Blog Archives

Mental Health's Tower of Babel: Science, Clinical Practice, the Criminal Justice System, Politics, and Individuals with "Mental Illness"

2/24/2018

There's A LOT to be said about the current lack of:

logic,
reason, and
coherent, clear and precise definitions

in Mental Health practice and policy.

We are only scratching the surface, but we will be continuing to develop these ideas because it is so important to rational:

Mental Health practice
Legal practice, and
Public Policy discussions and decision-making.

Ultimately, this ISN'T about knowing everything. It's really about:

Honesty
Honesty about what we do know;
Honesty about what we don't know;
& the Honesty to Limit Our Actions accordingly.

WE ARE NOT DOING THAT.

We've got an incoherent mess of systems and we've lulled ourselves into believing it doesn't really matter -- EXCEPT it does matter -- A LOT.

Science: The DSM 5 is not a valid diagnostic tool because it just describes symptoms and does not get to the underlying biology.

Science Up

New Science is Amazing, and it has HUGE Moral Implications for our society -- Now

Clinicians: Rely on the DSM 5 because they largely don't have anything else. This reliance extends to reports and testimony in the Criminal Justice System.

Criminal Justice System: They have their own standards for "insanity" and "incompetent to proceed" that don't mesh well with the DSM 5 much less current scientific knowledge and lack thereof. Of course, those LAWS are largely the result of the political process.

"Even a dog distinguishes between being stumbled over and being kicked"

Insanity

Politics: The will of the majority, largely concerned with SAFETY. Public policy discussions tend to use BROAD categories like "MENTAL ILLNESS" to discuss extremely complicated issues such as gun control. Clinicians can provide some refinement, but are largely unable to provide the clarity and precision that is needed.

Housing & Service Provision for people with "mental illness" are not provided as required by LAW or as needed, but on the basis of political budgetary calculations that may not be irrational from a SHORT TERM political calculation but are irrational both with respect to the TRUE NEEDS of people with disabilities and the LONG TERM COSTS to the Society. So we have a grossly inadequate supply of:

Housing;
Bed Space;
and Intensive Mental Health Services

Even though our Federal Laws and CMS Oversight Procedures would seem to prevent the ABUSE, NEGLECT and RIGHTS VIOLATIONS of people with disabilities that are rampant in most States and in Colorado -- when we don't follow or adequately enforce the LAWS -- it doesn't prevent the ABUSE, NEGLECT or RIGHTS VIOLATIONS of people with disabilities.

Colorado Abuse & Neglect Scandals

Alicia Keys & 60 Minutes: "Cause Right Now It Don't Make Sense"

Individuals with "Mental Illness": Are probably more acutely aware than most in the society, that "MENTAL ILLNESS" is BOTH a Biological Reality and a Social Construct. Tens of Millions of people with "mental illness" in the US are vulnerable to unfair stigma and refusal of reasonable accommodations. Additionally, over 300,000 people with mental illness are in the US Justice System, and Thousands are in the Colorado Justice System.

The CRYING NEED for Mental Health Policy Inclusion: for Planning, Coordination, Service Design, Oversight & Ultimately Innovation

2/22/2018

I do think that there are challenges for including anybody in public policy decisions. I think the challenges are generally overstated by governmental entities and often used as a SCAPEGOAT for why State policies are not more inclusive of the people they affect.

We just can't accept that anymore, and we really never could.

We REALLY NEED the voices of the people who are affected by these policies -- and they are often Homeless or Incarcerated.

I've been to some of those State meetings involving Criminal Justice and the LOW LEVEL OF INCLUSION is absolutely frightening.

If the State needs to contract out duties to provide for REAL INCLUSION -- THEN IT NEEDS TO DO THAT.

We don't mind if the State is CREATIVE and is able to come up with an ALTERNATIVE that is different than what we originally proposed but is mutually acceptable.

BUT what we won't accept are

PLATITUDES,
Non-Inclusive Policy Making that affects Marginalized People
FAILURE TO COMPLY WITH THE LAW, &
STONEWALLING

We've had ENOUGH of it.

Minnesota Court-Ordered Olmstead Plan

Includes Annual Goals To Increase the Number of People with Disabilities Involved in Public Planning Projects.

http://inclusion-international.org/

With regard to how far Colorado is behind a few States and some Countries in Public Policy Inclusion, is it a matter of Degree or Kind?

Whatever -- Colorado Public Policy Inclusion Can & Should Be Better

UN Convention on the Rights of People with Disabilities -- Norway's Initial Report

The Norwegian Labour and Welfare Administration (NAV) must offer services and benefits that are based on the capabilities and needs of the individual user.

Active user involvement is facilitated at individual and system levels to achieve this.

This requires a fundamental respect for users and a willingness to listen to and make use of users’ knowledge of their own situation and needs.

The object of such a focus/user perspective is to learn about users' needs by engaging in dialogue to find out what they need and how they experience the services, and to use this knowledge in constant efforts to improve quality and service.

This also entails a challenge in terms of how services are provided and how to design benefits so that they are perceived as relevant and beneficial to users. User involvement at individual level entails having the power to influence one's own personal services.

Each user must be heard in all phases of service provision, both when they are allocated and when they are provided. The right to be involved in one's own case is established by law.

User involvement at system level means having the power to influence the organisation and quality of services. User representatives sit on user councils at both local and national levels.

https://www.regjeringen.no/contentassets/26633b70910a44049dc065af217cb201/crpd-initial-report-norway-english-01072015.pdf

The Hickenlooper Administration Mixed Bag is Alive & Well with Politeness & Unresponsiveness

2/20/2018

The level of both good government and bad government within the Hickenlooper Administration on first blush seems pretty extraordinary -- except when one realizes most Administrations are like that.
Generally, most people shrug those things off and to a great degree we do, too.
BUT some of it is really SCARY BAD GOVERNMENT and for the most part there is no real intent to do harm or for that matter even an appreciation that they are doing harm.
So why would you modify anything, if you don't even realize there is a problem?
So what is it that is so BAD:

Not responding to a question about starting a waitlist for a critical mental health treatment, specifically Assertive Community Treatment-- now working on 3 years since the question was first asked -- (CO Dept. of Health Care Policy & Financing--- -- I mean you) ;
Putting your own agenda above complying with Federal Law, specifically Olmstead (CO Department of Human Services -- I mean you)
Putting forth bad faith, non-legal grounds for the State's non-compliance with Olmstead -- Gov. Hickenlooper's Office --- I mean you.
Parity: The State's Response [paraphrasing] -- "we were really too BUSY to talk about this right now in DETAIL -- BUT we will take your concerns into account." The BUSYNESS DEFENSE to REAL INCLUSION & SUBSTANTIVE ENGAGEMENT is a real favorite of the Hickenlooper Administration and we've encountered it numerous times over the years.

All three of these Departments or Offices with the State are full of--- super bright, super talented. and super caring people--- BUT they are NOT above:

STONEWALLING,
VIOLATING THE LAW, or
Rationalizing all manner of non-inclusive, non-responsive bad government.

We need all the people in those State Departments and the the Departments that weren't specifically mentioned.

BUT we gotta have some REAL SUBSTANTIAL CHANGE in Colorado Medicaid & CDHS & the Gov.'s Office (of course, that's getting ready to change anyway but we don't want the STATUS QUO or heaven forbid something worse).
If such bright, talented, caring people can't do what needs to be done in mental health -- who can?
Well, we do know we want an Administration that:

WILL CONFRONT TABOR. Such confrontation of TABOR is needed in order to prevent the abuse, neglect and rights violations of Coloradans with disabilities, including rights to Housing & Sufficient Services;
OR An Administration that will put in the TIME & ENERGY for an EFFECTIVE WORK-AROUND to TABOR to prevent the abuse, neglect and rights violations of Coloradans with Disabilities, including rights to Housing & Sufficient Services.
Is committed to RADICAL INCLUSIVENESS for State Mental Health Policy-- what we want isn't really "radical" --- the inclusion of people with intensive mental needs in service planning & oversight -- BUT it would be "radical" for Colorado;
Is committed to COMPLYING with Federal CIvil Rights Laws; and
Does not engage in very polite but NON-RESPONSIVE, STONEWALLING tactics -- we don't want rude non-responsive, stonewalling tactics, either.

There are so many people in the Mental Health Community that want to work with the State--BUT we want a BIG BREAK with the STATUS QUO--like

REAL INCLUSION -- NOT just platitudes of "Thank you for your comments we'll take them into account";
Federal Civil Rights Law Compliance BOTH in Theory & Practice.
COURAGE -- to confront the State's Funding Difficulties and its HORRIFIC IMPACT ON COLORADANS WITH DISABILITIES.

TIME IS RUNNING OUT ON THE HICKENLOOPER ADMINISTRATION & MOST PEOPLE HAVE ALREADY MOVED ON TO THE GOVERNOR'S RACE.

BUT EVEN IF THAT IS WHERE YOUR FOCUS IS -- KNOWING WHAT YOU DON'T WANT IS AS IMPORTANT AS KNOWING WHAT YOU DO WANT.

The Hickenlooper Administration isn't all bad -- and in many respects they do GREAT things -- BUT we don't want the PAST SCARY BAD HABITS of COLORADO STATE GOV'T to be our PRESENT OR FUTURE REALITY.

Tribes, Being "Different," Mental Health & Social Inclusion

2/20/2018

Most of our human ancestors started out in small groups and they were pretty wary of strangers -- picked up on differences very quickly -- to survive.
Societies have gotten A LOT MORE COMPLICATED in the interim.
One of the BIGGEST CHALLENGES for MODERN SOCIETY is recognizing the ENORMOUS DIVERSITY of the HUMAN POPULATION and providing for SAFETY and SOCIAL INCLUSION.
The Truth is none of us are really average -- and we have both a TREMENDOUS OPPORTUNITY and DUTY to take what we get and "TURN IT INTO HONESTY."
It's what we need as RUGGED INDIVIDUALS & it's also what the TRIBE NEEDS & what INDIVIDUALS within the TRIBE need for SAFETY and SOCIAL INCLUSION.
Human Health is extraordinarily complicated -- and one can definitely over-simplify it.
Yet, more and more, we are realizing the importance of SOCIAL INCLUSION to our HEALTH and the HEALTH of THOSE AROUND US.
i don't believe "Social Inclusion" will solve ALL our HEALTH problems --- BUT I think it could help A LOT, along with a STRENGTH-BASED approach to EDUCATION & EMPLOYMENT, with "reasonable accommodations" both for the individual and the majority.
Further, SOCIAL INCLUSION appears to be a STRONGER HEALTH PREDICTOR than:

Diet
Exercise, or even
A POSITIVE ATTITUDE.

Our need to belong to the TRIBE is pretty hard-wired and ALL those INDIVIDUAL DIFFERENCES have the potential to make the TRIBE much STRONGER --- IF WE ARE SMART ENOUGH TO HARNESS THEM.

"You Take What You Get and You Turn It Into Honesty,"

---from "Complicated"
Avril Lavigne

I'm including the above video again specifically regarding the observations on bipolar disorder: who gets it -- people who are intellectually above-average in the humanities, below-average, the main thing NOT average.

There is an emotional cost to being "different" in a society and the differences that societies focus on change with geography and from Age to Age. That "emotional cost" can and often does affect one's physical & mental health.

In modern Society --We sometimes like to think that discriminating on the basis of "intellectual" differences is more acceptable and objective -- but we don't have a great understanding of those "differences" and we often don't realize this filter contains as many biases as prior filters.

Of course, our DIRTY, LITTLE SECRET is that most of us are above-average in some things & below-average in others -- and very few of us are AVERAGE..

----Rumi

Author Johann Hari

Comedienne Lilly Singh

Mental Health & Sleep Apnea: When the Coping Mechanism You Need is OXYGEN -- There Really Is No Substitute

2/19/2018

More and more we are realizing the importance of SLEEP to our overall health.
SLEEP has been recognized for awhile as an important factor in Bipolar Disorder.
AND now it is recognized as a FUNDAMENTAL COMPONENT of our overall mental health.
So if there is something interfering with the natural restorative effects of SLEEP -- it turns out that can be a pretty BIG DEAL.
Further, NOT RECOGNIZING conditions that interfere with GOOD SLEEP & OVERALL GOOD MENTAL HEALTH--- can be a REALLY BIG DEAL.
SLEEP APNEA is just one of the IMPORTANT RISK FACTORS that is TOO OFTEN OVER-LOOKED in MENTAL HEALTH.
Further there are A LOT of things that can cause SLEEP APNEA:

obesity
allergies
deviated septum
high altitude
substance use
etc.

Strikingly, it has consistently been documented that high altitude counties in the US and specifically the Mountain States, have higher rates of Suicide -- EVEN THOUGH their rates for premature death from other causes are lower.
COLORADO has a very HIGH SUICIDE RATE, but it's rate for GOOD overall health is in the TOP 10. Hmmm . . .
Really across the Country, but especially in the Mountain States, we need Systematic:

Training,
Public Education
Routine Clinical Screens for Sleep Apnea;
Access to Sleep Studies, &
Proper Treatment

through our INTEGRATED PHYSICAL & MENTAL HEALTH Systems so that BOTH primary care and mental health professionals can address SLEEP APNEA effectively in the mental health context.
There is A LOT of skepticism about Altitude as a risk factor in the mental health professional community -- BUT the research is REALLY VERY STRONG that Sleep Apnea is a factor in mental health.
Further, it is not really counter-intuitive -- it's kinda what one would expect -- getting Oxygen to the brain is like really important.
It's just important to recognize that there are different types of sleep apnea such as altitude-induced or substance-induced -- and those risk factors are pretty significant -- including ALTITUDE.
We've known about Sleep Apnea since 1965. Since that time a lot of important connections with mental health have been made --It's more than time that mental health patients can systematically and routinely benefit from that knowledge.

Yes, You Can Die From Sleep Apnea--
Carrie Fisher Did

https://www.sleepapnea.org/carrie-fisher-yes-you-can-die-from-sleep-apnea/

CU School of Medicine Altitude Research Center

Institute for Altitude Medicine @ Telluride

See Also:

Prenatal Lack of Oxygen and Infant Sleep Apnea associated with later mental illness.

(Science Daily: ADHD Linked To Oxygen Deprivation Before Birth https://www.sciencedaily.com/releases/2012/12/121210080833.htm)

(Science Daily: Children's Sleep & Mental Health) https://www.sciencedaily.com/releases/2015/05/150506084427.htm)

Harvard: Sleep and mental health
Once viewed only as symptoms, sleep problems may actually contribute to psychiatric disorders
.https://www.health.harvard.edu/newsletter_article/sleep-and-mental-health

"Traditionally, clinicians treating patients with psychiatric disorders have viewed insomnia and other sleep disorders as symptoms.

"But studies in both adults and children suggest that sleep problems may raise risk for, and even directly contribute to, the development of some psychiatric disorders.

"This research has clinical application, because treating a sleep disorder may also help alleviate symptoms of a co-occurring mental health problem."

Altitude

CO HAS EXTREMELY HIGH USE OF SUBSTANCES -- & likely a high rate of substance-induced sleep apnea

Taiwanese Study Linking Sleep Apnea to Bipolar Disorder

Politics, Truth & Disability Rights --- No Colorado is NOT Complying with Olmstead, Parity or Medicaid Network Adequacy --- & It's Going to Take Honesty & The Combined Talents of the Disability Community & the State To Get Us There

2/17/2018

When I was in high school in the very early 80's, I took Russian language courses taught by a former US military guy who was still in the National Guard.
The Cold War was still raging.
Well, one of the first things our teacher taught us was a saying of the Russian people: правда не правда or The Truth is NOT the Truth.

I don't know anybody in the Disability Community who believes Colorado is complying with Olmstead -- that's mainly because Colorado is NOT complying with Olmstead. -- Where are those Measurable Goals, Reasonable Time Frames, & Funding to Support a Comprehensive, Effectively Working Plan as required by US Dept. of Justice Guidance (& US Attorney General Sessions Hasn't Stricken the Guidance -- Yet)
Parity: this is pretty new for Medicaid, and we've focused largely on Assertive Community Treatment -- it is going to take A LOT for Medicaid to get Parity for Intensive Community Mental Health Treatments.
Medicaid Mental Health Network Adequacy: OMG -- We don't have a network that is adequate for the people it's trying to serve -- & there are THOUSANDS OF PEOPLE WITH MENTAL ILLNESS who are incarcerated, homeless, in nursing homes, or in mental institutes because CO Medicaid Managed Care WAS NOT/IS NOT providing sufficient Mental Health Services in the Intensity needed and in the manner acceptable to Individuals.

So I'm coming back to this video of Tina Seeling on Divergent Thinking to make a Slightly Different Point than I've made before.

So the example Tina Seelig uses is a Math Problem -- and if you think of it in simple addition terms -- there's only one right answer.

On the other hand, if one thinks of the problem in algebriac terms -- there's an infinite number of RIGHT ANSWERS.

The Point I want to make is there is also an INFINITE NUMBER OF WRONG ANSWERS, TOO.

We would submit that LYING about Compliance with Disability CIVIL RIGHTS LAWS is REALLY STILL the WRONG ANSWER whether one is thinking about this in simple terms or algebriac terms.

Further it is the WRONG ANSWER POLITICALLY -- as hard as that may be to believe.

Complying with these LAWS is NOT EASY. It is really going to take the COMBINED:

CREATIVITY,
DIVERGENT THINKING,
ENTREPRENEURIAL SKILLS,
PRACTICALITY, &
SAVVY of

BOTH the DISABILITY COMMUNITY, of which the MENTAL HEALTH COMMUNITY IS SUCH A SUFFERING MEMBER, AND THE STATE.

The Mental Health Community & Mass Shootings: Are You a "Mental Illness Denier" In the Name of Stigma Prevention?

2/15/2018

Look, most people -- over 300 million in the US --- are NOT committing mass shootings.
Further, the one-fifth (1/5) to one-fourth (1/4) of the US population with a "diagnosable" mental health disorder is NOT committing mass shootings.
On the other hand, disturbing mental health indicators such as:

Suicide
School Shootings
Etc.

Are going up.

AND WE DON'T HAVE A REALLY GOOD HANDLE ON THESE PROBLEMS.

The DSM 5 is NOT VALID as a diagnostic tool -- How do you know the person doesn't have a "mental illness?"

Further, the National Drug Institute says Drug Addiction is a Mental Illness.

To talk about such a BROAD Category as MENTAL ILLNESS-- which is many MILLIONS of people in this Country doesn't make sense with respect to MASS SHOOTINGS.

BUT IT ALSO DOESN"T MAKE SENSE to be in a sense a "MENTAL ILLNESS DENIER" in the name of STIGMA PREVENTION.

Because there is a HOLOCAUST going on in the US Mental Health Community, and especially for those with intensive mental health needs ---- that impacts them, their families, the people they are around, and the ENTIRE COUNTRY.

Now most people with intensive mental health needs do not commit school shootings---- BUT we really have to question why we are going to SUCH LENGTHS to DEFINE people out of the HUGE MENTAL ILLNESS category who seem so clearly a part of it --- even if just a tiny, tiny fraction of it.

Hmmm . . . . BUT Doesn't It Depend On How We Define Mental Illness? ---------

Should we do more about gun control -- ABSOLUTELY. BUT Mental Health is having a HARD TIME coming to terms with REALITY -- AND if we can't do it -- someone's going to do it for us.

AND that could be VERY BAD for people with MENTAL ILLNESS.

Science Up

Drug Addiction Is A Mental Illness

An Orchid Valentine to the Mental Health Profession

2/13/2018

It probably has not escaped most people's notice that:

On the one hand, we are extremely critical of the Mental Health Profession,
On the other hand, we are vigorously arguing for intensive mental health treatment.

What's Going On?

Well, there's the idea that there is a fine line between Love & Hate.

We think what is really going on is: REALITY.

The Mental Health Profession is an incredibly complicated mixed bag -- right up there with the Legal System.

It does an enormous amount of GOOD, and it does an enormous amount of HARM.

For the most part it is pretty OBLIVIOUS to the HARM that is does, the mental health profession's first reaction to such claims is to assert the other person's "LACK OF INSIGHT" or maybe the person has an "ANTI-SOCIAL PERSONALITY DISORDER" [generally, for boys] or a "BORDERLINE PERSONALITY DISORDER" [often, although not always, for girls.]

Of course, that's a pretty HUMAN reaction -- that's pretty much what we all do.

EXCEPT, it is in the mental health profession and the CRIMINAL JUSTICE SYSTEM -- that one can really do A LOT of HARM with that kind of CRAP, and NOT EVEN REALIZE IT.

So most medical disciplines DON'T HAVE PERFECT KNOWLEDGE --- BUT they're generally not making claims in a CRIMINAL JUSTICE System beyond the discipline's or profession's knowledge base -- the mental health profession does it across this Country and in Colorado EVERYDAY.

So We've Got A BIG Problem with That.

On the other hand, we DON'T have a problem with the Mental Health Profession providing:

Person-Centered, Strength Based Care;
Engaging in Shared Decision-Making;
Doing the BEST IT CAN to determine Dangerousness;
ACKNOWLEDGING the PROFOUND Gaps in its Knowledge Base;
Refusing to allow itself to be used for purposes of punishment.

IT IS VERY COMPLICATED -- & IN MANY WAYS WE'RE RELYING ON THE MENTAL HEALTH PROFESSION AS CRITICAL PLAYERS IN THE TRANSFORMATION OF OUR SOCIETY.

BTW -- Wear a HELMET when going Skateboarding & Biking.

We Gotta Talk

So what are we trying to say with this video? We've been telling the mental health profession it needs to "Science Up" -- so that could be read as making things more "complicated." AND if one has followed our policy prescriptions, one realizes how complicated our relationship with the mental health profession really is. BUT what we're trying to say with respect to this video, is that the mental health profession's pretension to knowledge it doesn't have [even though they do have some knowledge in some respects quite a bit, in others not very much] -- DEEPLY HURTS the people they are trying to help -- that is certainly true in the Criminal Justice System.

----Stephen Covey

I love this video., and what I love about it is how HONEST the speaker is -- Steven Morgan with Soteria Vermont. Psychosis, mental health are COMPLICATED and we DON'T HAVE IT ALL FIGURED OUT -- acknowledging that might help give patients a mental health professional they could TRUST.

Soteria Project

Unscientific & Vague: Personality Disorders Must Be Reformed

CO Medicaid Mental Health Quality & Network Adequacy, Olmstead, & Contracting: Known Knowns, Known Unknowns, and Unknown Unknowns

2/13/2018

I think sometimes why Olmstead is so resisted by States is that it provides a dictate -- BUT it doesn't provide a lot in HOW.
The U.S. Supreme Court's decision was really designed to give the States flexibility. It has taken awhile since the original 1999 Olmstead Case to work some of this out.
The Minnesota Federal Olmstead Planning Case, the Georgia/DOJ MI/DD Comprehensive Settlement Agreement, the Delaware/DOJ Findings Letter re: NO Fundamental Alteration where bringing Housing & Services to Scale, DOJ Guidance on Olmstead-- at the end of the day there was a lot to be gleaned from those.
Then States like Colorado promptly ignored all that stuff -- also, known as LAW.
So it's a little bit, maybe a lot Pollyannish to say, "If the States just had the right tools, they would do the right thing."
BUT the States are doing some right things in Colorado and around the country -- they've even got some good things in their provider contracts -- although, not NEAR ENOUGH.
States spend A LOT MORE TIME on contracting with providers than they do with Olmstead Planning.

With Olmstead Planning -- often States just don't do Olmstead Planning at all or there are no MEASURABLE GOALS, etc. even though its pretty much common knowledge that the States have NOT brought Housing & Services to Scale to prevent unnecessary institutionalization of people with disabilities, including the great risk of institutionalization in homelessness.

BUT the Code of Federal Regulations & CMS have some "requirements" -- some softer than others -- regarding:

Managed Care Quality Assessment &
Improvement

One of the challenges to one's sanity is that we already have some pretty important known values::

Thousands of people with mental illness in Colorado Jails.
Thousands of people with mental illness in Colorado Prisons.
Thousands of People with mental illness who are Homeless.
Thousands of People with mental illness who are in nursing homes.
Federal Legal Duties on States to provide Housing & Services for People with Disabilities to avoid unnecessary institutionalization, or the great risk of institutionalization inherent in homelessness OR Provide a Comprehensive, Effectively Working Plan to do so with Measurable Goals, Etc..
Federal Legal Duties on States to Provide Mental Health Parity, including modifying CAPITATION RATE SETTING where necessary.
It is Medicaid Mental Health Managed Care that needs to have "NETWORK ADEQUACY" to provide for the people listed above in the Community. NEWS FLASH: COLORADO MEDICAID DOES NOT HAVE "NETWORK ADEQUACY" FOR THIS.
The State has made some improvements, BUT what it is doing is WAY NOT ENOUGH to comply with the LAW and even more importantly save Coloradans with mental illness from the Horrors of Abuse or Neglect or the Daily rights violations that have been and are occurring.

42 CFR § 438.330 Quality assessment and performance improvement program.

(a) General rules.

(1) The State must require, through its contracts, that each MCO, PIHP, and PAHP establish and implement an ongoing comprehensive quality assessment and performance improvement program for the services it furnishes to its enrollees that includes the elements identified in paragraph (b) of this section.

(2) After consulting with States and other stakeholders and providing public notice and opportunity to comment, CMS may specify performance measures and PIPs, which must be included in the standard measures identified and PIPs required by the State in accordance with paragraphs (c) and (d) of this section. A State may request an exemption from including the performance measures or PIPs established under paragraph (a)(2) of this section, by submitting a written request to CMS explaining the basis for such request.

(3) The State must require, through its contracts, that each PCCM entity described in § 438.310(c)(2) establish and implement an ongoing comprehensive quality assessment and performance improvement program for the services it furnishes to its enrollees which incorporates, at a minimum, paragraphs (b)(2) and (3) of this section and the performance measures identified by the State per paragraph (c) of this section.

(b) Basic elements of quality assessment and performance improvement programs. The comprehensive quality assessment and performance improvement program described in paragraph (a) of this section must include at least the following elements:

(1) Performance improvement projects in accordance with paragraph (d) of this section.

(2) Collection and submission of performance measurement data in accordance with paragraph (c) of this section.

(3) Mechanisms to detect both underutilization and overutilization of services.

(4) Mechanisms to assess the quality and appropriateness of care furnished to enrollees with special health care needs, as defined by the State in the quality strategy under § 438.340.

(5) For MCOs, PIHPs, or PAHPs providing long-term services and supports:

(i) Mechanisms to assess the quality and appropriateness of care furnished to enrollees using long-term services and supports, including assessment of care between care settings and a comparison of services and supports received with those set forth in the enrollee's treatment/service plan, if applicable; and

(ii) Participate in efforts by the State to prevent, detect, and remediate critical incidents (consistent with assuring beneficiary health and welfare per §§ 441.302 and 441.730(a) of this chapter) that are based, at a minimum, on the requirements on the State for home and community-based waiver programs per § 441.302(h) of this chapter.

(c) Performance measurement. The State must -
(1)

(i) Identify standard performance measures, including those performance measures that may be specified by CMS under paragraph (a)(2) of this section, relating to the performance of MCOs, PIHPs, and PAHPs; and

(ii) In addition to the measures specified in paragraph (c)(1)(i) of this section, in the case of an MCO,PIHP, or PAHP providing long-term services and supports, identify standard performance measures relating to quality of life, rebalancing, and community integration activities for individuals receiving long-term services and supports.

(2) Require that each MCO, PIHP, and PAHP annually -
(i) Measure and report to the State on its performance, using the standard measures required by theState in paragraph (c)(1) of this section;

(ii) Submit to the State data, specified by the State, which enables the State to calculate the MCO's,PIHP's, or PAHP's performance using the standard measures identified by the State under paragraph (c)(1) of this section; or

(iii) Perform a combination of the activities described in paragraphs (c)(2)(i) and (ii) of this section.

(d)Performance improvement projects.

(1) The State must require that MCOs, PIHPs, and PAHPs conduct performance improvement projects, including any performance improvement projects required by CMS in accordance with paragraph (a)(2) of this section, that focus on both clinical and nonclinical areas.

(2) Each performance improvement project must be designed to achieve significant improvement, sustained over time, in health outcomes and enrollee satisfaction, and must include the following elements:

(i) Measurement of performance using objective quality indicators.

(ii) Implementation of interventions to achieve improvement in the access to and quality of care.

(iii) Evaluation of the effectiveness of the interventions based on the performance measures inparagraph (d)(2)(i) of this section.

(iv) Planning and initiation of activities for increasing or sustaining improvement.

(3) The State must require each MCO, PIHP, and PAHP to report the status and results of each project conducted per paragraph (d)(1) of this section to the State as requested, but not less than once per year.

(4) The State may permit an MCO, PIHP, or PAHP exclusively serving dual eligibles to substitute an MA Organization quality improvement project conducted under § 422.152(d) of this chapter for one or more of the performance improvement projects otherwise required under this section.

(e) Program review by the State.

(1) The State must review, at least annually, the impact and effectiveness of the quality assessment and performance improvement program of each MCO, PIHP, PAHP, and PCCM entity described in § 438.310(c)(2). The review must include -

(i) The MCO's, PIHP's, PAHP's, and PCCM entity's performance on the measures on which it is required to report.

(ii) The outcomes and trended results of each MCO's, PIHP's, and PAHP's performance improvement projects.

(iii) The results of any efforts by the MCO, PIHP, or PAHP to support community integration for enrolleesusing long-term services and supports.

(2) The State may require that an MCO, PIHP, PAHP, or PCCM entity described in § 438.310(c)(2) develop a process to evaluate the impact and effectiveness of its own quality assessment and performance improvement program.

Assertive Community Treatment: Mental Health Parity, Olmstead, Capitation, & CMS Quality of Care Requirements for States Contracting with Managed Care Organizations

2/12/2018

So here we have it: ALL kinds of reasons why people with mental illness should have access to the Mental Health Care at the the level that they need AND one of the BIG REASONS why they don't.
These challenges are NOT unique to Community Mental Health or in fact to Managed Care. We have had serious quality of healthcare problems:

in Nursing Homes,
Abuse problems in facilities for people with developmental disabilities
Serious Staffing Problems @ the Colorado Mental Health Institute @ Pueblo for DECADES -- maybe the State is finally trying to tackle that this legislative session. We would like to see more Emergency Action on this.
The Deaths and maiming of Colorado Inmates with mental illness in the shadow mental healthcare system of our prisons and jails.
This is true in public health and its true in private healthcare. It is very difficult for patients and their families to enforce quality of care standards.

We are struggling as a Society "To Do The Right Thing" and at the same time "CYAing" ourselves to the maximum extent possible.

IT IS NOT WORKING.

On paper -- in the Statute books, the US Supreme Court Reporters, Federal Reporters, Code of Federal Regulations, CMS [Centers for Medicare & Medicaid Services] Guidance, State Regulations --- WE SHOULD NOT HAVE A PROBLEM WITH ACCESS TO PERSON-CENTERED, INTENSIVE ASSERTIVE COMMUNITY TREATMENT, ETC.

BUT WE DO HAVE A PROBLEM WITH ADEQUATE ACCESS TO ASSERTIVE COMMUNITY TREATMENT & A LOT OF OTHER THINGS.

If one has low to medium needs with regard to mental health treatment -- Managed Care may work out pretty well.

BUT Colorado Medicaid Managed Care it is a FRICKIN' EPIC FAIL when it comes to people with the most intensive mental health needs and is just NOT UP TO SCALE.

The State of Colorado knows that it doesn't have adequate capacity, and it's one of many reasons they have so powerfully passively resisted Olmstead Compliance and Planning and bringing needed housing & services to scale.

They are not necessarily opposed to those things, BUT they don't want to be held ACCOUNTABLE for them either.

Which brings us back to our Society that "Wants To Do The Right Thing" and spends a whole lot of time "CYAing" itself.

People Tort Reform is NOT going to get us to the Solution to this problem, mainly because it doesn't get us to Solutions to the "Root Causes" of the original presenting problems.

A LOT of the FOUNDATION for Solutions to the Systemic Problems we find in Mental Health Managed Care has really already been LAID -- in Statute, Caselaw, Federal Agency Guidance and Requirements, State Regulations.

It's really analyzing what are the BARRIERS to realizing this in PRACTICE and NOT just THEORY.

CMS -- Overview of Quality of Care Information for Managed Care

CMS on State Responsibilties for Quality Assessment & Improvement in Managed Care

CMS on State Responsibilities to Conduct External Quality Review of Managed Care Organizations

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