Public Hearing to examine the impact of the NYS Office of Mental Health’s plan to establish Regional Centers of Excellence on affected communities

http://www.nynp.biz/index.php/points-of-view/17210-what-is-excellence-without-universal-access

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

 Good afternoon. My name is Andrew Malekoff. I am executive director of the North Shore Child and Family Guidance Center, a community-based outpatient children’s mental health agency located in Nassau County. This is our 60^th anniversary. I have been with the Guidance Center since 1977. I thank you for the opportunity to be heard today.

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