes family support, day treatment, a variety of in-home community
support services, community residences, mobile crisis intervention, and respite
care. Many of these services were
originally funded with the reinvestment dollars saved from the 1990’s reduction
in state hospital beds. The largest of
these programs, Home and Community Based Services (HCBS) Waiver and Intensive
Case Management, are Medicaid-driven.
Nevertheless,
parents still find that there are major gaps in our service system. Even with the available community support
services, children with mental illness and their families continue to need
good, often intensive, outpatient clinical services. The onset of managed care resulted
in hospitals discharging children earlier, often before they are sufficiently
stabilized to return home. Mental health
outpatient clinics are then left with the task of trying to provide adequate
clinical care to these needy and often high-risk youths, but with highly
inadequate rates of financial support from insurance companies and government
funds.
More low-
and middle-income families than ever are in need of low-cost, high-quality
community-based mental health care. Yet
in New York State continued access to care is assured only to children and
families with Medicaid and Medicaid Managed Care insurance coverage. This leaves
a significant number of children in the lurch.
Here is a
true story to illustrate. About 25-years ago I was swimming in the ocean in
Long Beach, NY, and someone pointed to a group of girls that had drifted
towards the jetty. The girls must have been pulled out by the undertow and were
unnoticed by the lifeguards. I swam to them. When I arrived, there were three
little girls; one looked about nine-years-old. The others, who were crying and
holding on to the older girl, appeared to be six or seven. The older girl was
trembling and barely in control of her emotions. I wrapped my arms around the
three of them and said, “Hang on.”
Finally, the
lifeguards arrived and took over. I swam to shore and went back to my beach
chair. When I recall this encounter, I realize that the four of us were
strangers who spent maybe 90 seconds together. I said only two words to them:
“Hang on.” Ninety seconds, two words and 25-years and I still think about them
often. We were so close that I could see their freckles.
Now, let’s
consider another scenario. Try to imagine me swimming out to the three girls.
Now, imagine if, instead of telling them to hang on, if I treaded water at a
safe distance and asked them if they had Medicaid insurance. Imagine if they
answered, “No mister.” And, if I then said to them, “Sorry, girls,” and turned
my back on them and swam to shore.
This is the
situation that we now face as New York State has made a dramatic departure from
its responsibility to make sure that our most vulnerable citizens – our
children – get community-based mental health care, regardless of their family’s
economic status. They expect us to throw the underinsured middle class and
working poor overboard with no life preserver. I see nothing to suggest that
Regional Centers of Excellence will change this.
The American
reality today is 1 out of 5 children has a serious emotional disturbance and
more children suffer from psychiatric illness than from autism, leukemia,
diabetes and AIDS combined. Seventy-five percent of all serious mental illness
occurs before the age of 24; and 50% before the age of 14. Yet, only one out of
five children who have emotional problems receives treatment from a mental
health specialist.
Unfortunately,
the mental health system has become largely Medicaid-driven. For example, my agency,
at any given time, sees over 75% of children who do not have Medicaid or
Medicaid Managed Care. It is a constant struggle
to provide what is needed for the majority of our clients who are either
uninsured or underinsured middle class and working poor families.
In Nassau
County, and I suspect elsewhere, there are community-based outpatient mental
health programs that have closed their doors, have been taken over by larger
corporate entities with no community roots, have transformed their operations
into per-diem factories with little capacity for dealing with complex or crisis
situations, or have decided to turn away all clients who do not have some form
of Medicaid.
When I raise
the problem of inadequate access to care, I am advised by government officials
that the marketplace – meaning private practitioners – would take care of
children without Medicaid or Medicaid Managed Care. This belies reality, which
is that (1) a great many private practitioners do not accept commercial
insurance; and, (2) among those private practitioners who do accept commercial
insurance, most are unwilling or ill-equipped to address the highly-complex,
crisis-oriented needs of children with serious emotional problems.
The reality
is that only quality community-based children’s mental health organizations
with salaried employees, interdisciplinary teams and dedicated time for staff
supervision are capable of providing the labor-intensive quality of care
necessary to address the mental health needs of children with serious emotional
disturbances and their families.
What’s more,
for those children who need a longer period of hospitalization, Sagamore
Children’s Psychiatric Center has been the answer for the children on Long
Island. Unless another alternative is developed as part of the Regional Centers
of Excellence planning (i.e. dedicated long term beds supported by OMH in
not-for-profit community hospitals), these children will be dramatically underserved.
Queens and
the Bronx are not viable alternatives for most families. For seamless
transitions back to community, the children should be in the community; not in
a distant community that would make transportation, visits, home passes, and
attending meetings impossible for some families.
The
increasingly swinging doors of the community-acute care hospitals, which,
because of insurance limitations, are not able to keep kids long enough to
stabilize them in many cases. And, so, kids are being discharged to a community
with inadequate supports.
For example,
as many sister agencies have stopped accepting this population, our agency has
become a major landing point for these kids, as seen by our increasingly active
triage and emergency service. And, the kids who really need a hospital have
already experienced intensive community based services and have had at least
one or multiple hospitalizations and emergency room visits which did not
work.
With our
current community system, and inability to provide an adequate level of
outpatient clinical care without losing money, we cannot support these
kids. We need all levels of care, including a children’s psychiatric
hospital as a local part of the continuum. But, we also need more
well-supported and expanded outpatient services. Waiver slots, Intensive
Case Management and Coordinated Children’s Service Initiative are all good, but
these kids still require clinical care, and often not just once a
week.
In
conclusion, thinking back to my Atlantic Ocean memory, it is a story that is
about more than me and three little girls. It is about all of us and the
thousands of children that community-based mental health agencies across New
York State guide safely to shore every year, and offer them the chance to see a
brighter day. To do this we need to provide ready access to quality mental
health care for all children who need it.
To ensure universal access for all children in New York State,
regardless of socio-economic status, requires a commitment from the State to
enhance local assistance. When agency, client, community, and government work
together and contribute collectively we all win. Then, and only then, can we
refer to any entity formed on behalf of children with mental health problems as
a “center of excellence.”
Andrew
Malekoff, North Shore Child and Family Guidance Center, 480 Old Westbury Road,
Roslyn Heights, New York, 11577; E-mail: amalekoff@northshorechildguidance.org
