Category: D.J. Jaffe

In praise of D.J. Jaffe & SB19-222 -- the unacknow-ledged Debt the State & Traditional disability advocates owe the conserva-tiveS & Moderates & Orchid

4/26/2019

SB19-222 requires the State to strengthen and expand the behavioral health safety-net system so that individuals who are the hardest to serve do not end up in jails, caught in the child welfare system or homeless.

This really marks a major shift in policy and position -- for the State, State Government & the Disability Community.

What role if any did Orchid play in that?

How does that inform what we will be doing going forward?

What we really did was MARRY the CONSERVATIVE DISABILITY ADVOCACY of D.J. Jaffe and the Mental Illness Policy Organization & Treatment Advocacy Center with the Traditional Disability Activism & Sensiibilities symbolized by Olmstead.

We think that is the MIDDLE GROUND that the Community & Many Advocacy Organizations & Institutions can EMBRACE.

SB19-222 really embraces that and we know that some within State government and advocates are familiar with our criticisms of Colorado's Mental Health System & its "Continuum of Care Hell."

We think it is that Middle Ground that can be embraced nationally by:

Mental Health America,
NAMI
the National Disability Rights Network [the Nation's federally-mandated Protection & Advocacy Offices],
SAMHSA, &
CMS

We don't agree with everything D.J. Jaffe and the Conservative Mental Health Advocacy Movement want -- BUT they FORCED a CONFRONTATION with REALITY that the Mental Health Advocacy & Activist Community was doing its very best to ignore.

That reality was largely related to the GROSS HUMAN RIGHTS VIOLATIONS against people with cognitive disabilities in the CRIMINAL JUSTICE SYSTEM & HOMELESS.

NOW the Activist Community is Embracing those concerns of people in the Criminal Justice System and Homeless and involved with the Child Welfare System.

Further, Mental Health Advocates and Disability Advocates in general had gotten so pressured into believing that the ECONOMIC CASE for SERVICES was more IMPORTANT than the MORAL CASE that the SYSTEM that was CREATED was INCAPABLE of adequately serving people with intensive needs.

AND make no mistake about it the Disability Community got co-opted by States into going along with inadequately resourced systems because there was no clear vision of a Continuum of Care just a disdain for Institutionalization.

So this brings up one of the REALLY INCONVENIENT SYSTEMS FAILURES --the Mental Health Profession itself.

Where is the LEADERSHIP in the Mental Health Profession to address this -- we don't know.

We definitely need the American Psychiatric & Psychological Associations to step up to the plate & take responsibility and remedy the DSM 5 debacle.

That could be accomplished by just acknowledging their IGNORANCE -and stop allowing themselves to be improperly used by the Criminal Justice System.

Most specifically mental health professionals need to stop handing out those DAMNING "anti-social personality disorder" diagnoses -- when they really don't have knowledge to know what's going on.

Further, the mental health profession needs to wait for the National Institute of Mental Health's Research Domain Criteria Program to reform the DSM 5.

This is necessary in order to avoid the unscientific pronouncements the mental health profession is currently making that have the potential and often reality of greatly HARMING the lives of poor marginalized people with only partially understood cognitive issues.

There does seem to be INSIGHT & LEADERSHIP in the RESEARCH COMMUNITY and the Mental Health Activist Community to address what appears to be pretty inadequate mental health care in many cases.

We are interested in MARRYING the insights of the Immune-Brain-Gut Triad with approaches such as "Open Dialogue."

We're not for letting the Mental Health Profession continue to BILL for "CARE" without any commitment to address the HAVOC caused by a SCIENTIFICALLY INVALID DSM 5.

So what we really brought to the Table over the past 5 years was:

Information
Systemic Focus
Root Cause Analysis
& a willingness to Address Reality
while respecting Individual Rights & Needs

We've said this situation with THOUSANDS of Coloradans with cognitive disabilities in the Criminal Justice System & Homeless did NOT happen because 1 System FAILED.

Multiple Systems have FAILED. We will be continuing to provide information, a systemic focus and root cause analysis regarding those SYSTEMS THAT ARE IN DESPERATE NEED OF SUPPORT EVERY BIT AS MUCH AS THE INDIVIDUALS WHO DEPEND UPON THEM.

Of course, NONE OF IT WILL WORK WITHOUT INCLUSION.

SB19-222:

Individuals At Risk Of Institutionalization
Concerning the improvement of access to behavioral health services for individuals at risk of institutionalization, and, in connection therewith, making an appropriation.

BILL SUMMARY

The bill requires the department of health care policy and financing (state department) to develop measurable outcomes to monitor efforts to prevent medicaid recipients from becoming involved in the criminal or juvenile justice system.

The bill requires the state department to work collaboratively with managed care entities to create incentives for behavioral health providers to accept medicaid recipients with severe behavioral health disorders.

The bill requires the state department to determine if seeking a 1115 demonstration waiver is the necessary response to the requirements of 42 CFR 438.6 (e) to ensure inpatient services are available to individuals with a serious mental illness.

If the state department determines it is not appropriate, the state department is required to submit a report to the general assembly with the state department's reasoning and an alternative plan and proposed timeline for the implementation of the alternative plan.

The bill requires the state department to develop and implement admission criteria to the mental health institutes at Pueblo and Fort Logan.

The bill creates a community behavioral health safety net system (safety net system) and requires the department of human services (department), in collaboration with the state department, to conduct the following activities:

Define what constitutes a high-intensity behavioral health treatment program (treatment program), determine what an adequate network of high-intensity behavioral health treatment services includes, and identify existing treatment programs;

Develop an implementation plan to increase the number of treatment programs in the state;

Identify an advisory body to assist the department in creating a comprehensive proposal to strengthen and expand the safety net system;

Develop a comprehensive proposal to strengthen and expand the safety net system that provides behavioral health services for individuals with severe behavioral health disorders;

Implement the comprehensive proposal and the funding model no later than January 1, 2024; and
Provide an annual report from January 1, 2022, until July 1, 2024, on the safety net system to the public through the annual SMART Act hearing.

The bill makes an appropriation.

WHAT IN THE HELL----ALL TOO OFTEN IF OUR MENTAL HEALTH PROFESSION DOESN'T KNOW THE ANSWER -- THEY THINK THE ANSWER IS JAIL OR PRISON

12/19/2018

Is the Glass Half Empty or Half Full? We would be the first to acknowledge that is a HUGE MATTER OF PERSPECTIVE.

The mental health profession actually does do a lot of good things which we have a responsibility to honor.

On the other hand, we are not going to get to the root causes of our "Mental Health/Criminal Justice Crisis" if we can't acknowledge and correct the HUGE ROLE the Mental Health Profession has played in it.

That certainly includes Jaffe's "Insane Consequences" for difficult to treat "Bipolar Disorder" and "Schizophrenia."

But to us, it also includes "Anti-Social Personality Disorder" which is a pretty horrific unscientific rationalization for inadequate care.

If we don't have all the answers we need to acknowledge that --- BUT the DEFAULT ANSWER SHOULD NOT BE putting people in brutal environments in which they get worse.

WE CAN'T PUT UP WITH THAT ANYMORE.

Colorado Mental Health Centers have dumped their most difficult patients on the Criminal Justice System for Decades.

If we want that to STOP. we must do more than we are doing now.

God of the Gaps, Criminal Liability of the Gaps

Mental Health Parity & Assertive Community Treatment: CMS Guidance, Reasonable Medical Necessity, Quality & Quantity, CMS & SAMHSA, HCPF & OBH

2/9/2018

Mental Health financing in this Country is pretty convoluted and there are divided responsibilities -- BUT the BIG KAHUNA IS MEDICAID, health insurance, for funding of Community Mental Health Treatment.
Further, MEDICAID is an ENTITLEMENT and CMS has issued guidance on MENTAL HEALTH PARITY.
Even further page 36 of CMS' Mental Health Parity Toolkit references "Assertive Community Treatment" and "reasonable medical necessity" as the appropriate standard.
"Fidelity" to the Assertive Community Treatment Model is important and "Prioritizing" relevant populations is important -- BUT we gotta get REAL and move beyond "Prioritization" and make this an ENTITLEMENT under MEDICAID where "REASONABLY MEDICALLY NECESSARY"
Colorado's Department of Health Care Policy & Financing (HCPF) & Office of Behavioral Health (OBH) are in some senses a State reflection of the National division of the Centers for Medicare and Medicaid Services (CMS) and the Substance Abuse and Mental Health Services Administration (SAMHSA).
National advocacy groups such as the Mental Illness Policy Organization and the Treatment Advocacy Center have demonized SAMHSA we think quite unfairly, especially given the reality that it is CMS that funds most of the community mental health treatment in this country.
Well, Parity has the potential to address the INSANE CONSEQUENCES that D.J. Jaffe and the Mental Illness Policy Organization, the Treatment Advocacy Center, and the rest of us are so concerned about. BUT NOT through SAMHSA -- through MEDICAID.

Response From CO Medicaid Director Gretchen Hammer

The Behavioral Health Organizations are able to make a medical necessity determination for ACT, like all other BHO services. Their requirements for medical necessity determinations are in their contracts. The specific language is:

2.2.10. The Contractor may place appropriate limits on a service:
2.2.10.1. On the basis of criteria applied under the Medicaid State Plan, such as medical necessity.
2.2.10.1.1. All medical necessity determinations must utilize the medical necessity criteria defined in 10 CCR 2505-10 8.076.

The rule was recently updated by the Medical Services Board, the rule making authority for the Department. One can find the current rule on the Secretary of State website.

Orchid's Take: Most States employing a "reasonable medical necessity" determination for ACT specifically define it in Statute or regulation -- not under a general definition of reasonable medical necessity. That may be too vague and many providers likely need additional guidance.

What Colorado is really lacking is a definition for "reasonable medical necessity" for ACT.

AND How does that affect CAPITATION RATES?

There have been all kinds of "insane" incentives for Medicaid Community Mental Health to cost shift their neediest patients to the streets and the jails.
If those Community Mental Health Centers are not adequately reimbursed for Assertive Community Treatment -- one can be sure they are NOT going to be doing it.
Well, what does that mean: LOTS of People with Mental Illness in:

Prisons
Jails
the Streets
Nursing Homes, and
Mental Institutes

Medicaid Is A Mixed Bag And It Is NOT Some Innocent By-Stander in the Current Mental Health Crisis whether in Colorado or the Rest of the Country

1/17/2018

We're going to pick-apart Jaffe's summarized analysis of Medicaid's role in the current crisis and suggest why both Conservative and Liberal Mental Health Advocates have plenty to fear from Medicaid Mental Health and the States who administer the State Medicaid Programs.

With regard to "anti-psychotics," historically people and professionals including advocates thought they were going to work a lot better across the board than they did. So they were a HUGE part of de-institutionalization and the community mental health movement.
NOW -- we recognize that "genetic testing" may be really necessary to decide which medications are best. Further, a lot of these medications work on the brain globally and not on individual neural circuits and that is probably not a good thing, according to Cal-Tech neuroscientist David Anderson.
Further our whole understanding of "mental illness" is changing to something much more related to the brain, the gut and "immune system" than it was before. So the point being, we don't have a complete and comprehensive understanding of "mental illness" and and we're very slow to change incorrect old ideas.
So if you thought "anti-psychotics" were going to solve all these problems and "medication adherence" you probably didn't think you needed a lot in Community Mental Health and Medicaid Mental Health.
50 Years on or So -- SURPRISE! People with mental issues need a lot more than medication, the medication is more complicated than advertised, and "Medication Adherence" requires a competent profession and one that listens to its patients. We are lacking in both.
You just can't be a viable medical/healthcare profession and rely on outdated science like the DSM 5. Mental health professionals are NOT paid as much because they are NOT worth as much. Hopefully, the integration of physical and mental health which is so desperately needed in mental health will help both people with mental illness and the mental health profession raise its standards and its salaries.
So Medicaid is a BIG PART of that integration of physical and mental health care AND they deserve A LOT of credit for that.
BUT what happened when we realized "anti-psychotics" weren't going to be enough? We rushed right in to fund effective and expensive intensive community mental health treatments like -- Assertive Community Treatment, right?
HELL NO! We let the jails, prisons, homeless shelters and streets handle the intensive treatment needs.
This has gotten pretty nightmarish and Orwellian in Colorado where the State won't even answer a question whether it has an objection to a "waitlist" for ACT.
BUT now we're supposed to have Medicaid Parity, and the State continues to fail to fund this treatment as it would a medical/surgical treatment.
So it is this INTENSE STATE RESISTANCE to adequately fund Intensive Community Mental Health Treatments on par with medical treatments that led to:
- the Mental Health Crisis;
- Calls to get rid of the Institute for Mental Disease [IMD] Rule in Medicaid;
- AND a Call to a Return to Asylums
When State Medicaid Programs like Colorado's Resist the Large Funding Needs of People with Serious Mental Illness -- They Are Also Violating the Law & Civil Rights of Thousands of Coloradans with Mental Illness who are Homeless and Incarcerated.

From "Insane Consequences" . . .

"In spite of common lore, it is Medicaid, more than the advent of anti-psychotics and tranquilizers, or the construction of community mental health centers, that caused and continues to cause "de-institutionalization."

"The overall effect of exclusion [Medicaid's exclusion of payment for Institutes of Mental Disease] has been to create incentives or states to move patients out of state hospitals, which has contributed to homelessness and inappropriate incarceration."

See page 187 of the book.

See the Caption below for Colorado's Version of the Orwellian Nightmare

The Orwellian Nightmare is in one instance the Dominance of Irrational Political Concepts. Kind of like Colorado Medicaid's Refusal to Provide Assertive Community Treatment where "Reasonably Medically Necessary" Helps Coloradans with the most serious community mental health needs. Perhaps most distressing, the Orwellian practice of the Hickenlooper Administrations confusing politeness and cordiality with good faith and complying with the law.

Why D.J. Jaffe is Such A Hero -- States Must Have Community Mental Health Systems that Can Serve People Coming Out of Prisons, Jails, Nursing Homes, Homeless Shelters/Streets & Hospitals

9/17/2017

An Emerging Consensus Mental Health Policy for Citizens with Intensive Mental Health Needs After Decades of Gross Neglect

If one wins the debate, one may feel comfortable to start moderating -- and that seems to us to be the case with conservative D.J. Jaffe and the Mental Illness Policy Organization.
  Jaffe had to take on pretty much the entire mental health advocacy world including Bazelon and the National Protection and Advocacy System for People with Disabilities to make what now seems the obvious case that the sites of greatest institutionalization for people with mental illness in the US are jails and prisons.
  But even if you weren't in DENIAL, it seemed like Jaffe's policy prescriptions left something to be desired: GO BACK TO INSTITUTIONALIZATION and/or FORCED TREATMENT.
   Now, of course, Colorado has Assisted Outpatient Treatment [Outpatient Certification] -- what that really means without resources is pretty questionable and even Jaffe would acknowledge that.
  Of course, certification, inpatient or outpatient -- is really treatment failure -- and in this environment you have to look @ the paucity of resources as a potential factor -- and the paucity of resources for treatment of people with INTENSIVE MENTAL HEALTH NEEDS such that they would otherwise be in the:

Prison
Jail
Nursing Home,
Hospital. or
Homeless Shelter/Street

still shocks the conscience even with all the good things that have been done.
    In 2017, Jaffe is arguing for 50 psych beds for every 100,000 people.  That doesn't strike us as grossly unreasonable -- especially, in Colorado's case which has a very large and growing transient and homeless population which includes some people with serious mental health needs. It may especially be needed to stabilize people before more permanent placements.
      Colorado has a population of roughly 5.5 million people -- that would be about 2,750 psych beds. The mental health institutes have less than 600.
   Additionally, our understanding is that CMHIP is pretty much forensic at this point and they still don't have enough beds.
   As our understanding grows of some of these mental health issues in the criminal justice context we should anticipate more not less need for both inpatient and intensive community care.
   Of course, community care is less expensive than hospital care generally BUT INTENSIVE COMMUNITY MENTAL HEALTH SERVICES ARE NOT INEXPENSIVE --

THAT IS WHY Evidenced-Based Gold Standard in Community Mental Health Treatment --ASSERTIVE COMMUNITY TREATMENT --- IS NOT AVAILABLE TO ALL WHERE REASONABLE MEDICALLY NECESSARY

     That is BIG Time Discrimination CO Department of Health Care Policy & Financing / Hickenlooper Administration.

   And this brings us to where Jaffe really surprised us -- the call to FUND Community Mental Health Care for those with the most intensive mental health needs.

   We don't think you can just write off people with less intensive mental health needs ---- and maybe this is the beginning of a Beautiful Friendship.

D.J. Jaffe, CMHIP, Our Olmstead Planning Bill & TABOR: It Is Long Past Time To Have A Come To Jesus or More To The Point -- A Come To Reality

9/16/2017

Colorado Hasn't Allocated the Resources for the Inpatient Care or Community Care Colorado Citizens with the Most Intensive Mental Needs --- Need. That Has and Is Leading to in the words of Conservative Mental Health Advocate D.J. Jaffe "Insane Consequences." And that is true even in economically prosperous Colorado.

D.J. Jaffe is hardly a darling of the Left, in fact he is generally embraced by the Right, and we don't necessarily agree with all the prescriptions -- BUT he has pretty accurately described the problem in the US that people with the most intensive mental health needs have been written off as too expensive and cost shifted to the criminal justice system and the homeless shelter.

How can we have:

an evidenced based community mental health treatment such as Assertive Community Treatment that is the gold standard in intensive community mental health treatment
a major component of many MI US Dept. of Justice Olmstead Settlement Agreements, and
Yet not systematically required to be provided where reasonably medically necessary and desired --- politics? this is insane & life-destroying.

AND We Do Need More Beds & Sufficient Salaries for Staff.

We're asking the Hickenlooper Administration, Colorado Attorney General Coffman's Office, and the Colorado Legislature to look at the State's obligations under Federal Law as falling outside of TABOR restrictions based on the Supremacy Clause to the US Constitution.

Specifically, for our purposes that would mean:

State obligations to meet Federal Safety and Staffing requirements of facilities, etc.
Obligations under the federal Americans with Disabilities Act and the 1999 Olmstead decision and subsequent caselaw and federal guidance, etc.

National Review
By D.J. Jaffe
Price's War On Mental Illness
http://www.nationalreview.com/article/451039/mental-health-spending-serious-illnesses-should-get-bulk-spending

Val's Blog