By Craig Rennebohm, Pathways to Promise Senior Advisor
For almost 30 years I have summarized our justice, public witness, advocacy work in mental health ministry with these words:
We seek a readily accessible and eﬀective community mental health system.
Our calling is not simply to care for the individuals, who have been left out or left behind without service. Our calling is not only to support individuals and fami- lies in the course of healing and recovery. We are called to help create a health care sys- tem that educates the community about the brain, our emotional life, thoughts, behavior and human relationships. We are called to help create a health care system that begins working at the first signs of concern, provides early and assertive treatment, and matches the severity and persistence of illness with unceasing tenacity. We are called to help cre- ate communities of care which value maximum wholeness for every person – physical well- ness, healthy self, supportive connections with others, and a meaningful life rooted in faith, hope and love.
Far from seeing our streets filled with homeless souls struggling with overwhelming experiences; far from filling our jails and prisons with persons needing treatment; far from waiting for the next tragedy of a completed suicide, or a confrontation with police – we need the same thoughtful, well-funded, state of the art approach to mental health that we are committed to developing for heart care, cancer, diabetes or other health issues.
For much of human history we have treated people with severe and persistent emotional, cognitive and behavioral illness by quarantining persons away from the rest of the popula- tion. 2000 years ago cemeteries were home for the most ill persons. Until the 1960’s prison like state hospitals held individuals for an average stay of 25 years.
The Community Mental Health Act of 1963 envisioned a nationwide system of mental health care, with a community mental health center for every 250,000 Americans. Each center was to have an outreach, education, prevention team, an out-patient and long term care program, an on-site in-patient unit and a 24/7 crisis and emergency response service. No more than 25% of the centers envisioned were ever built; few had the full range of in- tended care.
The only such facility in King County where I live was closed and demolished more than five years ago. In a county of 2 million people, the community mental health system would now have at least 8 full service mental health centers, each serving a clearly defined area of Seattle and the surrounding communities. None exist. What we have is a patch work of a few outreach workers, an inadequate number of publically funded and private insurance based out-patient services, an insuﬃcient stock of aﬀordable, supported housing, a handful of inpatient psychiatric units, one crisis center and one emergency room with a dedicated mental health section, an expensive involuntary treatment program, an underfunded jail mental health service, and a small specialized court, diversion and parole/probation program. There is also a local VA hospital and out-patient program with a priority for serving veterans with service related mental health issues.
Over almost fifty years the various mental health programs, including substance use treatment have undergone peri- odic changes, reorganization and attempts at service and system integration. The implementation of the Aﬀordable Care Act is a new opportunity to create a readily accessible and eﬀective community mental health system.
The first step in the new system is enrolling every individual in an insurance plan and establishing each person, espe- cially youth and young adults in a “medical home,” with a primary care provider. The front line clinic and oﬃce staﬀ – receptionists, nurses, physician’s assistants, family practice doctors, internists – will increasingly be a key entry point into mental health care and treatment. Especially for individuals with a mental health concern, a local, neighborhood or community medical home provides ready non-stigmatized access both to an immediate assessment and the beginning of treatment.
Mental health issues can be cared for at the front line, medical home level, as part of a person’s primary, well-being care. An individual’s medical home is part of a larger system of specialty and hospital care. Specialty mental health services and in-patient care do need to be readily available within the larger Accountable Care Organization. Just as a primary care doctor refers a person for follow up with a cardiac specialist and hospitalization as needed, individuals facing a mental health crisis or severe and persistent condition are referred for the appropriate follow up care.
To complement primary, specialty and hospital levels of service, we will need to provide a coordinated network of supported housing, education, employment and spiritual care. A collaboration of public housing and community service departments, non-profit organizations, business and faith communities have a role to play in providing the community support framework necessary to full recovery and maximum well-being.
Finally let me suggest that there is a particular role for public health entities in a readily accessible and eﬀective com- munity mental health system. Public health departments take a broad and systematic view of health care to insure that all populations and especially the most diﬃcult to serve are appropriately cared for. Because the lack of care for persons with mental health concerns has a significant public impact and cost, I suggest that public health departments be responsible for assisting with outreach, crisis and commitment responsibilities of the mental health care system. The aim is not to dump the most diﬃcult to serve persons out of the health care system, but to build a collaboration that insures appropriate care for all.
I share this overview as a contribution to dialogue, as health care in our country enters a new era, and welcome your thoughts and comments.