November 2005 NACBHDD Newsletter
The monthly newsletter for the National Association of County Behavioral Health and Developmental Disabilities Directors
In this Issue...
The 2005 NACBHDD Newsletter series is brought to you by:
Medicaid Update: Concerns Continue Around House and Senate Bills
Melissa Staats has been updating the membership regularly on Congressional Medicaid developments as they unfold. On November 18, the House adopted a budget reconciliation bill before the two week Thanksgiving recess which contains large cuts to Medicaid ($12 billion, www.familiesusa.org) and other programs, such as foster care and food stamps. The Senate bill contains Medicaid cuts, but not the other human services reductions. Next, a House and Senate conference committee will meet when Congress reconvenes (December 5) to iron out the differences in the proposals. To read the complete November 18 electronic communication from Melissa Staats, click here.
In addition, members were recently sent detailed information on Medicaid and the appropriations process in the
November Washington Update from Melissa Staats. To view the Update, which includes information on Medicaid and
targeted case management and case management; appropriations and developmental disabilities and education; housing,
and veterans; and D.C. advocacy and strategy,
click here.
To view a chart comparing the bills in
the House and Senate, click here.
To view a chart of the budgets for the Center for Mental Health Services, the Center for Substance Abuse Treatment,
the Center for Substance Abuse Prevention, and for the National Institutes of Health,
click here.
And, NACBHD continues to work with the Campaign for Mental Health Reform to address specific Medicaid concerns in
Congress, particularly around targeted case management and the rehabilitation option.
More on NACBHD Medicaid advocacy efforts
In addition to ongoing work with the Campaign for Mental Health Reform on Medicaid, NACBHD is also putting a high priority on other Medicaid advocacy activities at this critical time, including:
NACBHD White Paper on Medicaid Reform
NACBHD's Medicaid Committee has developed a white paper on Medicaid Reform and NACBHD's formal position on Medicaid, which has been distributed to State Association Committee chairs. The paper and NACBHD's position on Medicaid are organized around the following principles:
To view the paper, click here. The paper will be posted to the web site soon.
NACBHD Member Survey
The NACBHD member survey was distributed to members September 1 and is a requirement of NACBHD's SAMHSA grant. It is intended to provide crucial information regarding local behavioral health and developmental disability issues, and, ultimately, will allow NACBHD to move forward as it advocates in the national arena, especially related to Medicaid Reform. NACBHD's newly created State Association Directors' Committee agreed at the Annual Conference to assist with obtaining more responses from the field. The Committee understands that the survey will be a critical tool in Medicaid advocacy. Given the support of the state associations, Melissa Staats will redistribute the survey in the next week. For background information on the survey, see the September newsletter.
Medicare Update
Important dates. CMS has auto-assigned approximately six million dually eligible beneficiaries (those receiving both Medicare and Medicaid) into Medicare prescription drug plans. These new Medicare drug plans will replace Medicaid as it is currently used by the dually eligible (and others) to support their access to medications. As of November 15, 2005, beneficiaries now may select another plan from the one in which they are auto-assigned. Failure to select an alternative plan will result in their auto-enrollment into the assigned plan. The new prescription coverage begins on January 1, 2006.
An ongoing inventory of resources for implementation of the MMA
During the October Executive Board meeting, held during NACBHD's annual conference in Portland Oregon, it was determined that tracking a few specific indicators of implementation would provide insight into the new program. Since the Developmental Disability Committee has had continued discussion of Part D in their agenda throughout the year, this committee was charged with the initial creation of the indicators.
The indicators have been put together in an effort to track issues that may arise during implementation of Medicare Part D. These are not exhaustive and there may be other issues, however this document provides a platform to voice concerns and track activity at the local level. This will also allow NACBHD to present local level impacts of Medicare Part D to federal level officials.
The indicators were designed to make this feasible for county behavioral health and developmental disability directors to track. Using the indicator guide, information will be entered onto the NACBHD website. This will provide staff and other members information about Part D in various parts of the country. NACBHD staff use this information to share with federal officials.
In the near future, please look for the list of indicators. We hope to have the indicators available and ready for use at the beginning of 2006. This information will be critical to capture issues surrounding this important program.
Medicare Modernization Act Resources
NACBHD's Developmental Disability Committee has taken the lead in supporting the cataloging of resources to help the NACBHD membership as implementation of the MMA proceeds, and to aid the membership in better understanding and planning for such activities as beneficiary plan selection, eligibility determination, formularies selection, and provider training. Maeghan Gilmore is compiling an inventory of outreach and education resources, which will be available on the NACBHD website soon. Beneficiaries, guardians, providers, physicians, pharmacists and case managers are those stakeholders who will likely have a direct role in implementation and will benefit from the inventory. In addition, NACBHD is routinely updating members on outreach and education efforts in the newsletter.
Update on the Campaign for Mental Health Reform
The Campaign for Mental Health Reform continues to actively work with national advocacy partners on critical issues, such as Medicaid, and is also planning some events to focus the agenda for the coming year and to recognize efforts in the mental health arena. The current emphasis is on:
Medicaid
See the preceding article on Medicaid in this newsletter.
December policy retreat will focus priorities for 2006
On December 1, Melissa Staats and Maeghan Gilmore attended a policy retreat of the Campaign member executive directors and lead policy staff. This full-day retreat was designed to assist the Campaign with identification of two or three priorities for 2006. Medicaid Reform headed the list. Other priorities discussed (although not yet determined) included: (1) veteran's mental health, (2) housing, and (3) mental health inclusion in the Centers for Disease Control agenda.
First Annual Awards Dinner for Leadership in Mental Health
The First Annual Awards Dinner for Leadership in Mental Health, scheduled for March 29, 2006, at the Washington, DC, Grand Hyatt, will honor members of Congress and others who have made mental health a national priority. Melissa Staats is a Dinner Co-Chair, along with other directors of Campaign partner organizations.
Autism Spectrum Disorders: A Father, Doctor, and Advocate Talks With NACBHD
A unique perspective
NACBHD last reported on autism spectrum disorders and the "explosion" in diagnosis in the September newsletter. Recently, NACBHD spoke with someone who has a unique perspective on autism spectrum disorders and the issues facing families and those in the behavioral health system involved in helping them. Dr. Louis Vismara, who speaks to the issue as the father of a son with severe autism, as a doctor, and as an advocate, reports that parents of children with autism spectrum disorders face their own unique frustrations and challenges - they often have to be doctors, researchers, and advocates for their children. Dr. Vismara retired from his practice as an interventional cardiologist in 2000 and became a full-time health-related policy consultant to the President Pro Tempore of the California State Senate, and he continues to work in this position for the current President Pro Tempore, Senator Don Perata. He focuses on relating legislative action to best practices and research.
In addition to his current work with the state legislature, Dr Vismara co-founded the multidisciplinary Medical Investigation of Neurodevelopmental Disorders (M.I.N.D.) Institute, housed at the University of California, Davis, Health System, which involves researchers, clinicians, educators, parents and children in investigating neurodevelopmental disorders, from autism to learning disabilities, and serves as a national resource center for these disorders. He is also its Chairman of Community Outreach. He serves on the State Proposition 10 (First Five California) Commission and co-chairs the Advisory Committee on Diversity, and he serves on several governing boards, including the Child Abuse Prevention Council, Project Help (regional substance abuse prevention), and the Advisory Board of the University of California Davis School of Education.
Early intervention
Since his son was diagnosed over ten years ago, Dr. Vismara says great strides have been made in early identification and intervention, and he says state policies that guarantee early intervention need to be implemented. He cited evidence pointing to the validity of early intervention - research from the M.I.N.D. Institute that found that infants as young as four to six months may have different eye tracking systems and an article by Forness and Kavale (see resources) that validated that most children with emotional and behavioral disorders may not be identified (or incorrectly classified) in schools until a much later age than their families may first notice symptoms. The fact that some worrisome issues may manifest in the early years, says Dr. Vismara, is further argument for early intervention.
Dr. Vismara believes that the "explosion" in diagnosis will shed light on autism spectrum disorders and a wide array of other behavior disorders related to impulsivity and cognitive impairment, as well as help to understand both the uniqueness and commonality of disorders.
Best practices and treatment
Another problem, says Dr. Vismara, is identifying best practices and treatments for the various manifestations of autism spectrum disorders. The entire spectrum of disorders is equally important, and a coalition of state and federal leaders is needed to address the financial situation surrounding the disorders, which Dr. Vismara describes as "nibbling around the edges and fighting for the crumbs."
Another issue Dr.Vismara cites is the tremendous complexity of case management -- so many individuals and systems are involved in interacting with children with Autism Spectrum Disorders including, parents, extended families, child care providers, school nurses, and teachers. In addition, individual case managers are coping with very large caseloads. And across Autism Spectrum Disorders, there is a lack of specialists in the country with the knowledge to evaluate these children.
To really make headway, Dr. Vismara says an area is needed that leaders can coalesce around; he believes this is early intervention across the board for behavioral disorders. He says that early intervention in the preschool years is a real opportunity, and that it is important to bring together a coalition of diverse partners with the same goals who reach out to preschool teachers and those involved with children in the early years, and partner at the national and state level. Early intervention and identification will save in terms of loss of lives and potential, and result in tremendous economic savings.
Dr. Vismara says a broad-based approach that is multi-disciplinary is the best treatment. Autism Spectrum Disorders are very challenging and very complex. He recommended the following:
He also believes reaching out to childcare providers is crucial; he says 70% of children are with childcare providers. He believes these individuals should be enlisted and engaged, through training and education, to look for the warning signs of Autism Spectrum Disorders.
Resources
For information and statistics on the incidence of Autism Spectrum Disorders:
Institute of Medicine Report Improving the Quality of Health Care for Mental and Substance-Use Conditions
On November 1, the Institute of Medicine (IOM) released Improving the Quality of Health Care for Mental and Substance-Use Conditions, which follows the framework of the IOM's 2001 report Crossing the Quality Chasm: A New Health System for the 21st Century. According to SAMHSA administrator Charles Curie in a November 1 SAMHSA press release, "The report, Improving the Quality of Health Care for Mental and Substance-Use Conditions, will help inform SAMHSA's decisions as we move forward with mental health transformation, addressing the needs of people with co-occurring mental and substance use disorders, and increasing capacity for treating substance abuse." SAMHSA is the government agency charged with carrying forth the goals and recommendations of the Final Report of the President's Commission on Mental Health. And, Mary Jane England, M.D., chair of the IOM report committee stated in a press release, "Americans will not have a high-quality health system if equal attention is not given to mental issues and substance abuse problems."
NACBHD last reported on Improving the Quality of Health Care for Mental and Substance-Use Conditions in the June 2004 newsletter, and will follow up on the report in more detail in a future newsletter. Copies of the report may be purchased or read free online. For a pdf summary, see www.nap.edu/execsumm_pdf/11470.pdf. The Institute of Medicine is part of the National Academies of Science, Engineering, and Medicine; information about the IOM and its reports can be accessed at www.nas.edu.
Look for more on Improving the Quality of Health Care for Mental and Substance-Use Conditions in future issues of the newsletter.
NACo Prescription Drug Discount Card Program Continues to Grow
County residents have saved more than $2.5 million on drug purchases in less than a year through the NACo prescription drug discount card program, reports County News Online, the National Association of Counties' online newsletter. Nineteen counties and parishes have signed up for the program, which provides an average savings of 19%, and 400 more have inquired about the program for the uninsured, underinsured, seniors, and jail inmates. NACo developed the program over four years, and examined proposals and comprehensive comparisons of the disadvantages and advantages of various programs before choosing Caremark.
To access the entire article on the program, see www.countynews.org, "County residents save with NACo's prescription drug discount card." For more information on the program, contact Andrew Goldschmidt, Director, Membership Marketing, at (202) 942-4221or at agoldschmidt@naco.org. NACo members may access information on the program from the members only section of the NACo website.
Legislative Conference: Mark Your Calendars for March 1, 2, and 3
Members are urged to mark their calendars for the NACBHD Annual Legislative Conference scheduled for March 1, 2, and 3 in Washington, DC. Registration and hotel information will be available on the website and in the newsletter soon. NACBHD is hoping to host a special panel of state Medicaid directors and state mental health programs directors to talk about the future of Medicaid.
Annual Conference: "Transformation, Recovery, & Self-Determination" Information Soon Will Be Available
The NACBHD Annual Meeting took place October 20-22 in Portland, Oregon. The theme for this year's conference was "County Government and County-Sponsored Authorities Leading Transformation, Recovery, & Self-Determination." Consumers, county authorities, and staff from national advocacy organizations led discussions on issues critical for transformation to a recovery-based system. Information about the conference will be available soon on the NACBHD website.
SAMHSA Announcements
From an October 25 SAMHSA press release:
SAMHSA Releases New Treatment Improvement Protocol on Medication-Assisted Treatment for Drug Abuse
A new Treatment Improvement Protocol, TIP 43, released by SAMHSA, provides treatment providers, physicians and other medical personnel with the latest information on medication-assisted treatment for people addicted to opiates, largely prescription narcotics or heroin. The TIP emphasizes the importance of supportive services such as counseling, mental health and other medical services, and vocational rehabilitation in facilitating recovery for patients receiving mediation-assisted treatment. Specifically, the document outlines best practices in the use of methadone, buprenorphine and naltrexone, including appropriate doses of medication, medically supervised withdrawal, medication maintenance, tapering off of treatment medications, associated medical problems, treatment for multiple substance use, and other crucial aspects of treatment for those who are addicted to opiates. The TIP, Medication-Assisted Treatment for Opioid Addiction in Opioid Treatment Programs, is the result of careful consideration of all relevant clinical and health services research findings and experience by a panel of non-federal clinical researchers, clinicians, program administrators, and client advocates.
The TIP discusses treatment with three medications, methadone, buprenorphine and naltrexone. Methadone is a synthetic opiate that has been successful over many years in treating addiction to opiates. Buprenorphine can be prescribed by physicians with appropriate certification in their private offices. Naltrexone blocks the cravings for heroin or prescription narcotics.
The new Treatment Improvement Protocol discusses the use of medications in treatment programs, as well as the use of medication-assisted treatment in physicians' offices. The TIP provides modern, best practices approaches to drug treatment, and replaces earlier TIPs. The new Treatment Improvement Protocol will also influence updates to accreditation standards for opioid treatment programs that dispense methadone, currently being undertaken by SAMHSA. The new TIP complements TIP 40, Clinical Guidelines for the Use of Buprenorphine in the Treatment of Opioid Addiction.
Methadone: TIP 43 cautions against providing methadone or buprenorphine to patients who are opioid addicted and also addicted to alcohol or sedatives such as benzodiazipines. The consensus panel that created the TIP endorses careful monitoring of persons who have been using alcohol or sedatives along with methadone and withholding or reducing methadone if the patient tests positive for these other substances. But the panel warns that adequate alcohol or sedative detoxification facilities need to be readily available. Both addictions should be treated simultaneously. The panel emphasizes that patients should be free from illicit drug use and abuse of prescription medications before being allowed to take home methadone. To be eligible to receive the maximum take home dose, a 30-day supply, patients must be demonstrably free from illicit substances for at least two years of continuous treatment. Patients should be clearly warned of the dangers of adverse effects, such as extreme sedation or even death, if they abuse alcohol or tranquilizers while being stabilized or maintained on methadone or buprenorphine.
Buprenorphine: The TIP emphasizes that physicians qualified to provide buprenorphine to patients addicted to prescription narcotics or heroin need to integrate their services with counseling and other support services so patients receive comprehensive care. The panel warns that physicians must await signs of withdrawal before administering the first dose of buprenorphine because buprenorphine, in some circumstances, can precipitate withdrawal.
Naltrexone: The consensus panel recommends that patients be abstinent from narcotic pain medications such as hydrocodone or oxycodone for at least seven days and from long-acting opioids, such as methadone, for at least 10 days before beginning the medication. Otherwise, patients could suffer potentially severe withdrawal symptoms.
The TIP panel was chaired by Steven L. Batki, M.D. of the Department of Psychiatry of SUNY Upstate Medical University in Syracuse. Co-chairs included Janice F. Kauffman, R.N., Vice President of Addiction Treatment Services at the North Charles Foundation, Inc. in Cambridge, Mass.; Ira Marion, M.A., executive director of the Division of Substance Abuse, Albert Einstein College of Medicine, New York City; Mark W. Parrino, M.P.A., President of the American Association for the Treatment of Opioid Dependence, New York City; and George E. Woody, M.D., Treatment Research Institute, University of Pennsylvania, Philadelphia.
The new TIP combines and updates information provided in previous TIPS on similar topics and complements TIP 40, Clinical Guidelines for the Use of Buprenorphine in the Treatment of Opioid Addiction. It will also be used to guide updates to accreditation standards for opioid treatment programs that dispense methadone, currently being undertaken by SAMHSA. TIP 43 can be ordered through SAMHSA's National Clearinghouse for Alcohol and Drug Information, P.O. Box 2345, Rockville, MD 20847-2345, by calling 1-800-729-6686, or via the website http://ncadi.samhsa.gov.
From a November 18 SAMHSA press release:
Eight Percent of Adults Experienced Major Depression in Past Year
An estimated 17 million adults ages 18 and older (8.0 percent) reported having experienced at least one major depressive episode during the past year, SAMHSA reported today. Around two thirds of them reported receiving treatment for that depression in the past year, according to the new report, "Depression among Adults". SAMHSA extracted the data from the 2004 National Survey on Drug Use and Health, which for the first time asked adults in the survey ages 18 and older questions reflecting the criteria for major depressive episodes in the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV). That manual, by the American Psychiatric Association, specifies that a major depressive episode is two weeks or longer during which there is either depressed mood or loss of interest or pleasure and at least four other symptoms that reflect a change of functioning, such as problems with sleep, eating, energy, concentration or self-image. During the 12 months prior to the interview, 65.1 percent of adults who had experienced a major depressive episode in the past year reported seeing or talking to a medical doctor or other health professional, or taking prescription medications for depression. This is the first time that questions about depression were asked in the National Survey on Drug Use and Health.
"The good news is almost two thirds of people with depression are seeking help," SAMHSA Administrator Charles Curie said. "Clearly, we are making progress in overcoming the stigma that has prevented people from seeking help. Mental illness is not a scandal. It is an illness. It is a treatable illness. And most important, we need to send the message that with help there is hope, and recovery is the expectation."
Past month illicit drug use was nearly twice as high among adults who had experienced a major depressive episode (14.2 percent) compared with adults who had not experienced such an episode (7.3 percent), and cigarette use was much more likely. The data show 39.7 percent of adults who suffered a major depressive episode in the past year smoked cigarettes during the past month compared to 25.9 percent of adults 18 and older who did not have a major depressive episode. Women were almost twice as likely as men to report a major depressive episode in the past year (10.3 percent versus 5.6 percent) and women who experienced a major depressive episode were more likely to receive treatment for depression (70.1 percent) than their male counterparts (55.2 percent). Major depressive episodes are more prevalent among adults ages 18-49, approximately 9-10 percent, than among adults ages 65 or older (1.3 percent). SAMHSA defines illicit drugs as marijuana, cocaine, inhalants, hallucinogens, heroin or non medical use of prescription drugs.
The National Survey on Drug Use and Health surveys close to 70,000 people ages 12 and older in their homes each year. The report and the complete survey are available on the web at www.oas.samhsa.gov.
From a November 22 press release:
SAMHSA Releases First National Survey of School Mental Health Services
One-fifth of students receive some type of school-supported mental health services during the school year, according to a new national survey released by SAMHSA. Elementary, middle, and high schools all cite social, interpersonal, or family problems as the most frequent mental health problems for students. Mental health problems are broadly defined in the new publication, School Mental Health Services in the United States, 2002-2003, covering a spectrum of concerns, from relatively mild, commonly seem problems such as difficulty adjusting to a new school, to more significant behavior problems such as bullying, to serious psychiatric and developmental disorders. Mental health services were defined as those services and supports delivered to individual students who have been referred and identified as having psychosocial or mental health problems.
"Taking action to address childhood mental health problems now can save lives, especially when school personnel work with parents to identify children and intervene appropriately before they develop significant problems," said SAMHSA Administrator Charles Curie. "This new survey shows schools are responding to the mental health needs of their students and provides new information on how these services are organized, staffed, funded and coordinated."
Topics explored in the survey report include types of mental health problems encountered in school settings; types of mental health services that schools are delivering; numbers and qualifications of school staff providing mental health services; types of arrangements for delivering mental health services in schools, including collaboration with community-based providers; and major sources of funding for school MH services.
Findings include: Virtually all schools reported having at least one staff member whose responsibilities included providing mental health services to students. The most common types of school mental health providers were school counselors, followed by nurses, school psychologists, and social workers. School nurses spent approximately a third of their time providing mental health services. The report provides the first national survey of mental health services in a representative sample of the approximately 83,000 public elementary, middle, and high schools and their associated school districts in the United States.
Copies can be obtained, free of charge, from SAMHSA's National Mental Health Information Center at 1-800-789-2647, or on the web at http://store.mentalhealth.org/cmhs/ManagedCare/pubs.aspx.
Correction to NACBHD Member's Title
The October newsletter incorrectly described immediate past Board President Deborah Donaldson's job title. Deborah Donaldson, LCP, MBA, is the immediate past President of NACBHD's Board of Directors, and her job title is Director, Division of Human Services, Sedgwick County Government, Wichita, Kansas. NACBHD apologizes for this error.
