From criminalization of mental illness to Mental Hospital Diversionary Respites.
(An article that was not published in Baltimore Sun.)
Almost 55 years had passed since President John F. Kennedy signed Community Mental Health Act into a law. This act provided funding to open 1500 Community Mental Health Centers and allowed the states to close many of the large mental institutions where people with serious mental health problems were warehoused. This Act also lead to adoption of Medicaid in 1965. In the following years the number of hospital beds was reduced by 90% as mental health care shifted towards outpatient services. However. the funding for Community Mental Health Centers was not sufficient and only half of the proposed 1500 centers were opened. The legislators who prepared the Act made no considerations for the long-term funding of those centers.
This problem remains unsolved to this day, causing many people with mental health problems to live on the streets while the prison system became a largest mental health provider in America.
Criminalization of mental illness occurs as 80% of the patients arrive through the criminal justice system, according to the article: “With psychiatric beds full, mentally ill in Maryland are stuck in jails.” Michael Dresser, Baltimore Sun, June 8, 2016.
As the number of beds is limited, people are sent to jails instead of being immediately hospitalized. Despite the court order for hospitalization, inmates who experience a mental health crisis may spend weeks in jail where their symptoms would become severely aggravated before being admitted to the hospitals. Those who arrive without a court order for hospitalization wait for more then a month on average, and in some cases are denied admission all together. It remains a common practice to use solitary confinement to punish inmates in Maryland prisons. The system makes it difficult to count the exact number of people with mental disorders who are incarcerated instead of being sent to the hospital.
The article “Maryland unveils plan to add beds in psychiatric hospitals” Michael Dresser, Baltimore Sun, January 23, 2018 tells us that following the contempt of court, Maryland Department of Health made plans to add 100 new hospital beds for court ordered patients. The costs of adding the required hospital beds lie in the range of tens of millions of dollars because of the associated staffing costs.
While mental hospitals only help some people recover, there is a growing number of patients that keep relapsing and keep coming back. Those patients are colloquially referred to as “frequent fliers” and state’s 30 day readmission rates are still higher than national averages, although they decreased since 2011 . Maryland has a 11.54% all payer readmission rate (2016) for psychiatric patients, while Georgia has a rate of 7.2% (2016) and the average for the national average is 8.8% (2016).
A considerable portion of hospital beds is occupied by readmitted patients whose condition has not improved after a routine inpatient treatment, review of medications and follow up visits with a psychiatrist. At the other hand, people in a very acute crisis are not admitted because there is a shortage of beds and some become incarcerated instead. Mental hospital stay is pricy as one day at the not-for-profit hospital, such as the Frederick Memorial Hospital costs $2,419 and a day at a for-profit Sheppard Pratt institution costs $2450.
Number of studies, including those conducted by the National Institute of Health have shown that diversionary respites reduce the cost of mental services and make them more effective, by decreasing rehospitalization rates. Diversionary respites allow people who would otherwise voluntarily check in to the mental hospital, to recover from crisis in a safe and supportive environment that resembles a home-like setting. Mental hospital diversionary respites may very well serve as Community Mental Health Centers that were envisioned by the legislators who prepared the Community Mental Health Act of 1963.
Peer Respite Action and Evaluation tells us that: “peer respites are voluntary, short-term, overnight programs that provide community-based, non-clinical crisis support to help people find new understanding and ways to move forward. They operate 24 hours per day in a homelike environment. Peer respites are staffed and operated by people with psychiatric histories or who have experienced trauma and/or extreme states.” Mental hospital diversionary respites are staffed by Certified Peer Recovery Specialists.
According to Substance Abuse and Mental Health Services (SAMHSA): “A peer provider (e.g., certified peer specialist, peer support specialist, recovery coach) is a person who uses his or her lived experience of recovery from mental illness and/or addiction, plus skills learned in formal training, to deliver services in behavioral health settings to promote mind-body recovery and resiliency.” In Maryland, the term Certified Peer Recovery Specialist (CPRS) is used. Some states actively employ certified peers in their mental health systems for more then two decades.
As the federal government left it up to the individual states to implement peer support into the healthcare system, 39 states have the legislation that allows for medicaid-billable peer support services. Georgia pioneered Medicaid Billable Peer Support and integrated peers into state mental health services in 1999. New York state began implementing peer services as early as 1997. Peer services in New York are funded from several sources including Medicaid.
States with more progressive mental health care systems, like Georgia.
There are states where mental health services work differently and Georgia is home to one of the most progressive mental health care systems in America. Georgia employs 1700 Certified Peer Specialists and has at least 5 diversionary respites, according to 2016 Peer Respite Essential Features Survey by Laysha Ostrow PhD and Bevin Croft PhD. A Maryland survey, conducted in June of 2018, conveys that there are 271 individuals who are operating as Peer Recovery Specialists in Maryland.
There are 10.43 million residents in Georgia while the population of Maryland is 6.05 million. To serve its population accordingly, Maryland would have to employ around 1000 peers in 3 diversionary respites. Mental health community of Maryland does not feel the presence of those respites.
A number of fellow peers have expressed a concern that the few employed Certified Peers that they encountered are performing caseworker or social worker duties that have very little to do with peer support.
Tedious process of CPRS certification
“Peer support is a two-way street” as Eric Wakefield, the executive director of On Our Own of Frederick explains it.
Several members of On Our Own of Frederick, a peer-run wellness and recovery center, began working on their certification as early as 2012. One of the members, Charisa Billigmeier, passed a final exam three weeks ago. Like many of the certified peers, she is waiting for Maryland legislators to make Peer Support a Medicaid-billable service. Many other trainees who completed all requirements, are waiting to take an exam because their career prospects as CPRS are limited under the current legislation. Only a small number of recovery specialist positions are presently available in Maryland due to the lack of funding.
What kind of questions did they ask at the CPRS exam? How long was the exam?
I cannot say that because they tell us not to talk about questions before or after.
The test was 75 questions and took me forty five minutes to complete, maximum time allowed was 2 hours.
How did you learn about Peer Support Specialist certification?
I was with the Way Station and saw a flyer for the Intentional Peer Support (IPS) training back in 2011.
Does certification expire?
Yes, after ten years. There are also some continuing education credits that I have to get in order to keep my certification.
How many jobs have you worked at since you began the CPRS training process?
In 2011 I looked for a job with a job coach for almost six months.
In 2012 – I worked with On Our Own – I had to complete 500 hours of work at the recovery center as a requirement for CPRS
In 2014, I worked at Sonic and Kohl's
Then I came back to work at On Our Own in 2015
In 2016, believing that I may soon be employed as CPRS, I became a Certified Nursing Assistant (CNA) – Geriatric Nursing Assistant (GNA), because I thought that it would be useful for me to have this kind of certification if I were to work in a diversionary respite – It took me 5 months of training to complete my CNA/GNA certification.
Then I worked at Visiting Angels, an elderly home care facility.
Currently I work at a pizza place.
If you become a peer support specialist, where would you like to work?
I would definitely like to work at the diversionary respite if one existed in Frederick.
I always wanted to work with people who are in crisis, in a place like an early intervention facility, mental hospital, being on call, being part of a mobile crisis team.
I would like to help divert people from the hospital, be able to connect with them so they wouldn’t go to the hospital or at least help them to feel comfortable so they would be able to explore their options.
We need one. Five years ago, I would have used a hospital diversionary respite if there was one. To be able to provide the diversionary respite service would be like a dream to come true for me.
When you went into CPRS what have you expected?
Did you expect it to grow as an industry?
Absolutely. I believe that there would be many job openings in the future.
I feel like I am on the cutting edge on it, I feel like I am a pioneer. I think that in a few years there would be a lot more jobs and a lot more prospects, but right now it is a little bit of a waiting game before those opportunities start to come up.
A person who wants to become a CPRS in the state of Maryland has to be affiliated with a peer-run wellness and recovery center such as On Our Own. CPRS training consists of an introductory Wellness and Recovery Action Plan (WRAP) session, WRAP facilitator training, as well as Intentional Peer Support (IPS), CCAR and Emotional CPR (ECPR) trainings. A participant has to acquire 500 hours of paid or volunteer peer recovery support experience in a clinical or community setting, complete 46 hours of behavioral health specific training and 25 hours of supervision work. Every two years, additional 20 hours of continued education are required.
Most of the trainings and meetings are not readily available and a quorum must enlist in order for those events to be arranged. Because many of the trainings take place in the Baltimore area, transportation from Frederick is another challenge considering that many of the trainees do not have cars.
We need a policy that would encourage more respites to open.
In depth research suggests that there are two main problems that impede the integration of peer support into the Maryland mental health system: The first reason is that a unification of Mental Health and Substance Abuse departments into a single organization is happening rather slowly. The second is that Maryland Medicaid billing system is different from many other states. The latter reason probably keeps the legislators from just copy-and-pasting the policy from another state.
Currently, very few options are available for someone who is experiencing a mental health crisis in the state of Maryland. While traditional stay in a mental hospital may temporarily suppress acute mental health symptoms, this treatment leaves no opportunity for a two-way street communication that happen during peer support in a diversionary respite or in a peer-run wellness and recovery center.
We shall know the legislation that brings the change by its fruits. Maryland needs policy changes that would encourage peer-run mental hospital diversionary respites to open in every county in order to reduce the load on the mental hospitals and to decrease the number of inmates. Medicaid-billable CPRS services would provide many resilient members of the mental health community with a livable wage and would empower us to help those who are in earlier stages of their recovery, making behavioral health services more effective at a lower cost.
It is noteworthy that Georgia employs a Uniform Reporting System for the key mental health data in the state. Mental health metrics are conveniently outlined by category making them very easy to navigate and to compare them to national averages. A simple Internet search does not reveal the same amount of mental health data for Maryland. Creating a Uniform Reporting System in Maryland may be a good place to start solving the problem.
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