Board Folder Contents November 2018
Page Description Dated Received
1 Table of Contents
2 Project SEARCH 10-18-18
3 How to be a Successful Advocate (CMHA) 10-23-18
31 A Vision for a World Class Public Mental Health System (CMHA) 10-24-18
37 Jackson County Board of County Commissioners Human Services 09-27-18 Committee Report for November 2018
43 Recipient Rights Advisory Council (RRAC) Meeting Minutes 10-25-18
46 LifeWays Board of Directors Meeting Attendance Report 10-26-18
50 LifeWays Board Executive Committee Meeting Minutes 11-01-18
52 LifeWays Internal Audit of Board-Approved Expenditures for Fiscal Year 11-01-18 2018
54 2018 County Health Rankings 11-05-18
75 Anatomy of: A Child; A Family; A Person; and A Community (Jackson 11-05-18 Collaboration Network)
79 Michigan Health Policy for the Incoming 2019 Gubernatorial Administration 11-07-18
95 2018 Election Results 11-07-18
108 Inpatient Data from the Certificate of Need Committee 11-15-18
116 Michigan’s Public Mental Health System Information (CMHA) 11-15-18
118 CMHA Connections Newsletter Fall 2018 11-16-18
11/2018 Board Folder Page 1 of 137
11/2018 Board Folder Page 2 of 137 How to be a successful ADVOCATE
11/2018 Board Folder Page 3 of 137 What is Advocacy?
What is Advocacy?
Advocacy = Education
Telling a legislator how a policy affects constituents. Meeting with a government official to explain how a particular problem/issue is affecting a particular group or organization (the environment, mental health, schools, etc.) Using social media to get the word out about a cause/issue.
Examples of advocacy – promote early childhood education, eliminate stigma related to mental health and addictions treatment. 2
11/2018 Board Folder Page 4 of 137 Advocacy Works!
During the final 3 weeks of the FY19 budget negotiations we had nearly 5000 emails go to legislators regarding Section 298 and Autism services. Don’t depend on someone else speaking up for you.
11/2018 Board Folder Page 5 of 137 Advocacy Works!
Compare the difference—over the past 8 years, campaign contributions given to current lawmakers:
•Michigan Assoc of Health Plans & for-profit health plan executives have given OVER $1 million dollars.
•CMH PAC has given around $40,000.
11/2018 Board Folder Page 6 of 137 Advocacy Works!
Still, he said, the priority was given to local constituents. “If you came from back home and sat in my lobby, I talked to you without exception, regardless of the financial contributions,” Mulvaney said in his address to the American Bankers Association.
11/2018 Board Folder Page 7 of 137 As former Senate Majority Leader Everett Dirksen (R-IL) said…
“When I feel the heat, I see the light.”
11/2018 Board Folder Page 8 of 137 Interacting with legislative offices
Interacting with staff
Put something in writing
Most offices prefer e-mail vs. snail mail
Easier to reply and track (send to state departments)
Most of the written correspondences to offices is email (95/5)
Know what outcome you are looking for
Having facts straight
Legislative process is complicated and can be confusing
Keep it simple
Be polite
Staff is usually the gatekeeper for the member and can be a powerful advocate on your behalf.
11/2018 Board Folder Page 9 of 137 Interacting with legislative offices
Interacting with legislators
Stay on Message
Keep it simple and to the point (5th grade level)
Don’t assume they know what you are talking about
4000 – 5000 bills introduced
Committee process
Respect the Legislator’s time
Give reasons for your position
Explain how an issue would affect you, your family, your business, profession or local community they represent.
Keep the Tone Positive and Constructive
Know your audience (Republican / Democrat)
Leave Fact Sheets
Share your knowledge
If you have specialized knowledge on an issue- share it! A concrete argument can be used by your legislator in determining the final outcome of a bill.
Thank you 11/2018 Board Folder Page 10 of 137 Interacting with legislative offices
Understanding a Legislators Schedule
Schedules Legislators are in Lansing on Tuesdays, Wednesdays and Thursdays. Mondays and Fridays are in-district days Many legislators have in-district office/coffee hours (each week or month) In-district meetings are the best time to interact with your legislator(s) the days activities are usually not as busy (in Lansing they usually have meeting after meeting – it’s a more distracting environment) Legislator are usually more casual
Legislative Session House session: Normally Tuesdays and Wednesdays at 1:30 p.m. and Thursdays at 12:00 noon. Senate sessions: 10:00 a.m. on Tuesdays, Wednesdays and Thursdays. Legislators also have committee meetings at various times of the day.
11/2018 Board Folder Page 11 of 137 Alternative Ways to Interact with legislative offices
Most legislators use social media as a way to communicate with the public Facebook & Twitter Many legislators post their votes and up coming community events on Facebook Easy way to track what they are doing in Lansing
Other Newsletters If your agency does a monthly/quarterly newsletter ask your legislator to write a guest column. Be willing to put legislative newsletters or publications in your lobby. Events Make sure you invite your legislator(s) to your community events
Agency Open House or annual meeting
Walk-a-Mile In My Shoes Rally
Quarterly breakfast meetings
11/2018 Board Folder Page 12 of 137 Impact of Term Limits
Term limits cause turnover in Lansing every few years, requiring constituents like you to keep educating your lawmakers on issues impacting the mental health community. Legislators are in Lansing to represent their constituents. If you don’t communicate your message, they can’t convey it to the entire legislative body.
Put a face on the issue
Keep it local – its best to incorporate local examples and local impact
Don’t assume they know the importance of the issue
Medicaid expansion – many legislators said they only heard from constituents opposed to expansion.
If an issue is important to you or your agency let them know.
Communication is a two way street.
Remember these are regular people, they just have a fancy title. 11/2018 Board Folder Page 13 of 137 Useful Information to stay informed
Michigan Votes – plain language descriptions of every bill, amendment, and vote that takes place in the Michigan legislature.
www.michiganvotes.org
Michigan Legislature – copies of the bills, find the status, summaries, etc.
www.legislature.mi.gov
Michigan House of Representatives & Michigan Senate – find legislative contact information, committee and session calendars, and you can watch committees and session live.
www.house.michigan.gov
www.senate.michigan.gov
11/2018 Board Folder Page 14 of 137 Crystal Ball: 2018 Elections
11/2018 Board Folder Page 15 of 137 2018 Election – What’s at stake
11/2018 Board Folder Page 16 of 137 2018 Election – Blue Wave?
All signs point to the election in 2018 being a VERY good one for Democrats – a Blue Wave…
Since President Trump has taken office 35 state legislative seats (special elections) have flipped from Republicans to Democrats, many of these have been long time R seats.
Republicans were 0-5 in high profile statewide elections last year
Alabama US Senate Seat, New Jersey Governor, Virginia Governor, LG, & AG
Republican lost the Pennsylvania – 18 Congressional District in March, a seat Trump won by over 20 points…
Last week Speaker of the House Paul Ryan announced he is not running for re-election.
History is on the Democrats side in 2018
Traditionally president's party generally loses ground in midterm elections. In midterms since 1862, the president's party has averaged losses of about 32 seats in the House and more than 2 seats in the Senate
1998, President Bill Clinton was +5 (approval rating of 66%)
2002, George W Bush was +6 (approval rating of 63%)
11/2018 Board Folder Page 17 of 137 President Trump Approval Rating
11/2018 Board Folder Page 18 of 137 Forecasting the race for the US House
11/2018 Board Folder Page 19 of 137 Forecasting the race for the US Senate
11/2018 Board Folder Page 20 of 137 Forecasting the race for the US Senate
11/2018 Board Folder Page 21 of 137 2018 Election – What’s at stake in Michigan
Who’s on the ballot this year due to term limits
Governor (Lt. Governor), Secretary of State , Attorney General – all will be new
All state legislative offices (110 House & 38 Senate seats)
28 of 38 State Senate seats will be open due to term limits
At least 40 House seats will be open
Republicans current hold a 63-47 majority in the House and a 27-11 majority in the Senate.
All legislative leadership positions will be open:
Senate Majority and minority leaders
Senate Floor Leader
Speaker of the House
House Floor Leader
Full Appropriations Chairs in House and Senate
Who else is on the ballot?
US Senator Debbie Stabenow is up for re-election
State Supreme Court Justices
University Board of Regents
As many as 3-4 ballot initiatives – legalize recreational use of marijuana, redistricting changes, prevailing wage changes (not on ballot) 11/2018 Board Folder Page 22 of 137 2018 Ballot Initiatives
11/2018 Board Folder Page 23 of 137 2018 Ballot Initiatives Details
What changes would the ballot initiative make to laws governing marijuana in Michigan?
Proposal 1 was designed to allow adults aged 21 years or older to possess and use marijuana for recreational purposes. Individuals would be permitted to grow up to 12 marijuana plants in their residences. The measure would create an excise sales tax of 10 percent, which would be levied on marijuana sales at retailers and microbusinesses. Revenue from the tax would be allocated to local governments, K-12 education, and road and bridge maintenance. Proposal 1 would also legalize the cultivation, processing, distribution, and sale of industrial hemp. Municipalities would be allowed to ban or limit marijuana establishments within their boundaries.[1]
What's the current congressional redistricting system in Michigan?
Redistricting is the process by which new congressional and state legislative district boundaries are drawn. As of 2018, the Michigan State Legislature is responsible for drawing congressional and state legislative district boundaries. These boundaries are subject to the governor's veto power. Adopting congressional or state legislative redistricting plans requires a simple majority vote in both chambers of the state legislature. The last time the state legislature adopted congressional maps was in 2011, which followed the 2010 U.S. Census. Republicans controlled the state Senate, state House, and governor’s office, thus holding a trifecta in state government.
What would Proposal 3 change about the state's voting policies?
Proposal 3 would add several voting policies to the Michigan Constitution. Some of these voting policies exist in state statute, but not the state constitution, while most others would be altered policies or new policies. The new policies that would be added to the state constitution include straight-ticket voting; automatic voter registration; same-day voter registration; and no-excuse absentee voting during the 40 days before an election. Proposal 3 would allow eligible persons to register to vote by mail until 15 days before an election, whereas current law allows them to register to vote by mail until 30 days before an election. The ballot initiative would also constitutionalize existing law providing that military members and overseas voters receive an absentee ballot at least 45 days before the election. Proposal 3 would add language to the constitution to provide for the use of secret ballots and election results auditing. The following table compares existing voting policies to those found in Proposal 3:[1]
11/2018 Board Folder Page 24 of 137 Next Steps / Follow up
Lame duck session – WE NEED YOUR HELP!! Educate those running for office and those who win in November. Invite them to learn more about your programs and issues. Remember to be a resource.
11/2018 Board Folder Page 25 of 137 Lame Duck Session
What is Lame Duck session? Whenever one Legislature meets after its successor is elected, but before the successor's term begins. 2018 Lame Duck session will run from November 27 – December 20 (4 weeks / 12 session days)
11/2018 Board Folder Page 26 of 137 Lame Duck Session
What we are going to FIGHT FOR:
Direct Care Wage – Minimum Wage Funding
.50 cent wage increase for direct care workers is in the FY19 budget recommendation (.50 cent increase cost $64 million gross).
The Michigan Legislature passed the minimum wage increase on September 5, 2018 (to preempt the proposed ballot initiative). As a result, the state's minimum wage will increase to $10.00 per hour on January 1, 2019 and increase to $12/hour by 2022.
Legislative leaders have indicated a desire to come back after the election and amend this, but what does that mean?
We are asking the legislature when they come back to recognize there is a Medicaid cost to that wage increase.
.75 cent increase = $33 million GF increase/$100 million gross increase.
Coalition goal is $2 above minimum wage as a base salary for all direct care workers.
11/2018 Board Folder Page 27 of 137 Lame Duck Session
What we are going to FIGHT AGAINST:
Rumors are swirling that MAHP will attempt to make changes to the Mental Health code or Social Welfare Act that could be damaging to our members and the people they serve during the lame duck session.
Removing the connection between CMHs to counties
Limiting/reducing the recipient rights process
Removing potential future barriers that could prohibit a total carve-in.
Language like 298 section 2(e).
Lame duck session – WE NEED YOUR HELP!!
Educate those running for office and those who win in November.
Invite them to learn more about your programs and issues.
Remember to be a resource. 11/2018 Board Folder Page 28 of 137 Key Pillars for public mental health system
11/2018 Board Folder Page 29 of 137 Contact Information
Community Mental Health Association of Michigan Alan Bolter Associate Director [email protected] (517) 374-6848
11/2018 Board Folder Page 30 of 137 ITEM X
Draft: for discussion only Community Mental Health Association of Michigan A vision for a world class public mental health system in Michigan
Background Recently, the Executive Board of the Community Mental Health Association of Michigan charged the Association staff with the formation of a workgroup to develop a document that captures, in one place, the Association’s vision for the state’s public mental health system. This document will: be used in discussions and advocacy with the incoming Governor, incoming MDHHS leadership, and Legislative leadership.
The need for such a document is based on three factors:
1. The rare opportunity afforded our system in developing a common vision and agenda with the incoming Governor, MDHHS leadership, and the Michigan State Legislature
2. The need for bold and politically viable proposals that strengthen Michigan’s public mental health system - taking the momentum and spotlight away from other proposals that are harmful to the public system and those served by that system
3. The gravity of a number of forces in our system’s environment: political and fiscal pressures, experienced by county-based mental health systems and the wide range of healthcare transformation efforts accelerating across the country and within Michigan
The workgroup met twice to develop the proposed vision document. The members of the CMH Association’s Vision Development Workgroup include:
Joe Stone, AuSable Valley CMH (Chair, CMH Association of Michigan) Brent Wirth, Easter Seals Connie Conklin, Livingston CMH Carlynn Nichol, Children’s Center Tina Hicks, Gratiot Integrated Health Network Clint Galloway, The Right Door for Hope, Recovery, and Wellness Sr. Augusta Stratz, North County CMH Carl Rice, Lifeways CMH (Secretary, CMH Association of Michigan) Eric Kurtz, Northern Michigan Regional Entity Karl Kovacs, Northern Lakes Pat Rozich, Copper Country CMH and Northcare Network Gerald McCole, Northpointe Behavioral Health Jane Terwilliger, CMH Partnership of Southeast Michigan John Obermesik, CMH for Central Michigan Sam Price, Ten16 Lynne Doyle, CMH of Ottawa County Ang Pinheiro, CMH for Central Michigan 1 | Page
11/2018 Board Folder Page 31 of 137 ITEM X
Factors that drive the structure of this paper
This vision setting document will be purposefully focused and lean, avoiding the murkiness that can accompany wordier documents. The time for more thorough white papers will come, in the coming months and over the four to eight-year term of the incoming Governor.
Components of the vision
Self-determination, person centered planning, full community inclusion, recovery orientation, cultural competence:
Ensure that funding, policies, and practices foster: the self-determination of the persons served, healthy development of the persons served, the use of person-centered planning with full integrity and fidelity, full community inclusion for those with mental health needs, recovery-oriented systems of care, and cultural and linguistic competence.
Governance:
Ensure that the governance of the system remains local and public; imbedded and linked to the counties served by the system.
Ensure that the persons served are mandated members of the local governance bodies (not advisory).
Foster the safety net role of the public mental health system (a focus on population-health, social determinants, and community collaboration):
The safety net role is made up of and fostered by the following components;
The community mental health system’s role as the population-based and place-based resource and public safety net committed to the common good is in considerable contrast with the enrollee-based coverage used in insurance models
Support the work of the system in coordinating the network of services necessary to address the range of social determinants of health: housing, employment, food access, transportation, income supports, primary care, education, family support, child care
Ensure the financing and remove barriers to innovative service delivery, financing, and governance partnerships between the public mental health system and a number of community partners: judiciary and criminal justice system, schools, homeless and housing providers, primary care providers, long term care providers.
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11/2018 Board Folder Page 32 of 137 ITEM X
Foster the full range of functions carried out by the public mental health system, including as:
o Providers, purchasers, and managers of a comprehensive array of services and supports across a network of providers in fulfillment of statutory role to serve the individuals, families, and communities regardless of the ability to pay
o Community conveners and collaborators – initiating and participating, often in key roles, collaborative efforts designed to address the needs of individuals and communities
o Advocates for vulnerable populations and a whole-person, social determinant orientation
o Sources of guidance and expertise, drawn upon by the public, to address a range of health and human services needs
Financing:
Increase funding to ensure that it is sufficient to meet the needs of: o Michigan’s Medicaid beneficiaries (The actuarial analysis used to determine Medicaid financing of the system must be improved to accurately reflect real need and real costs). o Michiganders without Medicaid or any insurance coverage who rely upon the public system as the safety net provider to support their community inclusion and recovery (GF – increase GF funding to meet needs of non-Medicaid Michiganders). o The crisis and support needs of residents of all Michigan communities – for services for which the public expects to be able to rely upon the public mental health system, as the safety net provider, regardless of their insurance coverage or income.
Equitable distribution of funding, reflecting population needs, and population dispersion – achieved through the addition of funding not through redistribution; no community is over-funded for mental health services.
Financing of risk reserves – the Medicaid rates must include sufficient contribution to the risk reserves of the PIHPs. Federal regulations required that the payments to risk-bearing entities, such as PIHPs, in a capitated/risk-based financing model, include a component for contribution to risk reserves.
Given the ability of PIHPs to fund risk reserves via the earmarked segment of the PIHP capitation payment, the CMHs should be allowed to retain savings for investment in the system.
Foster local millages and other efforts to build local funding base to support CMH and provider systems, while recognizing that local millages cannot/do not relieve state’s obligation to fund MH care via GF and Medicaid – to ensure uniformity of funding (blanket coverage for the state) regardless of ability of counties to fund millages and other local funding.
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11/2018 Board Folder Page 33 of 137 ITEM X
Breadth of populations served and services provided:
Retain and expand the populations served by the system (to meet the expectations of the community). These expectations include all of the populations currently served by the public system: adults with serious mental illness; children and adolescents with serious emotional disturbance; children, adolescents, and adults with intellectual/developmental disabilities; children, adolescents, and adults with substance use disorders.
Unite the state’s Medicaid mental health benefit under the system with the proven expertise to manage and provide such comprehensive services – the public CMH and PIHP system – by bringing the mild- moderate Medicaid mental health benefit, for adults and children, within the benefit package managed by the CMH and PIHP system.
Integrate substance use disorder treatment and prevention dollars into the financing, contracting, and network management system used for services to persons with mental illness and intellectual/developmental disability services.
Improve whole-person integrated care by fostering efforts to bring the management of the physical health care of the persons served by the public mental health system under the management of service delivery system designed to serve that population, the CMH/PIHP system.
Promote and fund prevention and early intervention services for all populations – aimed at preventing the development of harmful, life altering, and costly conditions
Primary and mental healthcare integration:
Foster real healthcare integration, not the consolidation of funding and profits, via clinical integration (where the client/patient receives services and supports) by supporting the current and emerging models in local communities, often led by the CMH/PIHP/provider system.
Access to care:
In tandem with the financing and population health recommendations, fund and support same day access, early intervention (including services to persons experiencing their first episode of psychosis), simplified referral from other providers, aggressive outreach, and other proven access improving practices.
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11/2018 Board Folder Page 34 of 137 ITEM X
Evidence-based and promising practices:
Fund and support the use of evidence-based and promising mental health practices, from client/patient/clinician specific practices to organizational and community-wide practices.
Risk management:
Move to a full risk contract between MDHHS and PIHPs to allow for a range of standard risk management practices by the PIHPs and their CMH sponsors.
Eliminate barriers to CMHs taking on full-risk, shared incentive and shared savings structures across a range of public and private payers.
Foster value-based payments via regional approaches to payment and outcomes (to reflect the CMH- sponsored health plan structure of our system).
Allow CMHs to retain earnings and assets from their Medicaid line of business, as is allowed for all other Medicaid providers, all of which will be retained in the public system for use in meeting unmet community need and invest in system improvements.
Workforce retention and recruitment:
Address the mental health workforce shortage issue by: implementing the recommendations of the Section 1009 workgroup for direct care workers (e.g., improve compensation, foster a career ladder, support continuing education), broadening loan repayment programs for a range of clinical disciplines experiencing shortages (psychiatrists, nurses, social workers, psychologists, occupational therapists), and other recruitment and retention approaches.
Support the public system’s longstanding role as the largest employer and trainer of mental health practitioners with experience in the latest clinical technologies.
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11/2018 Board Folder Page 35 of 137 ITEM X
Administrative simplification:
Reduce the administrative, regulatory, contractual, and other requirements by ensuring that these requirements tie to the core vision and values of the system and are uniform statewide and across payer types.
Health Information Technology, data analytics, outcome measurement:
Given the lack of access to the federal funds provided to the physical health system (via the Health Information Technology for Economic and Clinical Health (HITECH) Act), provide funding to the public mental health system to continue to build its health information technology infrastructure, fostering inter-organizational health care integration
Foster the use of a small and focused number of nationally recognized outcome measures, applied statewide that are tied to client/patient outcomes
Foster continued and expanded access to timely client-specific clinical and population health data and the data analytic tools to make use of these data.
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11/2018 Board Folder Page 36 of 137
Memorandum
TO: Jackson Board of County Commissioners
FROM: Maribeth Leonard, LifeWays CEO
SUBJECT: LifeWays – Monthly Report for November 2018 Human Services Committee
DATE: October 24, 2018
COPY: LifeWays Board of Directors
This monthly progress report provides updates on various strategies that were developed by Executive Leadership. The “State update” section is to keep our sponsoring counties informed regarding developments within the Mental Health industry.
First, thank you so much for your support of the capital improvements bond. I am grateful for the support of the Human Services Committee and the Jackson Board of County Commissioners.
LifeWays
Last month, I included the new Strategic Plan in my report, and noted that updates will be brought forward in each month’s report to the Human Services Committee. Below is the first report on the progress of our new Strategic Plan. Strategic Plan 2019-2021 Monthly Update This month begins our new three-year strategic plan. The following is a brief update of activity over this past month relative to the current strategic plan. Better Health • Develop architectural plan for building modifications to provide primary care services on site. (Working with The Center for Family Health, Jackson County Building Authority and Architect.) • Developed post-hospital review team to work address cases around inpatient recidivism. • Millage proposal for both Hillsdale and Jackson County have been reviewed and approved by both Jackson and Hillsdale County Commissions.
LifeWays Report to Board of County Commissioners 11/2018 Board Folder Page 37 of 137 Better Care • New technology was launched for reminder calls and text messaging to improve practices and reduce no shows. • LifeWays issued a Request for Proposals for Independent Facilitation and a new provider has been selected. • LifeWays issued a Request for Proposals for Specialized Residential to seek providers to provide residential services for those with challenging behaviors and a new provider has been selected. Better Experience • Strategies for recruitment and retention resulted in a fair market analysis and implementation of changes to salary structure. • Clinical trainings and focused orientation for onboarding is occurring. • Lifeways has established a relationship with two Michigan colleges and as a result have two clinical interns that began this fall. Lower Cost • Activity in this area is just now beginning.
Crisis R&R Update Please celebrate with me the success of this program to date. We have been providing this diversion service to our community as part of the State Innovation Model. The results of the first three months indicate that we have had 128 individuals utilize this service. This is fantastic news!!
JobSTAR Program LifeWays is a participating organization with JobSTAR. JobSTAR is a resource for employers to help their employees overcome obstacles that may impede their ability to work. A Success Coach confidentially works with employees to connect them to services and supports to help them overcome challenges that effects their job attendance and performance. The program began early this summer. There have been 16 individual employees at LifeWays who have contacted the Success Coach with issues that could interfere with work. Some issues were not resolvable because good resources and funding weren’t available. The following is the breakdown of the needs identified that the Success Coach helped them address: Transportation – 4 Auto Repairs – 3 Government Navigation (referring client to right agency) – 5 Housing – 5 Legal assistance – 1 Child day care – 1
LifeWays Report to Board of County Commissioners 11/2018 Board Folder Page 38 of 137 Health Insurance – 3 Financial coaching – 1 Personal Coaching – 1 Soft skills training – 1
The intent of this program is that it will make a stronger workforce, create financially stable families, have higher productivity and impact our economy.
Mid-State Health Network (MSHN)
MSHN received Rate Calculations from Milliman MSHN revised the FY 2019 Capitation Rates based on the rates received from Milliman. 11 of the Community Mental Health Services Programs (CMHSPs) are expected to return Medicaid money with an estimated projection of $21 Million. 10 of the CMHSPs are expected to be in a deficit with Healthy Michigan for a total of $1 million. Lastly, the Autism, except for one CMHSP being under with projection for a total of $8 million, with an estimated projection of $29 total savings.
MSHN Population Health & Integrated Health Plan Meetings are occurring monthly with eight health plans with care coordination plans in partnership with the CMHSPs. MSHN is working with data analytics around risk stratifications and the 19 metrics for monitoring.
• Reduction in number of visits to ER • Reduction in hospital admissions for psychiatric and physical health • Number of chronic conditions • Percent of consumers who have a primary care physician in past 12 months.
They looked at the 12 months prior to care coordination and past 12 months since enrolled in care coordination. It is a specific population based on risk stratification.
MSHN has developed protocols for diabetes screening for individuals with schizophrenia or bipolar disorder who are using antipsychotics. In addition, the other protocol is around the Chronic Obstructive Pulmonary Disease (COPD) diagnosis.
Value-Based Purchasing SUD Contracts Pilot MSHN worked with TBD Solutions (consultants) to work through the development of a value-based contract. They would initial pay for participation, pay for reporting and pay for performance and pay for success. They worked with Meridian and McLaren Health Plans. They focused on utilization data for the planning to move toward value-based contracting. They looked at chronic conditions and Emergency Room (ER) visits for the past 12 months.
LifeWays Report to Board of County Commissioners 11/2018 Board Folder Page 39 of 137 Currently they are working on incentive development and identifying areas like Primary Care Physician (PCP) and referrals and utilize CC360 data to stay informed of ER use to target coordination of care to reduce utilization and recidivism. The target population was looking at the chronic conditions who have not seen a PCP within past 12 months.
FY 19 Shared Metrics with Medicaid Health Plans (MHP):
• Implementation of Joint Care Management Process.
• Follow up after hospitalization for mental illness within 30 days.
• Plan all cause readmission. • Follow up after emergency department visits for alcohol and other drug dependence.
Community Mental Health Services Program and Regional Comparison Our performance is low as a region. Is it possible that the “no wrong door” approach is having an impact? Strategy is to provide education to the hospitals relative to understand the process for referrals and follow up. Current concerns regarding how the data is reporting and calculated, so this initial year will be sent on the process.
Michigan Department of Health and Human Services (MDHHS)
Section 298 Update
The Section 298 Initiative is a statewide effort to improve the coordination of physical health services and behavioral health services in Michigan.
In the current behavioral health system, the Michigan Department of Health and Human Services (MDHHS) contracts with Michigan’s 10 Prepaid Inpatient Health Plans (PIHP) to manage Medicaid- funded specialty behavioral health services. The PIHPs contract with 46 local Community Mental Health Service Programs (CMHSP) to deliver specialty behavioral health services. MDHHS also separately contracts with 11 Medicaid Health Plans (MHP) to manage Medicaid-funded physical health and mild-to- moderate mental health services. The MHPs contract with an array of different hospitals, primary care providers, and specialists to deliver these services.
In 2017, the Michigan legislature directed MDHHS to implement up to three pilots to test the integration of Medicaid-funded physical health and behavioral health services. As part of the pilots, MDHHS will contract with the Medicaid Health Plans (MHP) within the pilot regions for the management of Medicaid-funded physical health and behavioral health services. The MHPs will contract with the Community Mental Health Service Programs (CMHSP) within the pilot sites for the delivery of specialty behavioral health services and supports. The three pilot sites are: HealthWest and West Michigan Community Mental Health; Genesee Health System; and Saginaw County Community Mental Health Authority.
LifeWays Report to Board of County Commissioners 11/2018 Board Folder Page 40 of 137 The MHPs and CMHSPs within the pilot sites must assure continued access to the required array of services and supports under Medicaid policy and contracts. The MHPs and CMHSPs must also abide by all current public policies within the public behavioral health system, which includes person-centered planning, self-determination, family-driven and youth-guided care, recovery orientation, and access to home and community-based services. Finally, the legislation requires that any savings that are achieved as part of the pilots must be reinvested in services and supports for individuals having or at risk of having a mental illness, an intellectual or developmental disability, or a substance use disorder.
MDHHS is working with the MHPs and CMHSPs to implement the pilots by October 1, 2019. The pilots will operate for at least two years.
MDHHS has also contracted with the University of Michigan to evaluate the performance of the pilot sites. The pilot sites will be assessed on a set of metrics that will measure health, wellness, and quality of life outcomes for individuals who receive Medicaid services. The performance of the pilot sites will also be evaluated against a set of comparison sites. The results of the evaluation process will be presented to the legislature for consideration on whether the pilots should be expanded statewide or discontinued.
Approximately 25% of the Medicaid population is not enrolled in an MHP for management of their physical health services. However, the PIHPs manage the specialty behavioral health benefits for this sub-population. Examples of individuals who may not be enrolled in an MHP (also known as the “unenrolled population”) include but are not limited to: • Individuals who recently became eligible for Medicaid but are not yet enrolled in an MHP; • Individuals who are dually eligible for Medicare and Medicaid; • Individuals who have third-party insurance; • Individuals who are Tribal citizens; • Individuals who are receiving services in a nursing facility or state psychiatric hospital; and • Individuals who are eligible for coverage based upon a deductible (also known as spenddown).
MDHHS is not able to enroll these individuals in the MHPs for the purposes of the pilots due to federal regulations. MDHHS has been evaluating options to manage the specialty behavioral health benefits for the unenrolled population during the pilots. MDHHS has conducted outreach to stakeholder groups to solicit input on the options for managing the specialty benefit for the unenrolled population.
Based on this process, MDHHS will be issuing a Request for Proposals (RFP) to select a single existing PIHP to manage specialty behavioral health benefits for the unenrolled population across the three pilot sites. The selected PIHP will also contract with the CMHSPs within the pilot sites for the delivery of specialty behavioral health services and supports.
The selected PIHP must assure continued access to the required array of services and supports under Medicaid policy and contracts. The selected PIHP must also abide by all current public policies within the public behavioral health system, which includes person-centered planning, self-determination, family- driven and youth-guided care, recovery orientation, and access to home and community-based services.
LifeWays Report to Board of County Commissioners 11/2018 Board Folder Page 41 of 137 Finally, MDHHS will work with the selected PIHP and pilot CMHSPs to ensure continuity of care for individuals who live in the pilot region and are part of the unenrolled population.
MDHHS will issue an RFP to select a single existing PIHP no later than January 2019. MDHHS will work with the selected PIHP and the pilots CMHSP to implement the transition process by October 1, 2019. Individuals in the unenrolled population who are outside of the pilot region will continue to receive specialty behavioral health services through their current PIHPs.
LifeWays Report to Board of County Commissioners 11/2018 Board Folder Page 42 of 137
Minutes for the Recipient Rights Advisory Council Meeting October 25, 2018
Members Present: Ed Woods, Melissa Callison, Robin Cyphers, Barb Freysinger, Marcia Smith, Kristen Wright
Members Absent: Barb Freysinger, Cliff Herl, Maribeth Leonard (Chief Executive Officer), Gail W. Mahoney, Al Ringenberg
Staff Present: Clevester Moten (Recipient Rights Officer), Kaitlin Burnham, Kristi Benn, Taelar Horsch
Others Present:
The meeting was called to order at 9:40 a.m.
Approval of Recipient Rights Advisory Council (RRAC) Minutes of June 28, 2018
The minutes have been approved for June 28th, 2018.
Office of Recipient Rights (ORR) News & Updates
Caseload Review – Clevester Moten, Recipient Rights Officer, advised the committee that ORR currently has forty-one (41) investigations. ORR is currently investigating the DART program with Hope Network. This particular consumer is a child that is now inpatient because the staff have failed to follow the Treatment Plan (TP) accordingly. Mrs. Freysinger asked what the DART program is. Mr. Moten advised that this is a children’s autism program within Hope Network. He also advised that we are working on an investigation at Flatrock Manor, which is an out-of-county provider. These investigations have been opened for Crisis Prevention Intervention (CPI) investigations because the staff are not following the Treatment Plans (TP).
Mr. Woods asked how the Class Action cases have been going. Mr. Moten advised that this impacted about 53 consumers total. Mr. Moten also advised that this was an administrative issue and that these issues have been progressing. He said that the caseloads have lessened. He also advised that we just recently substantiated against Hope Network for not meeting the face-to-face contacts. We are currently working with LifeWays Contracts department and will update the Committee at the next meeting.
RRAC Minutes 10/25/18 Page 1 of 3 11/2018 Board Folder Page 43 of 137 Incident Report (IR) follow up- Mr. Moten advised that the last time the Committee met it was questioned why the guardians are not able to obtain the Incident Reports (IR). Kaitlin read the email verbatim that was sent to the state asking why the guardians are not able to receive the actual physical copy of the IRs. Kaitlin advised the committee that Cynthia Shadeck from Michigan Department of Health and Human Services (MDHHS) Office of Recipient Rights (ORR) stated that the IRs are a peer review document and, besides ORR, the only person that should have a copy of the IR is the person who wrote it. Ms. Smith stated that LifeWays modified the form. She also stated that she receives IR’s from other counties. Mr. Woods stated that the question needs to be asked again but in the correct way. The question that needs to be asked is if LifeWays uses a different IR form than what Licensing uses? ORR will reach back out to the state to ask whether the Licensing Form that Ms. Smith is speaking about is different than the IR that LifeWays is using; ORR will have an update at the next meeting.
Annual Training Banners Update- Kaitlin advised the Committee about the new banners. Mr. Woods asked the team how many banners there are. There are 12 of them and they are now easier to carry. The Committee gave compliments on how professional the banners look.
Michigan Department of Health and Human Services (MDHHS) Assessment Tool Tracking
Mr. Moten advised the Committee that the ORR is meeting all of the required standards. ORR is roughly investigating within 78 to 80 days. He also advised that ORR is getting to the complaints within 2 out of the 5 days allotted. Mr. Moten stated that the transition has been very uplifting and noticeable. The Abuse & Neglect investigations are being sent out timely as well.
Also, the site visits have been going well. Mr. Moten advised that this has been assigned to Kristi Benn, ORR Specialist. The site visit monitoring report will be updated for the next meeting. Mr. Moten gave kudos to the team on how well everyone has been working together and he is very confident for the next audit. Mrs. Freysinger advised that the reviews that she is receiving from her staff about site visits is that they are very helpful and not intimidating. There is nothing helpful about coming in heavy handed, especially because it’s so hard to find good staff these days. It’s good to hear that it’s been uplifting.
Mr. Moten also advised the Committee that all of the directors within Recipient Rights are going to be meeting quarterly to improve the assessment tool. He will update the Committee on these standards as he receives them.
Semi Annual Recipient Rights Report
Mr. Moten presented a spreadsheet to the committee that showed ORR entertained 127 complaints and substantiated 41 cases out of that 127. There are no interventions pending from the time frames of 10/31/17 to 3/31/18 for Fiscal Year 2018. He explained that the complaint sources came from the Recipients themselves, Staff members or ORR. ORR is able to open complaints, and this normally stems from reviewing and coding Incident Reports
RRAC Minutes 10/25/18 Page 2 of 3 11/2018 Board Folder Page 44 of 137 (IR’s). He also reported that there were 4 anonymous complaints. He also explained the Recipient Population tab in the report. This shows the different diagnoses of Recipients involved in each opened case. These numbers can look higher because of the dual diagnoses. Mrs. Freysinger advised that that was nice to know because she figured it would only be categorized by the primary diagnosis. Mr. Moten advised the committee on the different allegation classes. The highest number was 48 cases for Treatment Suited to Condition. He advised the committee that these numbers are down from last Fiscal Year.
Quarterly Recipient Rights Report
Mr. Moten advised the Committee that this report mirrors the Semi-Annual Report that the Committee just reviewed. He advised them that this shows the average number of complaints, number of days it took to send out correspondence, and number of days to complete an investigation for Quarter 1 and Quarter 2. He advised that Ms. Burnham’s average decreased from 85 to 82 and Mr. Moten’s decreased from 76 to 72. He advised the committee that there will be a significant decrease in the next report with bringing a new staff person on board.
Residential/Licensed Private Hospital (LPH) Reciprocity Tools
Mr. Moten advised that Kaitlin would go thru the inpatient tool. Kaitlin stated that she’s been working with Melissa Davis at Mid-State Health Network (MSHN) to work with the new “box” as well as the other regions at Henry Ford Allegiance and Hillsdale Hospital. We no longer have to be present for these site visits. We will be collaborating with other CMH’s that are close to these places; as long as they do a site visits and everything is done to standards then ORR can sign off on it. Kaitlin said that the whole process has improved significantly. The Committee responded that they really enjoy the tool and it should be helpful to the state. Kaitlin advised that the tools has brought it very close with other regions to get any answers necessary. This also strengthens ORR’s relationship with other providers.
Mr. Moten advised that the Residential template is having some issues when being used. The state is receiving the feedback and will be making some modifications to it.
Next Meeting
Mr. Woods advised to reach out to the team and asked what times are going to work best to accommodate everyone.
Adjournment
The meeting was adjourned at 10:54 a.m.
RRAC Minutes 10/25/18 Page 3 of 3 11/2018 Board Folder Page 45 of 137 2018 Board Member Meeting Attendance_4th Quarter
Bradley Bohner Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Board Corporate Compliance Committee N/A N/A P N/A N/A A N/A N/A P A Board Executive Committee Board Facilities Committee P P A P P A P A A A Board Program & Finance Committee Board QI & Credentialing Committee A P A P P A P P A A Board Meeting A P P* P P A P P A A Recipient Rights Advisory Council Board Ad HOC Committee A Board Work Session/Misc N/A N/A N/A N/A N/A A P P A N/A 62%
Ruth Brown Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Board Corporate Compliance Committee Board Executive Committee Board Facilities Committee Board Program & Finance Committee Board QI & Credentialing Committee P P P P P Board Meeting P P P P P Recipient Rights Advisory Council Board Ad HOC Committee Board Work Session/Misc P P P P N/A 100%
Melissa Callison Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Board Corporate Compliance Committee N/A N/A P N/A N/'A P N/A N/A P N/A Board Executive Committee P P N/A N/A P P P P P P Board Facilities Committee P Board Program & Finance Committee P P P P P P P Board QI & Credentialing Committee P P P Board Meeting P P P P P P P P P P Recipient Rights Advisory Council N/A A P N/A N/A N/A A Board Ad HOC Committee Board Work Session/Misc N/A N/A N/A N/A N/A P P P P N/A 95%
11/2018 Board Folder P=Present; P*=Present by Phone; P** Visiting; A=Excused Absence; U=Unexcused Absence; n/a=No Meeting Held Page 46 of 137 2018 Board Member Meeting Attendance_4th Quarter
Bruce Caswell Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Board Corporate Compliance Committee Board Executive Committee P N/A N/A P* P P P P P Board Facilities Committee P P P Board Program & Finance Committee P P* A P P P P Board QI & Credentialing Committee P P P P P* A P P P P Board Meeting P P P P P* A P P P P Recipient Rights Advisory Council Board Ad HOC Committee P P P P Board Work Session/Misc N/A N/A N/A N/A N/A A P P P N/A 91%
John Clark Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Board Corporate Compliance Committee P N/A N/A A N/A N/A P N/A Board Executive Committee Board Facilities Committee P P P P* P P P Board Program & Finance Committee Board QI & Credentialing Committee P P P* P A P P P Board Meeting P P P P* P A P P P Recipient Rights Advisory Council Board Ad HOC Committee Board Work Session/Misc N/A N/A N/A P A P P P 88%
Clifford Herl Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Board Corporate Compliance Committee Board Executive Committee N/A P P P P P P* Board Facilities Committee P P P* P P Board Program & Finance Committee A P P P P P P* Board QI & Credentialing Committee P P P Board Meeting P P P P P P P P P A Recipient Rights Advisory Council P P P Board Ad HOC Committee Board Work Session/Misc N/A N/A N/A N/A N/A A P P P N/A 92%
11/2018 Board Folder P=Present; P*=Present by Phone; P** Visiting; A=Excused Absence; U=Unexcused Absence; n/a=No Meeting Held Page 47 of 137 2018 Board Member Meeting Attendance_4th Quarter
Daniel Mahoney Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Board Corporate Compliance Committee Board Executive Committee Board Facilities Committee A A A P P Board Program & Finance Committee Board QI & Credentialing Committee A A P* P P A P A P P Board Meeting A P A P P A P P P P Recipient Rights Advisory Council Board Ad HOC Committee Board Work Session/Misc N/A N/A N/A N/A N/A A P P P N/A 62%
Jeffrey Peterson Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Board Corporate Compliance Board Executive Committee P P N/A N/A P P P P P P Board Facilities Committee P P P P* P P P P P P Board Program & Finance Committee P P P Board QI & Credentialing Committee P* P P* P P P P Board Meeting P P P P* P P P P P P Recipient Rights Advisory Council Board Ad HOC Committee Board Work Session/Misc N/A N/A N/A N/A N/A P P P P N/A 100%
Carl Rice, Jr. Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Board Corporate Compliance Committee Board Executive Committee Board Facilities Committee P A A P P Board Program & Finance Committee P P P P P P P A P P Board QI & Credentialing Committee P A P P P Board Meeting P A P P P P P P P P Recipient Rights Advisory Council Board Ad HOC Committee Board Work Session/Misc N/A N/A N/A P N/A P P P P P 86%
11/2018 Board Folder P=Present; P*=Present by Phone; P** Visiting; A=Excused Absence; U=Unexcused Absence; n/a=No Meeting Held Page 48 of 137 2018 Board Member Meeting Attendance_4th Quarter
Alan Ringenberg Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Board Corporate Compliance Committee N/A N/A A Board Executive Committee P P N/A N/A P P P P P P Board Facilities Committee P P P P P P P P P P Board Program & Finance Committee A P P P P P P P Board QI & Credentialing Committee Board Meeting P P P P P P P A P P Recipient Rights Advisory Council P P P N/A P A N/A N/A N/A A Board Ad HOC Committee P Board Work Session/Misc N/A N/A N/A N/A N/A P P A P N/A 89%
Jim Shotwell, Sr. Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Board Corporate Compliance Committee N/A N/A P N/A N/A P N/A N/A P N/A Board Executive Committee P** P** Board Facilities Committee P P P P P P P P P P Board Program & Finance Committee P P P P P P P P P P Board QI & Credentialing Committee Board Meeting P P P P P P P P P P Recipient Rights Advisory Council Board Ad HOC Committee P P P P P Board Work Session/Misc N/A N/A N/A N/A N/A P P P P P 100%
Edward Woods Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Board Corporate Compliance Committee N/A N/A P Board Executive Committee Board Facilities Committee Board Program & Finance Committee A P P P A P A P A P* Board QI & Credentialing Committee P P P P P P P P A P* Board Meeting P P P P P P P P P P* Recipient Rights Advisory Council P A P N/A P P N/A N/A N/A P Board Ad HOC Committee P P P P P Board Work Session/Misc N/A N/A N/A N/A N/A P P P P P 87%
11/2018 Board Folder P=Present; P*=Present by Phone; P** Visiting; A=Excused Absence; U=Unexcused Absence; n/a=No Meeting Held Page 49 of 137
BOARD EXECUTIVE COMMITTEE Minutes of the Meeting November 1, 2018
Board Members Present: Melissa Callison (Chair), Jeffrey Peterson (Vice-Chair), Alan Ringenberg (Immediate Past Chair), Bruce Caswell (Secretary), Clifford Herl (Treasurer via telephone)
Staff Present: Maribeth Leonard (Chief Executive Officer), Karen Cascaddan (Executive Director, Governance)
The meeting commenced at 4:00 p.m.
1. Bond Request – Status Report Maribeth Leonard, Chief Executive Officer (CEO), provided an update on the status of the Capital Projects bond request. • Bond counsel had prepared the bond documents for release on December 20, 2018; however, the closing is delayed due to a technical issue with the notice in the newspaper. The release will now likely be January 20-24, 2019. • The LifeWays Board will have one more Resolution to approve, authorizing Maribeth Leonard to sign the documents. (This was done previously but have since added the actual name of the bond to insert in the documentation.) This will appear on the November agenda of the Finance Committee. • Meetings are occurring weekly with the Architect and Design Team. • Some LifeWays staff have visited Kalamazoo Community Mental Health (CMH) and will plan a site visit to Saginaw CMH and to Common Ground (in Oakland) to look at their primary care integration space and 24/7 crisis model.
2. Board Member Attendance Monthly Report • This report was distributed for the committee’s reference. • A copy will be included in the November Board folder. • The report is submitted to the County quarterly.
3. Audit of Board-Approved Expenses through October 17, 2018 • This information was posted on the Board’s web site and attached to the agenda for this meeting. • The report will appear in the November Board Folder.
4. Report on Assignment to Chair: Succession Planning/Community Emergency • A revised Procedure was distributed for review.
11/2018 Board Folder Page 50 of 137 BOARD EXECUTIVE COMMITTEE Minutes of the Meeting November 1, 2018 Page 2
• A Flow Chart will be developed to distribute to the Executive Committee in December.
5. Other
A. Winter Conference • The Community Mental Health Association of Michigan (CMHAM) has scheduled Winter Conference for February 5-6 (with preconference institutes on February 4) at the Radisson Plaza Hotel, Kalamazoo. • Because it is an in-state conference, all Board members are encouraged to attend. • The conference agenda has not yet been established. • Chair Callison suggested two gentlemen as presenters/speakers, who she heard speak at the Annual Celebration of Capable – an Employee Resource Group. She said one was Lee Montgomery, who is a World Champion Paralympian and Michigan native who lost his legs from the knees down, has an incredible story of perseverance, and would have an interesting workshop for athletes with disabilities. The other was a gentleman who, at the age of 10, suffered a debilitating brain aneurysm but is now married and has two daughters. He has started a company where he videotapes people with disabilities who are looking for work because often the greatest barrier for those people are the inability to interview well.
o Ms. Leonard said that although she does not know what CMHAM’s process is relative to how they seek speakers for conferences, she encourages Ms. Callison to contact CMHAM about the two gentlemen.
There being no further matters for discussion, the meeting adjourned at 4:16 p.m.
11/2018 Board Folder Page 51 of 137 Internal Audit of Board-Approved Expenditures Fiscal Year 2018
DATE BOARD APPROVAL (MOTION) AMOUNT AMOUNT APPROVED SPENT/NOTES
9/19/18 Approval of Out of State Travel for Julia $2,845.00 Will be Grescowle, Prevention and Wellness Coordinator, reported in to Attend Critical Incident & Stress Management February Training, December 6-8, 2018 in San Diego, CA for 2019 an estimated Amount of $2,845.00 to include Registration, Transportation, Lodging and Meals 9/19/18 Approval of Out of State Travel for Maribeth $2,838.00 Will be Leonard, Chief Executive Officer, to Attend Health reported in Management Association’s (HMA) Annual November Medicaid Conference September 29 – October 2, 2018 2018 in Chicago, Il for an estimated amount of $2,838.00 to include Registration, Transportation, Lodging and Meals 9/19/18 Approval of Renewal of Contribution for Michigan $37,498.00 $18,749.00 Municipal Risk Management Authority pd. on Participation for Liability Coverage from October 10/1/18 1, 2018 to October 1, 2019 in the Amount of $37,498.00 9/19/18 Approval of Out of State Travel for Julia Grescowle, $8,500.00 Will be Prevention & Wellness Coordinator, and Ella reported in Hephzibah, Prevention & Wellness Specialist, to December Attend the Youth Mental Health First Aid Train the 2018 Trainer, October 29-31, 2018 in Minneapolis, MN for an estimated Amount of $8,500.00 to include Registration, Transportation, Lodging and Meals. 9/19/18 Approval of Out of State Travel for Julia $3,856.00 Will be Grescowle, Prevention & Wellness Coordinator, reported in and Ella Hephzibah, Prevention & Wellness November Specialist, to Attend the safeTALK Training for the 2018 Trainer, September 17-18, 2018 in Burlington, Ontario for an Estimated Amount of $3,856.00 to Include Registration, Transportation, Lodging and Meals 8/15/18 Approval of Emergency Generator Project and $154,287.00 $22,500.00 Transmit to County of Jackson as a Request for pd. 10/18/18 Payment in an Amount Not to Exceed $154,287.00
11/2018 Board Folder Page 52 of 137 DATE BOARD APPROVAL (MOTION) AMOUNT AMOUNT APPROVED SPENT/NOTES 6/20/18 Approval to Lease-Purchase Three (3) Vehicles for $112,487.44 Consumer Transport and Community Services 2 Ford Escapes are $26,563.92 each = $53,127.84 1 transit van is $59,359.60 6/20/18 Approval of Expenditure of $13,500.00 for Merit $13,500.00 Pd. $6,750.00 Network to Conduct LifeWays Security 9/26/18 Assessment
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Michigan Health Policy for the Incoming 2019 Gubernatorial Administration
Megan Foster Friedman, Senior Healthcare Analyst Marianne Udow-Phillips, Executive Director
Center for Healthcare Research and Transformation 2929 Plymouth Road, Suite 245 Ann Arbor, MI 48105 [email protected], [email protected]
August 2018
This is one in a series of white papers being prepared at the direction of the Michigan State University Extension Center for Local Government Finance and Policy for a series entitled “Michigan at the Crossroads” funded by the C.S. Mott Foundation. All errors are the sole responsibility of the authors. We wish to thank Sara Wycoff McCauley for contributing to this effort.
11/2018 Board Folder Page 79 of 137 1 Michigan’s Key Health Policy Issues, 2018
Introduction This brief will provide an overview of four key and timely health The Michigan government has jurisdiction over a wide array of policy topics: Medicaid and the Healthy Michigan Plan; the health policy issues. From the regulation of insurance products, individual health insurance market and the Health Insurance to oversight of the state’s Medicaid program, to investing in Marketplace; the opioid epidemic; and integration of services local public health efforts, Michigan policymakers craft policies to address social determinants of health. It will explore some and budgets that impact the health of millions of Michiganders. of the forces influencing our state’s health and discuss policy approaches to today’s health and health care issues. Overview: Health Spending and Health Outcomes in Michigan
spending. K-12 and higher education represent the next largest Spending 6 Nationally, health care spending accounted for nearly 18% of share of state spending, at 29% of the state budget. gross domestic product in 2016 – growing 4.3% over the previous In FY2017-2018, Medicaid represented approximately 26% of year to $3.3 trillion, or an average of $10,348 per person.1 Health the state budget ($10.84 billion for traditional Medicaid and care spending comprises 18% of Michigan’s gross state product, $3.86 billion for HMP). The GF portion of Medicaid funding as well.2 In 2014 (the most recent data available), health spending was $1.34 billion, including $1.17 billion for traditional Medicaid in Michigan was $79.9 billion, or an average of $8,055 per and $173 million for HMP. Medicaid spending in Michigan has person.3,4 Health care and public health account for a substantial risen steadily since FY2000-2001, but at a lower rate than that of portion of Michigan’s state budget. general medical inflation. The average per-beneficiary annual cost has increased by 44%, from $4,900 in FY2000-2001 to $7,000 in FY2017-2018. For comparison, if the average per-beneficiary cost had increased by the rate of general medical inflation during this period, it would have risen by 82% to approximately $8,900 by FY2017-2018.7 Health Status Michigan lags behind the national average in the overall health of our residents. According to America’s Health Rankings, in 2017, Michigan was ranked the 35th healthiest state in the nation. While Michigan has a low uninsured rate and high numbers of primary care providers, we also have high rates of smoking, cardiovascular death, and obesity.8 These findings illustrate an important point: health is often about much more than just health care. While it is important to have health insurance coverage and access to medical care, there are a multitude of Source: Michigan House Fiscal Agency other social, economic, and environmental factors that shape the health of Michiganders. In FY2017-2018, the Michigan Department of Health and Human Services (MDHHS) accounted for 46% of Michigan’s $55.8 Health Insurance Coverage billion state budget and 43% of the state’s $10.1 billion General Michigan residents obtain health insurance coverage from a Fund/General Purpose (GF/GP) budget. Funding for MDHHS variety of private and public sources. In 2016, nearly half of has grown by 79% since FY2003-2004. Federal funding for Michigan residents had employer health coverage. Nineteen Medicaid and the addition of the Healthy Michigan Plan (HMP) percent of residents received Medicaid health coverage, 12.5% likely account for most of that increase. The state GF/GP portion received Medicare, 6% purchased coverage directly from of funding for MDHHS has stayed relatively steady during this insurers, and 8% held another type of private or public coverage. period, remaining under $5 billion annually.5 Health services 5.4% of Michigan residents went uninsured in 2016, the lowest (which are largely delivered through Medicaid) represent nearly rate in recent history.9 33% of the state’s FY2017-2018 budget, the largest share of state 11/2018 Board Folder Page 80 of 137 2 Medicare, a federal program, and Medicaid, a federal-state program, are the two largest health insurance programs for Americans. Medicare primarily covers adults age 65 and older or individuals with serious disabilities under age 65; Medicaid covers low-income individuals. Medicare is funded federally through a combination of general revenues, payroll taxes and beneficiary premiums. Medicaid is jointly funded by the federal government and the states. Approximately 2 million Michigan residents are covered by Medicare and 2.5 million are covered by Medicaid.10,11 Some low-income individuals qualify for both Medicaid and Medicare and are known as “dual-eligibles” or “duals.” Duals receive assistance from Medicaid to help pay for Medicare cost-sharing, and can receive additional Medicaid benefits that are not covered under Medicare, such as long-term services and supports.
Source: 2016 American Community Survey 1-Year Estimates
Issue 1: Medicaid and the Healthy Michigan Plan
Low-income children and parents comprise the majority of “Traditional” Medicaid individuals receiving coverage through Medicaid (57%), and “Traditional” Medicaid generally refers to the program’s 12,13 Medicaid funds nearly half of all births in Michigan. One in structure prior to the passage of the Patient Protection and four Michigan residents– 2,499,464 individuals as of March 2018 Affordable Care Act (ACA) in 2010. Prior to the enactment of – receive health coverage through Medicaid. Of these, 72% were the ACA, many states, including Michigan, restricted the ability enrolled in “traditional” Medicaid and 28% were enrolled in the for adults without children or disabilities to enroll in Medicaid. 14 Healthy Michigan Plan. The federal government sets overall standards to determine who is eligible for Medicaid coverage, but states have flexibility to establish income standards based on the federal poverty level (FPL).1 In Michigan, the following groups with the noted maximum income limit qualify for traditional Medicaid:
Eligibility Category Maximum income limit in Michigan Families receiving cash 49% FPL assistance benefits Aged, blind, or disabled 75% FPL individuals receiving Supplemental Security Income Elderly and disabled 100% FPL Source: Michigan Department of Health and Human Services Children under 18 160% FPL While children and parents are the majority of those getting Pregnant women and 195% FPL coverage through Medicaid, seniors and those who are disabled newborns represent a significant percentage of the spending in Medicaid. MI Child (Children’s Health 212% FPL Many of these individuals are duals who have health coverage Insurance Program) through both Medicare and Medicaid. Although seniors and individuals with disabilities make up just 18% of Medicaid Individuals who need long- 222% FPL enrollment, they account for 49 percent of Medicaid spending. 15 term supports and services 1 In 2018, the federal poverty level was $12,140 annually for an individual and $25,100 for a family of four.
11/2018 Board Folder Page 81 of 137 3 All state Medicaid programs must cover certain services. healthy behaviors. HMP enrollees are expected to complete Michigan Medicaid includes several additional services in its a health risk assessment, engage in a healthy behavior (such coverage: as smoking cessation or weight loss), and contribute modest premiums and co-pays (depending on income) to health savings Services Required by Additional Services CMS covered by Michigan accounts. Medicaid HMP enrollment quickly outpaced initial expectations, with Inpatient and Behavioral health, over 240,000 individuals enrolling in coverage in the first two outpatient hospital, pharmacy, adult home months of the program alone. As of June 2018, approximately physician, nursing help, dental, home 690,000 Michiganders are enrolled in HMP.16 facility, laboratory and and community-based x-ray, emergency, and services, hospice, and The Healthy Michigan Plan has also generated state budget pregnancy-related the Program of All- savings and economic activity. Prior to the launch of the Healthy services; all approved Inclusive Care for the Michigan Plan, the state of Michigan funded certain health care prescription drugs Elderly (PACE) programs with GF/GP funds. As individuals previously served by those programs transitioned to the Healthy Michigan Plan, the For traditional Medicaid, the portion of cost paid by the federal federal government funds covered those programs, creating $1.2 government varies based on a formula that takes into account the billion in cumulative GF/GP savings from FY2013-2014 through average per capita income for each state. The maximum federal FY2016-2017. In addition to the budgetary savings, the economic share is 73%. In Michigan, in 2018, the federal Medicaid share impacts of the Healthy Michigan Plan have generated 30,000 was 64.45%. new jobs annually, resulting in $2.3 billion in additional personal 17 Healthy Michigan Plan spending power and $150 million in state tax revenue each year. The ACA originally required states to expand Medicaid coverage For the Healthy Michigan Plan, the federal government paid to all adults with incomes below 138% of the federal poverty 100% of the cost of coverage from 2014-2016. From 2017 through line (approximately $16,800/year for an individual and $34,600/ 2020, the federal government decreases its match rate, covering year for a family of four in 2018). A 2012 Supreme Court decision, 95% of the cost of coverage in 2017 but decreasing to 90% of the however, made Medicaid expansion optional for states. As of cost of coverage in 2020 and beyond. In FY2017-2018, the state May 2018, 33 states and the District of Columbia have adopted 5% GF/GP match for Healthy Michigan was $172 million while a version of the Medicaid expansion. Michigan’s expansion, the the federal government provided $3.6 billion.18 Healthy Michigan Plan (HMP), launched in April 2014. HMP PA 107 of 2013 included a clause requiring the state to end HMP is available to adults age 19-64 who earn less than 138% of the if costs to the state exceed savings from the program. The House federal poverty line. Fiscal Agency projects that the state will continue to reap Public Act 107 of 2013, the Healthy Michigan Plan legislation, savings from the Healthy Michigan Plan through at least FY2019- authorized the state to expand its Medicaid program, and passed 2020. In subsequent years, they expect the costs of the program with bipartisan support in both chambers of the Legislature to exceed savings, which could trigger the sunset provision. using a series of federal “section 1115” waivers. These federal Discontinuing the Healthy Michigan Plan would require the waivers allow Michigan to make changes to the structure of state to restore some GF/GP funding for health care services its Medicaid program beyond parameters set by the federal it had funded prior to HMP, mainly community mental health government. Along with several other features, Michigan’s services, or reduce the level of those services.19 Healthy Michigan Plan is unique nationally in its focus on
Emerging Policy Actions: Work Requirements In early 2018, the U.S. Centers for Medicare and Medicaid Services (CMS) announced a sweeping change in federal Medicaid policy that would allow states to request federal permission to establish work and community engagement requirements for certain adults receiving health insurance coverage through Medicaid. As of May 2018, work requirement proposals have been approved for four states: Arkansas, Indiana, Kentucky, and New Hampshire. Seven additional states have submitted applications to the federal government for these work requirements, and a number of other states are considering or preparing proposals. In June 2018, Governor Snyder signed PA 208 into law, the first step in preparing a work requirement proposal for Michigan. Beginning in 2020, the law would require non-elderly, non-disabled HMP enrollees aged 19-62 to document an average of 80 hours of work per month to maintain eligibility for Medicaid benefits. Activities that would meet the work requirement include employment, job training, community service (up to 3 months per year) education, unpaid workforce engagement (e.g., an internship), tribal 11/2018 Board Folder Page 82 of 137 4 continued from page 4 employment program, or drug treatment. If enrollees fail to meet monthly requirements for any 3 months in a year, their coverage is suspended for at least one month until they come back into compliance. Exemptions would be available for individuals age 63 and older, individuals who are disabled and medically frail, full-time students, caregivers, pregnant women, those who were recently incarcerated, those with medical conditions resulting in work limitations, those receiving unemployment compensation, former foster care youth, and those who qualify for a good cause exemption. The House Fiscal Agency estimated that of the 690,000 individuals enrolled in HMP in June 2018, approximately 20% (138,000) would qualify for an exemption and 80% (552,000) would be required to report their work hours.20 In addition to these requirements, PA 208 added additional termination triggers for the Healthy Michigan Plan beyond the sunset provision included in PA 107. Under PA 208, the Healthy Michigan Plan will be terminated if: 1. CMS fails to approve Michigan’s proposal within 12 months; 2. CMS denies Michigan’s proposal and does not approve an amended proposal within 12 months of resubmission; 3. CMS cancels Michigan’s proposal at a future date and does not approve an amended proposal within 12 months of resubmission; or 4. CMS approves Michigan’s proposal, but the approved proposal does not comply with the Healthy Michigan Plan law.21 Many HMP enrollees are already working. A 2016 survey conducted by the Institute for Healthcare Policy and Innovation at the University of Michigan found that 49% of HMP enrollees were employed or self- employed full or part time, and those who reported being out of work or unable to work were more likely to have chronic physical and/or mental health conditions preventing them from working.22 There is evidence that having health insurance makes individuals more likely to find or maintain work. A separate survey conducted by the Institute for Healthcare Policy and Innovation at the University of Michigan found that 55% of people enrolled in HMP said the coverage helped them with their job search, and 70% said it helped improve their work performance.23 Issue 2: Individual Market Coverage and the Health Insurance Marketplace
Insurance Market Reforms: Terms to Know Michigan’s Individual Market >> Guaranteed Issue: Insurers are prohibited from denying Approximately 6% of Michigan residents purchase health coverage to an individual based on their health status insurance coverage through the individual market. Prior to or a pre-existing condition. the Affordable Care Act (ACA), Blue Cross and Blue Shield of Michigan (BCBSM) served as the insurer of last resort. BCBSM >> Community Rating: Insurers are prohibited from varying was required to cover all individuals regardless of health status premiums based on health status or gender. Insurers (guaranteed issue). Since January 1, 2014, the ACA requires are, however, allowed to charge differing rates based on all health plans offering coverage in the individual market to age, geographic location, and smoking status. cover all individuals regardless of health status and with certain >> Essential Health Benefits (EHBs): Health plans offered limits on premium adjustments. Individuals can purchase in the individual and small group markets must provide ACA-compliant individual market coverage in two ways: either coverage for ten categories of services deemed through the Health Insurance Marketplace created under the essential health benefits. In addition, certain preventive ACA (“on-Marketplace”), or by purchasing coverage directly care services are covered with no out-of-pocket cost from an insurer (“off-Marketplace”). Insurers offering plans sharing. both on and off the Marketplace must comply with several rules instituted by the ACA to ensure access to comprehensive health >> Metal Levels: The ACA created Bronze, Silver, Gold, insurance coverage and establish common standards among and Platinum plans that cover varying levels of costs. private health insurance plans. Silver plans, which are the most popular types, cover 70 percent of costs. Low-income individuals who enroll in silver plans are eligible for extra reductions in their out of pocket costs. 11/2018 Board Folder Page 83 of 137 5 Financial Assistance for Trends in Plan Offerings, Pricing, Marketplace Plans and Enrollment The ACA also created several types of financial assistance Michigan has a relatively stable and competitive individual for individuals purchasing coverage on the Health Insurance health insurance market.24 Since the launch of the Health Marketplace. Individuals between 100 and 400 percent FPL Insurance Marketplace in 2014, the state has enjoyed high levels receive tax credits to help pay the cost of their premiums. of insurer participation and plan options (see table below). Premium tax credits are based on two factors: the premium Michigan has not experienced the same degree of insurer exits for the local benchmark silver plan (defined as the second- as many other states, though several insurers did exit the lowest-cost silver plan in the enrollee’s county), and an Marketplace in 2016, 2017, and 2018. These insurers tended enrollee’s household income. Individuals receiving these tax to be start-ups or had limited experience selling individual credits contribute a percentage of their household income market products. In 2018, eight insurers sold coverage on the to their premium (ranging from approximately 2.01 to 9.56 Marketplace, and each of Michigan’s 83 counties had at least percent of income). The amount of the tax credit is determined two insurers offering Marketplace coverage. Largely as a result by subtracting the enrollee’s premium contribution from the of the decision by the federal government not to pay health plans premium for the local benchmark plan. In addition, individuals for required cost sharing premium reductions and uncertainty between 100 and 250 percent FPL receive cost-sharing about federal policy towards the ACA, premiums increased reductions to help lower deductibles and other out-of-pocket significantly in Michigan and many other states in 2018.27 In costs. Finally, the ACA sets limits on the amount of out- addition, the federal government shortened the length of the of-pocket consumer cost-sharing ($7,350 for individuals and 2018 open enrollment period by half – moving from a 12-week $14,700 for families in 2018). period for 2017 to a 6-week period for 2018. In part due to this volatility and policy uncertainty, Michigan and most other states experienced enrollment declines in 2017 and 2018. In Michigan, there were 293,940 individuals who enrolled in 2018 compared to 321,451 in 2017, a 9% decrease.
Michigan’s Health 2014 2015 2016 2017 2018 Insurance Marketplace insurer participation and Number of 13 16 14 10 8 plan options carriers Number of plans 73 193 165 167 90 Number of plan 272,539 341,183 345,813 321,451 293,940 selections25 Average gross $254 $255 $260 $278 $381 benchmark premium26
Emerging Policy Actions: Federal Changes and Projected Impacts for 2019
Cost-sharing reduction payments and “silver loading” Source: Michigan Department of Insurance and Financial Services, U.S. Centers for Medicare and Medicaid Services Under the ACA, insurers offering Marketplace coverage must reduce cost-sharing expenses (e.g., deductibles and co-pays) for individuals earning less than 250% of the federal poverty line who enroll in silver plans. In 2017, 49% of Michigan residents who enrolled in Marketplace coverage received cost- sharing reductions.28 The federal government reimbursed insurers to cover the cost of these payment reductions, but these federal payments were terminated in September 2017. While the federal government will no longer make these payments to insurers, insurers are still required under the law to provide cost-sharing reductions to eligible individuals. In order to compensate for the lost CSR payment revenue, insurers in Michigan and many other states increased premiums on silver Marketplace plans, a practice referred to as “silver loading.” As a result, in Michigan the average premium
11/2018 Board Folder Page 84 of 137 6 continued from page 6 for a benchmark silver plan was on average 34% higher than the premium for those plans in 2017.29 Because premium tax credits for individuals are based on the price of the second-lowest cost silver plan offered in an area, an increase in silver plan prices translates to an increase in the amount of tax credits eligible individuals receive. In 2018, 82% of Michigan’s Marketplace enrollees received premium tax credits.30 Silver loading insulates these individuals from the impacts of premium rate increases. It also allows consumers who would pay the full price of the Marketplace plan to enroll in a lower-priced but otherwise identical off-Marketplace silver plan. In 2018, silver plans accounted for 54% of plan selections in Michigan. Individual mandate penalty repeal The individual mandate of the ACA requires individuals to enroll in minimum essential coverage for a full year or face a financial penalty when filing that year’s taxes. The intent of the individual mandate is to bring healthy individuals into insurance risk pools to ensure market stability. By requiring these individuals to purchase insurance, risk is spread across a broad population and premiums are kept lower than if only individuals with significant health needs were in the risk pool. In 2018, the individual mandate penalty is $695/adult or 2.5% of household income above $10,500, whichever is higher. According to the Internal Revenue Service (IRS), approximately 189,160 Michigan residents paid the individual mandate penalty in tax year 2015.31 In December 2017, President Trump signed into law the Tax Cuts and Jobs Act of 2017 (H.R.1). This legislation repeals the individual mandate penalty effective in 2019. It is expected that the lack of a financial penalty will cause some individuals to forego insurance coverage or switch to less generous, non-ACA compliant coverage. Because those who would shift coverage are likely to be young or healthy, premiums will increase for individuals who remain in the ACA-compliant market. However, in Michigan, fears of substantial premium increases in 2019 have not materialized: carriers are proposing a modest 1.7% average statewide rate increase for individual market plans in 2019. Short-term coverage and Association Health Plans In October 2017, President Trump issued an executive order directing the Departments of Health and Human Services, Labor, and the Treasury to issue regulations expanding access to Association Health Plans (AHPs) and Short Term Limited Duration Insurance (STLDI). These regulations are intended to provide greater access to alternative insurance options in the small group and individual markets. In an Association Health Plan (AHP), multiple small employers with a common business interest may form an association to obtain health insurance for their employees. In June 2018, the U.S. Department of Labor finalized a rule to expand the types of employers that are allowed to form an AHP, and to regulate AHPs as large group health plans. By acting as a large group, AHPs may have greater negotiating power when purchasing insurance than if one small employer acted alone. AHPs are exempt from many of the ACA’s requirements that apply to the individual and small group markets, though states have substantial authority to regulate this type of coverage. While AHPs cannot discriminate based on health status, these plans could still offer more limited benefit packages that would primarily appeal to those who are younger, healthier, or have lower health care costs. If healthy individuals shift from the small group market to AHPs, those that remained in the small group market would likely face higher premiums. According to the Congressional Budget Office (CBO), starting in 2023 approximately 4 million additional people will enroll in an AHP, 90 percent of whom will switch to an AHP from some other form of coverage.32 Short-term insurance plans are intended to provide temporary coverage to individuals and are generally not renewable, unlike most other insurance products. These plans have been available for purchase on the individual market since before the ACA. In 2016, the Obama Administration issued guidance restricting the duration of short-term plans to three months. In August 2018, the Departments of Health and Human Services, Labor, and Treasury issued a final rule that would expand the maximum duration of short-term coverage from 3 months to 364 days, with the ability to renew short-term plans for up to 36 months. While the rule allows states to continue to regulate short-term plans, many stakeholders, including state regulators, have raised concerns that short term coverage as defined by the new rules could further
11/2018 Board Folder Page 85 of 137 7 continued from page 7 destabilize the individual market. State regulators do, however, have considerable authority to regulate these products.33 Short-term plans are exempt from most ACA requirements. They are not required to cover essential health benefits, are not subject to limits on cost-sharing, can impose annual and lifetime limits on coverage, and are allowed to exclude or charge higher premiums to individuals with pre-existing conditions. Because the scope of coverage is limited, short-term plans are often substantially cheaper than ACA-compliant plans. A Kaiser Family Foundation analysis estimated that the cheapest short-term plan available charged 20% of the premium for the cheapest ACA-compliant Bronze plan in an area.34 However, this analysis also found that only 38% of available short-term plans covered substance use treatment services, 29% offered prescription drug coverage, and none offered maternity coverage.35 Short-term plans do not qualify as minimum essential coverage under the ACA, so individuals selecting these plans currently are subject to the individual mandate penalty. With repeal of the individual mandate penalty scheduled to take effect in 2019 and new federal rules extending the maximum length of these plans, it is expected that more individuals will shift from ACA-compliant coverage to short-term coverage. The CBO estimates that an additional 2 million individuals will enroll in short-term plans beginning in 2023, 65 percent of whom will have switched from another type of coverage.36 Because these individuals are likely to be younger and healthier than the overall individual market, those who remain in ACA- compliant coverage will likely face a 2 to 3% increase in premiums, according to the CBO.37 The final rule upholds states’ ability to regulate short-term plans, and states will have considerable latitude to restrict the sale of short-term plans and institute protections for those who purchase short- term coverage. Some states, including Michigan, currently regulate the sale of short-term plans beyond federal guidance. New Jersey, for example, bans the sale of short-term plans. Other states limit the duration of these plans, limit their renewal, or require coverage of certain benefits (though no state requires STLDI to cover essential health benefits). Currently, Michigan restricts the length of short-term coverage (including any renewals of that coverage) to a maximum of 185 days per year.38 In addition, premiums from short-term plans cannot exceed 10% of an insurer’s total individual market premiums.39
Issue 3: Opioids
Opioid Use in Michigan 1990s. Today, Michigan has the tenth worst opioid death rate in The legal and illegal use of opioids – including prescription the nation. In 2016, there were 1,762 opioid overdose deaths in painkillers and illegal opioids such as heroin – has risen Michigan, accounting for 75% of all drug overdose deaths in the 40 dramatically in both the United States and Michigan since the state. In addition, Michigan has higher rates of opioid overdose deaths, opioid prescriptions, and neonatal abstinence syndrome (NAS) than the national average (see table on this page). Rates of opioid overdose deaths, opioid prescriptions, and neonatal abstinence Today’s opioid epidemic began in the 1990s, when providers syndrome (NAS) began prescribing increasing rates of opioid painkillers, such Michigan United as oxycodone and hydrocodone, to their patients. Overdose States deaths from prescription opioids began rising as early as 1999, and has steadily risen since then. More recently, illicit forms Opioid overdose death rate 18.5 13.3 of opioids have contributed to the continued rise in overdose (deaths per 100,000 deaths. In 2010, overdose deaths from heroin began to rise, and persons) 41 more recently, overdose deaths involving synthetic opioids Opioid prescribing rate 96.1 70 such as fentanyl have sharply risen as well.44 Increases in illicit (opioid prescriptions per opioid use are a symptom of broader opioid use. As prescription 42 100 persons) opioids became more expensive and were reformulated to deter Neonatal abstinence 6.7 6 abuse, many prescription opioid users transitioned to heroin use syndrome rate (NAS cases because it was easier to obtain, cheaper, and more potent than per 1,000 births) 43 prescription opioids.45 11/2018 Board Folder Page 86 of 137 8 In Michigan, prescription painkillers account for most opioid- manages outpatient mental health services for Medicaid-covered related overdose deaths. According to MDHHS, in 2015 there individuals with mild to moderate mental health needs. BHDDA were 884 overdose deaths involving prescription opioids, administers state-funded substance use disorder programs, the compared to 391 overdose deaths involving heroin.46 From 2009 federal Substance Abuse Prevention and Treatment Block Grant to 2015, Michigan experienced a 41% increase in the number of and Mental Health block grant, and other specialty services and opioid prescriptions written in the state. By 2016, there were 11 supports. million prescriptions written for opioids in Michigan – meaning There are three types of organizations that manage and there were more opioid prescriptions written that year than administer publicly-funded behavioral health benefits: Prepaid there were residents of the state. Opioid prescribing rates are Inpatient Health Plans (PIHPs), Community Mental Health highest in mid-Michigan, the northern Lower Peninsula, and the Services Programs (CMHs), and Substance Abuse Coordinating Upper Peninsula.47 However, deaths from prescription opioids Agencies (CAs). PIHPs receive fixed monthly (“capitated”) and heroin are more dispersed across the state, and many of payments from MDHHS to manage behavioral health services the counties with the highest death rates are located in the for Medicaid enrollees. MDHHS allocates funds to PIHPs based southeastern part of the state. on the number of Medicaid enrollees in their service area. PIHPs There are several types of strategies to address the opioid use their capitated payments to pay providers directly for their epidemic, including: access to treatment for opioid use (including services. County-based CMH agencies provide comprehensive both medication-assisted treatment and long-term recovery mental health services to children and adults with serious programs), harm reduction (e.g., using naloxone to reverse opioid mental illness and/or intellectual/developmental disabilities. CAs overdoses), prescribing practices, and safe disposal. provide comprehensive planning for substance use treatment, recovery, and prevention services. Following the merger of Structure of the Substance Use CAs with PIHPs in 2014, PIHPs are now responsible for the Treatment System coordination of substance use disorder services. Ten PIHPs and As in many other states, Michigan residents wishing to receive 46 CMHs serve all 83 of Michigan’s counties. services for substance use often face significant barriers to Prior to the passage of the ACA, SUD services were primarily accessing treatment. Nationally, the Kaiser Family Foundation funded through the state general fund, local community funds, estimates that only 29% of individuals with opioid addiction and federal block grant funds. Medicaid expansion shifted received treatment for their addiction in 2016.48 Medicaid is nearly the full cost of these services to the federal government as a primary source of treatment services for individuals with many individuals receiving SUD services enrolled in the Healthy substance use disorder (SUD). Nationally, nearly 40% of adults Michigan Plan and therefore received enhanced federal funding under age 65 with an opioid addiction are covered by Medicaid, for services. Of the $235 million in annual state budget savings and adults covered by Medicaid are more likely to receive resulting from Medicaid expansion, $168 million came from substance use treatment than those with private coverage.49 Medicaid-funded mental health services that were previously Medicaid covers inpatient and outpatient substance use funded through the state general fund.50 At the same time, the treatment services, as well as medication-assisted treatment federal government continued to provide stable funding for (such as buprenorphine or methadone). Unlike many private the Substance Abuse Prevention and Treatment Block Grant, insurers, Medicaid also provides case management, counseling, meaning more resources became available for SUD with the shift peer supports, supported employment, and other services for in Medicaid costs to the federal government. In Michigan, this individuals with substance use disorders. resulted in increased access to coverage for peer services and Within the Michigan Department of Health and Human Services medication-assisted treatment that PIHPs had previously been (MDHHS), behavioral health and SUD treatment services fall unable to provide. In FY2016, 14% more people in Michigan under the authority of the Behavioral Health and Developmental received SUD services than in FY2012, prior to Medicaid Disabilities Administration (BHDDA) and Medical Services expansion. Residential admissions for SUD treatment increased 51 Administration (MSA), the state Medicaid agency. MSA by nearly 40% during this period.
11/2018 Board Folder Page 87 of 137 9 Emerging Policy Actions: Prevention and Treatment The Michigan Legislature and the Snyder Administration have taken several actions to attempt to address the opioid epidemic in Michigan, including the introduction of a bipartisan legislative strategy in early 2017. These actions attempt to address opioid prescribing practices, expand access to treatment, and increase the availability of naloxone to reverse opioid overdoses. In 2017, Michigan launched a new prescription drug monitoring system, known as the Michigan Automated Prescription System (MAPS). MAPS tracks prescriptions of controlled substances and scheduled drugs, which can help health care providers identify individuals at risk of prescription drug abuse. On December 27, 2017, Lt. Gov. Brian Calley signed into law legislation requiring health care providers to check the Michigan Automated Prescription System (MAPS) before prescribing opioids to a patient. The state is providing funding for health systems, physician groups, and pharmacies to integrate MAPS into their clinical workflows, allowing health care providers to have immediate access to prescription drug information in a patient’s electronic medical record. These changes aim to increase the number of prescribers using MAPS. Health systems in Michigan are also pursuing initiatives to change opioid prescribing practices among physicians. The Michigan Opioid Prescribing Engagement Network (Michigan OPEN), housed at the University of Michigan, received a $7 million five-year grant from MDHHS to curb opioid prescribing in acute care settings, particularly after surgery. Michigan OPEN also works with health systems to reduce the illegal diversion of prescription opioids and provides information to the public on safe opioid disposal. In May 2017, MDHHS Chief Medical Executive Dr. Eden Wells authorized a standing order for naloxone, which allows Michigan pharmacies to dispense naloxone over-the-counter to individuals at risk of an overdose and their family members and friends, without a doctor’s prescription. The intent of the standing order is to increase access to naloxone, which reverses the effects of an opioid overdose and can prevent overdose deaths. As of May 2018, Michigan pharmacies have dispensed 7,154 orders of naloxone, 2,306 of which were authorized through the standing order and 4,848 of which were prescribed by other physicians.52 Some states have enacted opioid prescribing limits for physicians; these generally include limits on the quantity of opioids prescribed, the number of days supplied, or dosage limits. Some states have also instituted “first fill” restrictions – limits on the amount of opioids prescribed to first-time users – in an attempt to prevent new opioid users from progressing down a continuum of opioid use. Michigan has not adopted these approaches, but several commercial payers in the state have. For example, Blue Cross Blue Shield of Michigan and Blue Care Network of Michigan instituted 30-day limits on opioid prescriptions for their members beginning in February 2018. Priority Health and Health Alliance Plan have implemented similar prescribing limits.53 States are also working to address barriers to accessing substance use treatment. Many opioid users recover from addiction using medication-assisted treatment (MAT) to mitigate symptoms of opioid withdrawal. Methadone has historically been the primary MAT method, but newer medications such as buprenorphine have less potential for abuse and are somewhat easier to administer. However, physicians who are authorized to prescribe buprenorphine can do so for no more than 100 patients. Recent changes in federal law have attempted to increase the number of certified buprenorphine providers, but Michigan has a shortage of certified providers, meaning many individuals are unable to access buprenorphine. According to a recent analysis conducted by Avalere, in 2016 there were only 670 certified buprenorphine providers in Michigan – meaning there were over 2.5 opioid overdose deaths for every buprenorphine prescriber in the state that year, compared to a national average of 1.6 opioid overdose deaths for every buprenorphine prescriber.54 Increasing the number of providers who can prescribe buprenorphine could allow more individuals to access MAT.
11/2018 Board Folder Page 88 of 137 10 Issue 4: Integration of Services
Integrating Health and Human Given the large impact that social and economic factors have on health outcomes, the health care sector has begun to pay Services to Address Social more attention to interventions that can address these factors. Determinants of Health Historically, efforts to improve health outcomes have focused Social and environmental conditions, such as housing, education, primarily on improvements within the traditional health care employment, and socioeconomic status, have an important system. However, with a growing recognition that social and influence on health outcomes. These factors account for 50 to 60 economic factors significantly impact health, recent initiatives percent of health outcomes, while clinical care accounts for just at the local, state, and federal levels as well as within the 10 to 20 percent.55 Commonly referred to as “social determinants private sector have attempted to address social determinants of health,” the environments in which people live are the of health, reduce health disparities, and link health care and primary drivers of their health. Social determinants of health can human services systems. In Michigan, there are numerous efforts include income, education, employment, food security, access at the state and local levels to address social determinants of to transportation, air and water quality, and racial and ethnic health. Two main areas in which communities are working are: discrimination. Inequities in social and economic conditions strengthening connections between the worlds of health care often lead to health disparities, defined as differences in health and human services, and integrating behavioral and physical outcomes between populations. Policymakers seeking to reduce health care. health disparities in our state should understand the outsized Historically, the delivery of services related to social impacts of social determinants of health in order to target policy determinants of health have been a primary focus of two public solutions accordingly. systems: local public health and community mental health. Clear health disparities can be found in Michigan across both 30 county-level health departments, 14 multi-county health geography and race/ethnicity. An example of a geographic departments and one city health department serve all 83 of disparity would be the difference in health outcomes between Michigan’s counties. In addition to clinical services, disease residents of neighboring Oakland and Wayne counties. Though surveillance, food safety, and other public health responsibilities, these counties share a border, their residents experience a vastly local health departments promote healthy behaviors and chronic different quality of life. Oakland County ranks ninth in the state disease prevention, work to improve nutrition and physical and Wayne County ranks last among Michigan’s 83 counties activity, address tobacco and substance use, and engage in for general health outcomes (length and quality of life).56 As policies related to access to health insurance, affordable and an example of a racial disparity, the overall infant mortality safe housing, and education.59 Of the 46 community mental rate in Michigan has declined significantly over the past 40 health service programs in Michigan, 32 are single-county and years, but declines in infant mortality were greater for White 14 serve multiple counties. In addition to mental health services, residents than for Black residents.57 Infant mortality rates have CMHs provide a variety of other supportive services to address not declined at the same rate across different racial and ethnic social determinants. To carry out these responsibilities, local groups, and the infant mortality rate has actually worsened for health departments and CMHs receive funding from a variety of infants born to Arab women.58 sources, including state and federal grants, Medicaid funding, state general funds, and county funds. Change, Infant mortality 2005-2007 The Affordable Care Act encouraged health systems to place a rate 2005- 2011- to greater emphasis on addressing the health of the populations and (per 1,000 births) 2007 2013 2011-2013 communities they serve. Under the ACA, tax-exempt nonprofit health systems are now required to conduct Community Black 17.3 13.8 -20.2% Health Needs Assessments (CHNAs) every three years. Often American Indian/ 9.7 7.5 -22.7% conducted in partnership with community organizations and Alaska Native local government entities, CHNAs help hospitals identify health Arab 6.8 7.2 +5.9% needs in a community, prioritize strategies to respond to the needs, and communicate progress on addressing the needs. Over Asian 7.6 4.6 -39.5% time, health insurers have also become increasingly aware of the Hispanic 7.5 6.5 -13.3% connection between medical care and social determinants of White 6.0 5.2 -13.3% health, and many health plans in Michigan have launched efforts to address social determinants of health among their members.
11/2018 Board Folder Page 89 of 137 11 Emerging Policy Actions: State Innovation Model The State Innovation Model (SIM), a federal grant program administered by the Center for Medicare and Medicaid Innovation (CMMI), encourages states to pursue innovative approaches to connect health care and human services systems. Michigan’s 3-year SIM grant aims to meet the goals of the Institute for Healthcare Improvement’s Triple Aim: improving population health, improving quality and patient satisfaction, and reducing per capita health care costs. Michigan’s SIM has two major initiatives: Patient- Centered Medical Homes, and Community Health Innovation Regions. Over 300 primary care practices statewide are designated as SIM Patient-Centered Medical Homes (PCMHs). These practices receive payments to transform their health care delivery, as well as dedicated funding for care teams to manage population health. SIM PCMH practices are also required to screen patients on an annual basis for socio-economic needs and connect patients to local resources to address those needs. Practices screen for a variety of social determinants of health, including food insecurity, housing, transportation, and unemployment. Five regions of the state are designated as Community Health Innovation Regions (CHIRs): Genesee County, Jackson County, Muskegon County, Washtenaw/Livingston Counties, and ten counties in the Northwest Lower Peninsula. CHIRs are tasked with testing innovative ways to align health care and human services systems in their community and establish interventions to address the needs of individuals who frequently use the emergency department. These interventions are developed through a community process to connect residents with high emergency department (ED) usage to needed social services. In addition, some CHIRs are aggregating data from local SIM PCMH social needs screenings to identify gaps in services and prioritize funding for resources in their communities.
Integrating Mental Health and follow through on the referral. As a result, between 60 and 70 percent of those who seek behavioral health treatment in ERs Primary Care Services and primary care settings in the United States end up leaving Michigan residents have higher rates of depression and anxiety those settings without receiving treatment for their behavioral than the national average. According to the Centers for Disease health condition.61 Control and Prevention (CDC), 22% of Michiganders reported being diagnosed with depression at one point in their life, To address unmet mental health treatment needs, states and the compared to 17% nationwide.60 However, Michigan’s mental federal government are increasingly investing in new primary health care system is fragmented and does not have sufficient care models that provide comprehensive and coordinated capacity to meet demand for mental health services. physical and behavioral health services, with the goal of improving health outcomes and lowering health care costs. In Michigan, as in most other states, behavioral and mental One area of focus is the integration of behavioral health services health care is delivered separately from physical health care. in primary care sites. Some mental health conditions, such as Individuals most commonly seek treatment for mental health depression and anxiety, can be managed within a primary care issues in emergency rooms and primary care settings, but ER and setting.62 In a fully integrated model, primary care providers primary care providers often are not able to treat mental health screen all patients for behavioral health issues, including SUD, needs. Physical health providers will sometimes refer these depression, and other conditions; provide self-management patients to behavioral health providers, but face barriers due to support and some behavioral interventions; direct a care team mental health provider capacity issues or insurance coverage. (which can include a care manager and/or behavioral health Many behavioral health referrals end up being unfulfilled, either specialist) to treat behavioral health conditions; and refer due to lack of provider capacity or because the patient did not patients to psychologists or psychiatrists, as needed. 63
11/2018 Board Folder Page 90 of 137 12 Emerging Policy Actions: Section 298 Initiative In Michigan, the effort to integrate physical health and behavioral health benefits within Medicaid is commonly referred to as the “Section 298 Initiative.” This term refers to section 298 of Governor Snyder’s FY2016-2017 executive budget, which called for the transition of Medicaid behavioral health benefits from the existing PIHP system to Medicaid Health Plans. Partially in response to backlash from stakeholders who wanted more input in the planning process, the final FY2016-2017 budget instead directed MDHHS to form a working group to develop recommendations for the integration of physical and behavioral health services within Medicaid. Throughout 2016, the Section 298 work group met regularly to develop over 70 policy recommendations delivered to the Legislature in March 2017.64 The FY17-18 budget directed MDHHS to develop a pilot program where Medicaid Health Plans would contract with the state to manage both physical and behavioral health services in the pilot’s geographic region. Medicaid Health Plans will, in turn, contract with local CMHSPs to deliver specialty behavioral health services in pilot regions. The pilots will test whether or not financial integration of Medicaid physical and behavioral health benefits will result in greater coordination of these services for consumers – defined in terms of better health outcomes, increased efficiencies in service delivery, and increased reinvestment in behavioral health services.65 In March 2018, MDHHS announced the selection of three pilot sites: Muskegon County CMH and West Michigan Community Mental Health; Genesee Health System; and Saginaw County Community Mental Health Authority. MDHHS originally targeted a pilot launch date of October 1, 2018, but has since delayed implementation until October 1, 2019.66 Pilots will operate for at least two years.
Conclusion
With the expansion of Medicaid and the launch of the Affordable private sector are engaged in many innovative initiatives to Care Act’s individual Health Insurance Marketplace, the address these issues and improve the health of communities. In numbers of uninsured Michiganders have been considerably particular, the state has committed to programs that are intended reduced since 2013. Yet Michigan policy makers will still face to improve health equity and focus on the social determinants numerous policy issues and decisions related to health care of health. All of this work is being conducted at a time of great coverage, health disparities, and access to care in the years to political change and considerable turmoil at the federal level. The come. Our state will continue to struggle with complex health new governor and the 100th Legislature will be faced with both issues such as substance use and access to mental health services. tremendous responsibility and opportunity to shape the health Michigan policy leaders, local public health agencies, and the policy landscape for years to come.
11/2018 Board Folder Page 91 of 137 13 Endnotes
1 Hartman, M., Martin, A. B., Espinosa, N. et al (2018). National Health Care Spending In 2016: Spending And Enrollment Growth Slow After Initial Coverage Expansions. Health Affairs, 37(1), 150-160. doi:10.1377/hlthaff.2017.1299 2 U.S. Bureau of Economic Analysis, Total Gross Domestic Product for Michigan [MINGSP], retrieved from FRED, Federal Reserve Bank of St. Louis; https://fred.stlouisfed.org/series/MINGSP, June 26, 2018. 3 State Health Facts: Health Care Expenditures by State of Residence, 2014. Kaiser Family Foundation. https://www.kff.org/other/state-indicator/health-care-expenditures-by-state-of-residence-in- millions/?currentTimeframe=0&selectedRows=%7B%22states%22:%7B%22michigan%22:%7B%7D%7D%7D&sort Model=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D 4 State Health Facts: Health Care Expenditures per Capita by State of Residence, 2014. Kaiser Family Foundation. https://www.kff.org/other/state-indicator/health-care-expenditures-by-state-of-residence- in- millions/?currentTimeframe=0&selectedRows=%7B%22states%22:%7B%22michigan%22:%7B%7D%7D%7D&sort Model=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D 5 Frey, S., Koorstra, K., Wild, V. (2018). Budget Briefing: Health and Human Services. Michigan House FiscalAgency. https://www.house. mi.gov/hfa/PDF/Briefings/DHHS_Overview_BudgetBriefing_fy17-18.pdf 6 What are the largest programs supported by state government? Michigan State Budget Office. https://www.michigan.gov/ budget/0,4538,7-157-40794-139071--,00.html. 7 Koorstra, K. (2018). Budget Briefing: MDHHS – Medical Services and Behavioral Health. Michigan House FiscalAgency. https://www. house.mi.gov/hfa/PDF/Briefings/DHHS_Medicaid_BudgetBriefing_fy17-18.pdf 8 America’s Health Rankings: State Findings, Michigan, 2017. United Health Foundation. https://www.americashealthrankings.org/ explore/annual/measure/Overall/state/MI 9 2016 American Community Survey 1-Year Estimates, B27010: Types of Health Insurance Coverage by Age. United States Census Bureau. https://factfinder.census.gov/bkmk/table/1.0/en/ACS/16_1YR/B27010/0400000US26 10 Medicare Enrollment Dashboard. Centers for Medicare and Medicaid Services. https://www.cms.gov/Research- Statistics-Data-and- Systems/Statistics-Trends-and-Reports/Dashboard/Medicare- Enrollment/Enrollment%20Dashboard.html 11 Green Book Report of Key Program Statistics, January 2018. Michigan Department of Health and Human Services. https://www. michigan.gov/documents/mdhhs/2018_01_GreenBook_616269_7.pdf 12 Priest, C., Hanley, F. (2017). Medical Services Administration Fiscal Year 2018 Presentation to the Appropriations Subcommittee on Health and Human Services. Michigan Department of Health and Human Services. https://www.michigan.gov/documents/mdhhs/ MSA_FY_18_Budget_Presentation_FINAL_553727_7.PDF 13 State Health Facts: Births Financed by Medicaid. Kaiser Family Foundation, 2015. https://www.kff.org/medicaid/state-indicator/births- financed-by- medicaid/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D 14 Green Book of Key Program Statistics, March 2018. Michigan Department of Health and Human Services. https://www.michigan.gov/ documents/mdhhs/2018_03_GreenBook_622707_7.pdf 15 Priest, C., Hanley, F. (2017). 16 Green Book Report of Key Program Statistics: June 2018. Michigan Department of Health and Human Services. https://www.michigan. gov/documents/mdhhs/2018_06_GreenBook_629223_7.pdf. 17 Ayanian, J. Z., Ehrlich G. M., Grimes D. R., Levy H. (2017). Economic Effects of Medicaid Expansion in Michigan.N Engl J Med 2017; 376:407-410. https://www.nejm.org/doi/full/10.1056/NEJMp1613981 18 Frey, S., Wild, V., Koorstra, K., Burris, T. (2017). Line Item and Boilerplate Summary, Health and Human Services, Fiscal Year 2017- 2018. Michigan House Fiscal Agency. http://www.house.mi.gov/hfa/PDF/LineItemSummaries/line18_DHHS.pdf 19 Udow-Phillips, M., Fangmeier, J. (2012). The ACA’s Medicaid Expansion: Michigan Impact – State Budgetary Estimates and Other Impacts. Center for Healthcare Research and Transformation. https://www.chrt.org/publication/acas-medicaid-expansion-michigan- impact-state-budgetary-estimates-impacts/ 20 Summary as Passed by the House of Senate Bill 897 House Substitute (H-2), June 7, 2018. Michigan House Fiscal Agency. https://www. legislature.mi.gov/documents/2017-2018/billanalysis/Senate/htm/2017-SFA-0897-C.htm 21 Randolph, M., Udow-Phillips, M. (2018). Proposed Work Requirements for Medicaid in Michigan, June 7, 2018. Center for Healthcare Research and Transformation. https://www.chrt.org/publication/proposed-work- requirements-for-medicaid-in-michigan-june-7-2018/ 22 Tipirneni, R., Goold, S. D., Ayanian J. Z. Employment Status and Health Characteristics of Adults with Expanded Medicaid Coverage in Michigan. JAMA Internal Med 2018;178(4):564-567. https://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2664514
11/2018 Board Folder Page 92 of 137 14 23 Goold, S. D., Kullgren, J. (2018). Report on the 2016 Healthy Michigan Voices Enrollee Survey. University of Michigan Institute for Healthcare Policy and Innovation. https://www.michigan.gov/documents/mdhhs/2016_Healthy_Michigan_Voices_Enrollee_Survey_-_ Report Appendices_1.17.18_final_618161_7.pdf 24 Foster Friedman, M., Fangmeier, J., Baum, N., Udow-Phillips, M. (2017). ACA Exchange Competitiveness in Michigan. Risk Management and Insurance Review 2017; 20,2:211-232. https://onlinelibrary.wiley.com/doi/abs/10.1111/rmir.12077 25 State Health Facts: Marketplace Enrollment, 2014-2018. Kaiser Family Foundation. https://www.kff.org/health- reform/state-indicator/ marketplace-enrollment-2014- 2017/?activeTab=graph¤tTimeframe=0&startTimeframe=4&sortModel=%7B%22colId%22:%22 Location%22, %22sort%22: %22asc%22%7D 26 State Health Facts: Marketplace Average Benchmark Premiums, 2014-2018. Kaiser Family Foundation. https://www.kff.org/health-reform/state-indicator/marketplace-average-benchmark- premiums/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D 27 Udow-Phillips, M., Foster Friedman, M., Randolph, M. (2018). The Resilience of the Affordable Care Act: The Michigan Example. Health Affairs Blog. https://www.healthaffairs.org/do/10.1377/hblog20180730.31405/full/ . 28 2018 Marketplace Open Enrollment Period Public Use Files. U.S. Centers for Medicare and Medicaid Services. https://www.cms.gov/ Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/Marketplace- Products/2018_Open_Enrollment.html 29 Foster Friedman, M., Udow-Phillips, M. (2017). Rate Analysis: 2018 Health Insurance Marketplace. Center for Healthcare Research and Transformation. https://www.chrt.org/publication/rate-analysis-2018-health-insurance- marketplace/ 30 2018 Marketplace Open Enrollment Period Public Use Files 31 SOI Tax Stats - Historic Table 2. Internal Revenue Service. https://www.irs.gov/statistics/soi-tax-stats-historic-table-2 32 Federal Subsidies for Health Insurance Coverage for People Under Age 65: 2018 to 2028 (2018). Congress of the United States, Congressional Budget Office. https://www.cbo.gov/system/files/115th-congress-2017- 2018/reports/53826- healthinsurancecoverage.pdf. 32 Federal Subsidies for Health Insurance Coverage for People Under Age 65: 2018 to 2028 (2018). Congress of the United States, Congressional Budget Office. https://www.cbo.gov/system/files/115th-congress-2017- 2018/reports/53826-healthinsurancecoverage.pdf. 33 Keith, K. (2018). The Short-Term, Limited-Duration Coverage Final Rule: The Background, The Context, and What Could Come Next. Health Affairs Blog. https://www.healthaffairs.org/do/10.1377/hblog20180801.169759/full. 34 Pollitz, K., Long, M., Semanskee, A., Kamal, R. (2018). Understanding Short-Term Limited Duration Health Insurance. Kaiser Family Foundation. https://www.kff.org/health-reform/issue-brief/understanding-short-term- limited-duration-health-insurance/ 35 Ibid. 36 Federal Subsidies for Health Insurance Coverage for People Under Age 65: 2018 to 2028 (2018). 37 Ibid. 38 Palanker, D., Lucia, K., Corlette, S., Kona, M. (2018). Proposed Federal Changes to Short-Term Health Coverage Leave Regulation to States. Commonwealth Fund. http://www.commonwealthfund.org/publications/blog/2018/feb/short-term-health-plan-proposed- changes 39 The Insurance Code of 1956, PA 218 of 1956. MCL 500.2213b. http://legislature.mi.gov/doc.aspx?mcl-500-2213b 40 State Health Facts: Opioid Overdose Deaths and Opioid Overdose Deaths as a Percent of All Drug Overdose Deaths, 2016. Kaiser Family Foundation. https://www.kff.org/other/state-indicator/opioid-overdose- deaths/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D 41 Michigan Opioid Summary: Opioid-Related Overdose Deaths (2018). National Institutes of Health: National Institute on Drug Abuse https://www.drugabuse.gov/drugs-abuse/opioids/opioid-summaries-by-state/michigan- opioid-summary 42 Ibid. 43 Ibid. 44 Opioid Overdose: Understanding the Epidemic (2017). Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, Division of Unintentional Injury Prevention. https://www.cdc.gov/drugoverdose/epidemic/index.html 45 Report of Findings and Recommendations for Action (2015). Michigan Prescription Drug and Opioid Abuse Task Force. https://www. michigan.gov/documents/snyder/Presciption_Drug_and_Opioid_Task_Force_Report_504140_7.pdf 46 Mack, J. (2017). Michigan has More Annual Opioid Prescriptions than People. MLive. https://www.mlive.com/news/index.ssf/2017/06/ michigan_opioid_heroin.html 47 Ibid.
11/2018 Board Folder Page 93 of 137 15 48 Zur, J., Tolbert, J. (2018). The Opioid Epidemic and Medicaid’s Role in Facilitating Access to Treatment. Kaiser Family Foundation. https://www.kff.org/medicaid/issue-brief/the-opioid-epidemic-and-medicaids-role-in- facilitating-access-to-treatment/ 49 Medicaid’s Role in Addressing the Opioid Epidemic (2018). Kaiser Family Foundation. https://www.kff.org/infographic/medicaids- role-in-addressing-opioid-epidemic/ 50 http://house.mi.gov/hfa/PDF/HealthandHumanServices/HMP_Savings_and_Cost_Estimates.pdf 51 Baum, N., Rheingans, C., Udow-Phillips, M. (2017). The Impact of the ACA on Community Mental Health and Substance Abuse Services: Experience in 3 Great Lakes States. Center for Healthcare Research and Transformation. https://www.chrt.org/publication/ impact-aca-community-mental-health-substance-abuse-services-experience-3- great-lakes-states/ 52 Lt. Gov Calley: Naloxone Available Over the Counter to Reverse Overdoses (2018). Office of Governor RickSnyder. https://www. michigan.gov/snyder/0,4668,7-277-57577_57657-468171--,00.html 53 Greene, J. (2017). Blue Cross to Limit Opioid Scripts to 30-day Supply. Crain’s Detroit Business. http://www.crainsdetroit.com/ article/20171208/news/647161/blue-cross-to-limit-opioid-scripts-to-30-day-supply 54 Pearson, C. F., Soh, C. (2018). Midwest and Mid-Atlantic States Face Provider Shortage to Address Opioid Epidemic. Avalere. http:// avalere.com/expertise/life-sciences/insights/midwest-and-mid-atlantic-states-face- provider-shortage-to-address-opioid-ep 55 Schroeder, S.A. (2007). We can do better- improving the health of the American people. N Engl J Med 2007; 357:1221-8. 56 2018 County Health Rankings and Roadmaps. Robert Wood Johnson Foundation. http://www.countyhealthrankings.org/app/ michigan/2018/compare/snapshot?counties=26_125%2B26_163 57 Michigan Health Equity Access Report: Focus on Maternal and Child Health (2013). Michigan Department of Community Health. https://www.michigan.gov/documents/mdhhs/HE_Status_Report_506754_7.pdf 58 Michigan Health Equity Project, 2016 Update: Michigan Healthy Equity Tables and Related Technical Documents (2016). Michigan Department of Health and Human Services. https://www.michigan.gov/documents/mdhhs/HEDP_Update_2016_559814_7.pdf 59 2016 National Profile of Local Health Departments (2017). National Association of County and City HealthOfficials. http:// nacchoprofilestudy.org/wp-content/uploads/2017/10/ProfileReport_Aug2017_final.pdf 60 BRFSS Prevalence & Trends Data (2015). Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Division of Population Health. https://www.cdc.gov/brfss/brfssprevalence/ 61 Klein, S., Hostetter, M. (2014). In Focus: Integrating Behavioral Health and Primary Care. Commonwealth Fund. http://www. commonwealthfund.org/publications/newsletters/quality-matters/2014/august-september/in-focus 62 Ibid. 63 The Business Case for Behavioral Health Care (2013). Substance Abuse and Mental Health Services Administration. https://www. integration.samhsa.gov/financing/The_Business_Case_for_Behavioral_Health_Care_Monograph.pdf 64 Final Report of the 298 Facilitation Work Group (2017). Michigan Department of Health and Human Services. https://www.michigan. gov/documents/mdhhs/Final_Report_of_the_298_Facilitation_Workgroup_-_Version_for_Publication_554605_7.pdf. 65 Frequently Asked Questions About the Section 298 Initiative (2018). Michigan Department of Health and Human Services. https:// www.michigan.gov/documents/mdhhs/FAQ_about_the_Section_298_Initiative_616881_7.pdf 66 Weekly Update for the Section 298 Initiative, May 28, 2018. Michigan Department of Health and Human Services. https://www. michigan.gov/documents/mdhhs/Weekly_Update_for_May_28_2018_624190_7.pdf
MSU is an affirmative-action, equal-opportunity employer, committed to achieving excellence through a diverse workforce and inclusive culture that encourages all people to reach their full potential. Michigan State University Extension programs and materials are open to all without regard to race, color, national origin, gender, gender identity, religion, age, height, weight, disability, political beliefs, sexual orientation, marital status, family status or veteran status. Issued in furtherance of MSU Extension work, acts of May 8 and June 30, 1914, in cooperation with the U.S. Department of Agriculture. Jeffrey W. Dwyer, Director, MSU Extension, East Lansing, MI 48824. This information is for educational purposes only. Reference to commercial products or trade names does not imply endorsement by MSU Extension or bias against those not mentioned. 08:2018-WEB-JL WCAG 2.0 AA 11/2018 Board Folder Page 94 of 137 16 11/2018 Board Folder Page 95 of 137 11/2018 Board Folder Page 96 of 137 11/2018 Board Folder Page 97 of 137 11/2018 Board Folder Page 98 of 137 11/2018 Board Folder Page 99 of 137 11/2018 Board Folder Page 100 of 137 11/2018 Board Folder Page 101 of 137 11/2018 Board Folder Page 102 of 137 11/2018 Board Folder Page 103 of 137 11/2018 Board Folder Page 104 of 137 11/2018 Board Folder Page 105 of 137 11/2018 Board Folder Page 106 of 137 11/2018 Board Folder Page 107 of 137 11/2018 Board Folder Page 108 of 137 11/2018 Board Folder Page 109 of 137 11/2018 Board Folder Page 110 of 137 11/2018 Board Folder Page 111 of 137 11/2018 Board Folder Page 112 of 137 11/2018 Board Folder Page 113 of 137 11/2018 Board Folder Page 114 of 137 11/2018 Board Folder Page 115 of 137 11/2018 Board Folder Page 116 of 137 11/2018 Board Folder Page 117 of 137 FALL 2018
Leadership lies in the power of convening Clint Galloway
L eaning over the table for em- ference. See, for a 5 versus a 4 – so, for a 4, all that energy phasis and to assure I heard, and ambition and drive is about them. It’s about what they John said, “Leadership lies in get. It’s about how they look. It’s about what they make. It’s the power of convening.” This about what accrues to them. It’s about whether they are the begged the question; what is center. That’s a 4. [In] 5s, all that same level of energy and the secret to that power of con- drive and ambition is channeled outward into a cause, into a vening? Paraphrasing Jim Col- company, into a culture, into a quest, into something that is lins, author of Good to Great, bigger and more enduring than they are. Level 5s lead in a John said, “Creating a compel- spirit of service, and they subsume themselves and sacrifice ling vision that others see as for that.”1 That’s John, and that helps explain the renaissance their own.” Later, John made occurring in Southwest Detroit. John VanCamp clear that the ensuing vision for Somewhat acquainted with John’s legacy, I approached him Southwest Solutions (SWSOL) about two years ago to write this story. After numerous un- was a shared vision articulated by numerous individuals to warranted apologies by John, it dawned on me that to cap- give expression to their passion, not one he created by him- ture the essence of this story, I needed to go to Detroit and self. The vision is “to enhance the quality of life, success witness John’s work. A few days later I was swallowed up and self-sufficiency of individuals and families.” in the morning rush hour traffic on interstate 96 all the way That was the key; it all began to come together. The late lunch into Detroit, exiting just before the Ambassador Bridge. My in one of John’s favorite Mexican restaurants in Southwest presence was another example of John’s engaging gift of Detroit was not only a treat, it was part of the “show and bringing people to the table. John had meticulously planned tell” whirlwind tour of a renaissance occurring in Southwest a tightly packed eight hour schedule of “show and tell” dur- Detroit that was exhibit “A” of this shared passion. Com- ing which I saw, heard, and even tasted what’s happening mensurate with this style of leadership, John possesses some in Detroit. It has forever changed my impressions of not profound personal characteristics, three of which have be- only what is occurring in Detroit, but how the same trans- come obvious to me: a sense of mission rooted in compas- formative strategies can and are fostering a new generation sion, a vision constantly honed by a deepening appreciation of healthcare that includes not just people based strategies for the complexity of life and what constitutes emotional but also incorporates place based strategies. Enhancing the well-being, and finally, humility. To again quote Jim Col- quality of life requires more than addressing what afflicts lins, commenting on the five levels of leadership: “The X our bodies; it also demands attention to the place where we factor of truly great leadership is humility – humility com- live. Touring the streets of Detroit I saw both the signs of bined with a ferocious will for something bigger than your- decay that we often associate with what has afflicted many self, humility in a very special way. I want to be very clear. metropolitan areas as well as the impressive transformations These people are ambitious. They have tremendous energy. occurring under the style of healthcare leadership practiced They are often exhausting. They never want to stop. They’re (Continued on Page 17) utterly relentless. Okay, they have all that, but here’s the dif- 1 https://www.jimcollins.com/media_topics/level-5-Leadership.html
fall 2018 11/2018 Board Folder ConnectionsPage 118 of 137 Healthcare Transformation Social Determinants and Adverse Childhood Events Robert Sheehan, CEO, Community Mental Health Association of Michigan
his edition of Connections re- intimate partner violence, substance misuse in the family, T volves around a number of household mental illness, parental separation or divorce, themes, central among them the pow- and incarcerated household member. While the resilience of er and importance of social determi- children is often sufficient to overcome the impact of one or nants to the health of all of us. While two of these, since the initial study in the 1990s, research our system and Michigan’s health- repeatedly finds that the impact of a number of incidents care system is involved, in the main, without intervention, seriously impacts both childhood and in the provision of clinical and related adulthood. The cumulative impact is dramatically negative services and supports, it is key that in a number of the dimensions of that person’s life. Without Robert Sheehan we recognize and take on the chal- services and supports, the effects include: early and harm- lenge related to the recognition that ful drug use, higher rates of suicide attempts, higher rates these social determinants – housing, employment, income/ of lifetime depression, higher rates of high-risk sexual be- poverty, race, social connections, family functioning, envi- haviors, poorer fetal outcomes of babies born to high ACE ronmental factors, among others – are more important to the mothers, poorer physical health, and poorer dental health. health of individuals and the entire community than any of our clinical interventions. There are two lessons to learn in the recognition of the im- pact of ACEs on As the chart here the lives of chil- illustrates, only dren and adults. 20% of a person’s The first, and the health is impacted one often taken by clinical health- up by health care care and related providers, educa- supports and ser- tors, and human vices. So, while services provid- we must continue ers, is the need to to provide high identify children quality, accessible, and adults with a person-centered, high number of community based ACEs and to pro- services and sup- vide the trauma- ports, (recognizing that Michigan’s public mental health informed interventions needed to overcome or mitigate the system is one of the most advanced and comprehensive and impact of these events. The second lesson – and one that is community-oriented in the country), we cannot stop there. often ignored – is the need to work to prevent these events To provide these services and supports while not addressing from happening to the children in our nation, our state, and these social determinants, physical environmental factors our community. We cannot treat these conditions as simply and healthy behaviors (most of which are the result of the being the normal course of life in the world as it is. We must social determinants and environmental/family factors) is to recognize that these events are the result of actions that we, ignore the causes of the mental and physical health needs as a society, choose. We must work to prevent these events that we are working to address. from happening through supports, services, and preventa- tive measures in our families and in our communities. Only One of the starkest examples, and one that thankfully is when we recognize the need for such pre-emptive action that highlighted by the popular press, is the impact of adverse address these social determinants will we be able to prevent childhood events (ACE) on the health of children, continu- the devastating harm that adverse childhood events have on ing as they mature into adulthood. ACEs include: physical our fellow community members. abuse, sexual abuse, emotional abuse, physical neglect,
2 fall 2018 11/2018C Boardonnections Folder Page 119 of 137 On Community and Healing James Madden, System Coordinator Children and Youth Mental Health System, Ontario, Canada
n the Spring 2018 issue of generally for good reason; it has been and continues to be IConnections, Ron Manders- very effective and powerful – lifesaving – for individuals cheid called on us to incorpo- suffering from many bio-physical, “medical” conditions. rate the neglected dimension I would argue that the bio-medical model is not wrong, but of community into our efforts rather incomplete and limited, especially as regards mental to more effectively support, health. An indicator of the ongoing, outsized influence of care for, and promote the the medical model on community mental health systems, is healing of those of us who the extent to which we treat those suffering with mental and suffer with mental and emo- emotional distress as though the source of their suffering lie tional distress. In his article, exclusively or predominantly in some genetically or bio- Manderscheid reminded us logically-based disorder or malfunction of their individual that our understanding of organism, or in some individual character weakness or mor- James Madden mental health and wellness al failing leading to poor behavioral and lifestyle choices. has undergone a corrective, Even when our therapeutic modalities are not specifically has become enlarged and enriched in recent decades – health medical (e.g. prescribing psychotropic medicine), we pre- being defined by the World Health Organization (WHO) as dominantly rely on individual treatment behind closed doors more than the mere absence of disease, to include “a com- (individual psychotherapy). We tend to pathologize those plete state of physical, mental, and social well-being.”1 Fur- suffering mental and emotional distress, treating them as de- ther to this, the WHO (2014) has defined mental health as fective individuals that need to be fixed. To the extent that “a state of well-being in which an individual realizes his or we employ approaches such as family systems therapy we her own abilities, can cope with the normal stresses of life, have moved a degree away from an overly individualistic can work productively and is able to make a contribution model toward understanding individual mental health and to his or her community.” In this article I want to dialogue well-being as being embedded in a social context. with and expand upon some of the ideas Manderscheid in- troduced, particularly the notion that intervening at the level The Social Determinants of Mental Health of community may be an impactful and fruitful way of pro- If bio-medical and individual psychotherapy models are moting and supporting mental health. We will explore cur- insufficient, then what? As Mandersheid briefly alluded to, rent understanding of how social and community context in- the idea that through the dimension of “community” may fluence mental health and mental illness, and consider some lie critical and effective mental health interventions, this particular examples of community-level mental health inter- fits with the social determinants of health (SDOH) model. ventions. I will conclude by suggesting some principles and The SDOH model took root within the disciplines of public qualities that characterize effective community-level mental health and population health and has arguably become the health practice. most important model guiding public health interventions Beyond Biomedical and Individualistic Models over the last 10 to 15 years. The fundamental insight of the of Mental Health SDOH perspective is that social, economic, political, and cultural factors within which individuals are born, grow and Many readers will recognize in this call for inclusion of a develop have the greatest impact on health and well-being community-level perspective, a shift away from exclusive over the life course, far greater than “lifestyle” and individ- reliance on a bio-medical model as the dominant paradigm ual health behaviors.2 for our understanding of health and illness. The bio-medical model has held sway in our approach to treating illness more Consistent with both bio-physical and SDOH perspectives, we know that a complex interacting (Continued on Page 4)
1 To this definition I would add the spiritual dimension, in solidarity with 2 the world’s great religious traditions. The medicine wheel shared in com- Having made that point, I think it is important to avoid casting the discus- mon by many of North America’s Indigenous communities, depicts the sion in simplistic either/or terms. Of course individual agency matters, but physical, emotional, intellectual, and spiritual dimensions of healthy life in individuals are always embedded in social contexts which profoundly shape, balanced harmony. enable or constrain, the structure of opportunities, choices, and life chances. fall 2018 3 11/2018 Board Folder ConnectionsPage 120 of 137 On Community and Healing (From Page 3) web of causal factors – genetic, familial, community, and • Health and Health Care broader social forces – influence whether any individual will • Neighborhood and Built Environment come to struggle with mental illness.3 We know that at any • Social and Community Context.5 given point in time, about 20% of the population in “west- ernized” societies suffers with a clinically significant mental Applying the SDOH model to mental health per se, the Ca- health problem – i.e. a problem that interferes with reason- nadian Mental Health Association (CMHA) specifies the ably normal functioning in terms of carrying on satisfying following three social determinants as particularly important relationships with family and friends, the ability to find and with respect to mental health: freedom from discrimination maintain and violence, social inclusion, and access to economic re- 6 All of us struggle from reasonably sources. satisfying Trauma and Attachment time to time with what work, and might be called ordinary participate Embedded in these social determinants of mental health, are two factors that demand particular emphasis – trauma emotional distress–anxiety meaningful- ly in com- and disordered attachment relationships in early childhood. and depression–just as a munity life. Over the last 20 years or so, tremendous advances in neuro- function of being human. No doubt biology – in our understanding of the way brain, body, and this statistic social relationships interact to produce mental health and will have included at one time or another many people read- well-being or mental distress and illness – have demonstrat- ing this article. All of us, regardless of socio-demographic, ed how profoundly childhood physical and sexual abuse, religious, or cultural background have a friend or family and emotional neglect and abuse affect mental health. The member who has struggled with mental health concerns. All emotional responses to adverse childhood and subsequent of us struggle from time to time with what might be called traumatic events become encoded in implicit memory, in ordinary emotional distress – anxiety and depression – just the body and the brain. Individuals become susceptible to as a function of being human. Just by virtue of being hu- being re-traumatized (flooded with implicit memories and man and living in a complex society undergoing rapid so- fight/flight/freeze responses) when triggered by events or cial, economic, and technological change wherein many are situations in the present that in some way resemble the past displaced, and the once secure basis of identity has become traumatic event. The individual literally experiences this tenuous, most all of us are at risk for developing mental ill- neurologically as though the past event or situation is hap- ness. In addition, a particularly provocative and robust find- pening again in the present. This is how a person suffering ing from the SDOH literature indicates that the greater the with PTSD experiences a traumatic flashback. degree of economic and social inequality in a society, the Those with insecure or disordered attachment unconsciously poorer the health outcomes for the entire society (all social reproduce relationships in their adult lives that restage early 4 strata), including those in higher income groups. childhood experience, leaving them feeling fearful, inse- The literature on SDOH typically enumerates lists of spe- cure, and unloved. In addition to these stressors, many face cific social determinants that vary somewhat depending on systemic factors including structural unemployment, with context. The U.S. Center for Disease Control, in a report its attendant chronic economic insecurity, and racialized entitled “Healthy People 2020,” describes five SDOH do- discrimination. The result is chronic activation of the fight/ mains: flight/freeze response which literally transmutes psychoso- cial stress into physical and mental illness. And as Gabor • Economic Stability Maté demonstrates in his brilliant book, In the Realm of • Education Hungry Ghosts (2010), virtually all addiction originates in early childhood trauma and abuse which over time neuro- logically predisposes the (Continued on Page 8) 3 Research indicates that this is true even for mental illnesses that are usually understood to have a genetic basis such as schizophrenia and bi-polar disor- 4 der. For example, Barlow, et. al., in Abnormal Psychology: An Integrative See for example, “The Inner Level: How More Equal Societies Reduce Approach. Toronto: Nelson (2015), conclude that the only safe generaliza- Stress, Restore Sanity and Improve Everyone’s Wellbeing” by Richard tion that can be made with respect to genetic influences, is that “genes are Wilkinson and Kate Pickett (2018). responsible for making some individuals vulnerable to schizophrenia” and 5 https://www.cdc.gov/nchs/data/hpdata2020/HP2020MCR-C39-SDOH.pdf that moreover, that there is a “complex interaction between genetics and 6 environment” (pp. 476-477). http://ontario.cmha.ca/documents/mental-health-promotion-in-ontario-a- call-to-action/ 4 fall 2018 11/2018C Boardonnections Folder Page 121 of 137 ACQUIRING CULTURAL COMPETENCY Dr. Hakeem Lumumba, PhD, LMSW, LPC
he purpose of this the Pangaea (large land mass). Scholars have estimated that T paper is to explore humans began to migrate to various parts of the world and the concepts of what is their physical features changed due to the various climates. cultural competence, Scientists have proven that individuals who reside in the how to become cultur- warmer climates, tend to develop certain physical features ally competent, and such as dark skin complexion. On the other hand, an indi- why becoming cultur- vidual who resides in a colder climate tends to develop light ally competent is im- skin complexion. The reason for the changes in our skin perative to the delivery complexion is due to the body production and/or under pro- of behavioral healthcare duction of melanin which is a natural defense mechanism Dr. Hakeem Lumumba to clients. More impor- to protect us from our indigenous climates. There are other tantly, this paper is de- physical features that are influenced by the indigenous cli- signed to stimulate your intellect and your ability to apply mates, such as our hair texture, the shape of our lips and sound reasoning. nostrils, height and weight, etc. I have had the privilege and pleasure of serving as a clinician Of all our various physical features, it seems that mainstream and as an administrator in Behavioral Health since 1982. In society tends to focus on skin complexion as the marker to doing so, I have encountered and interacted with various determine what is acceptable. For example, historically, in cultures. It has been my experience that we all share some the United States, there has been significant focus on two similarities and some differences. However, each individual groups of people, those who are of dark complexion (i.e., has his/her own uniqueness from a genetic perspective. One African Americans) and those who are of light complexion of the challenges that we face is establishing an appreciation (i.e., European American). We have missed opportunities to for our differences without feeling too uncomfortable. How expand our knowledge of humanity more specifically of our does one accomplish this task? diverse cultures. I have often wondered what goes through Recently, I read a West African Proverb that states, “To not the minds of individuals from other cultures when most of know is bad; not to wish to know is worse.” How many of the mainstream’s focus is on the relationship between Afri- us wish to know? How many of us are willing to admit that can Americans and European Americans. Do they feel left we are too afraid to know? How many of us are aware of out, ignored, or have they simply accepted this reality? what we do not know and that our perceptions have been To become culturally competent, we need to challenge our- formed by our environment? What is your definition of the selves to go beyond skin complexion and give ourselves per- following terms – a) indoctrination and b) education? Based mission to explore other cultures. This is especially true in on your definition of these terms, which one best describes the field of behavioral health where our client population has your state of mind towards cultures other than your own? become more diverse and unique. In addition, I would invite What is Cultural Competence? the readers to enhance their scholarship by reading about the Leakys and their work with identifying the original humans. First, we must approach it from the following standpoints: Furthermore, study the effects that climates have on human historically, geographically, anthropologically, climatically, beings’ physical features and the role of melanin. and scientifically. Historically, there have been many schol- arly debates as to the origin of human beings. According to How to Become Culturally Competent Louis Leaky and Mary Leaky, British Anthropologists, the To become culturally competent, we must examine the for- original human beings came from the region known as Ke- mulation of our perceptions of people in general. For ex- nya, Africa. They came to their conclusion after extensive ample, it is common for human beings to have certain biases examinations of human fossils using sophisticated radio- whether it be towards race, religious beliefs, sexual orienta- carbon dating. According to the Leakys, there is only one tions, or languages. How do we arrive at our perceptions race, the human race. From a geographical point of view, that lead us to develop biases? Today, we are inundated with at one point of time the earth was one land mass known as a plethora of information via the media. This information is (Continued on Page 6) fall 2018 5 11/2018 Board Folder ConnectionsPage 122 of 137 Cultural Competency (From Page 5) available 24 hours per day, 365 days per year. Oftentimes, versus what is not. Our interactions would become less anx- the information is delivered very quickly and with biases. iety provoking and less uncomfortable. Perhaps you have We do not take time to analyze the information before for- noticed that we have evolved into a highly sensitized society mulating our opinions and perceptions, therefore, whether where we can make a benign statement and be viciously at- consciously or unconsciously, we develop our perceptions tacked by our supervisor, peer, or perhaps by the media. I about certain people before getting to know them. have often wondered why we have evolved into this level of intense scrutiny. There is a part of me that believes that it is For example, how often have the media painted a grim pic- designed to keep us from communicating with each other, ture about a certain culture to the point that it has influenced especially interculturally. In other words, if we are too afraid your perception about this culture? Most likely, you have al- of saying something that may be perceived as offensive and ready formed an opinion before interacting with this culture. of being viciously penalized by default we will gradually re- As behavioral health providers, we are supposed to deliver frain from interacting with other people or, if we do, make a quality, fair, and unbiased care to our consumers. However, conscious effort to “say the correct thing” even if we do not because we are exposed to the media’s perceptions of a cer- believe what we are saying. If my perceptions are correct, tain culture, we do not deliver unbiased care. Often, we are then we will remain in our cultural silos. assigning diagnoses to clients based on our perceptions of their culture rather than from a sound clinical evaluation. The Importance of Cultural Competence Quite frankly, I believe that we have become apathetic when in Behavioral Health it comes to filtering out the accuracy of information that has been disseminated. Part of the reason is due to the speed that In early 2000, I began to observe a cultural shift in the type information is conveyed. To become culturally competent is of individuals seeking substance abuse disorder treatment being able to form our own perceptions with minimal influ- and mental health treatment. At the time, I was employed as ence from the media and from other people. an administrator for a major healthcare system in an affluent area of Metropolitan Detroit. Up to this point, my experi- To become culturally competent is to explore the impact of ence had been that most individuals seeking the aforemen- our significant influencer (e.g., parents, guardians, educa- tioned treatments were of either European American descent tors, entertainers, etc.) early in life. For example, depending and/or African American descent. However, there started to upon who reared you, their influence shaped your percep- be a gradual influx of individuals seeking treatment of East tions and attitudes toward your culture and other cultures. It India descent, Chaldean descent, Jewish descent, Spanish is conceivable that you grew up being afraid or having nega- descent, and Asian descent. In addition, there was an influx tive thoughts about certain cultures. The sad part about this of individuals with various sex orientation preferences and is that your attitudes and negative thoughts were formulated Islamic individuals. Finally, we began to see an increase in before you had contact with these cultures. young adult, Suburban European American individuals who By default, as we mature, we tend to interact with various were opiate dependent. cultures. Sometimes, we discover that we were misinformed As this was occurring, I began to ponder, “Are we prepared by our significant influencers. In some cases we begin to to serve this growing diverse population?” Starting with change our perceptions and attitudes. However, there are myself, I concluded that we were not prepared, primarily other times when we maintain our negative attitudes toward because of our “cultural encapsulation.” This is a term that other cultures because of our family traditions even after means cultural blindness. For me, it was somewhat surpris- we have discovered that we were misinformed. Having the ing that the East Indian descent and Asian descent popula- courage to rethink and challenge old ideas are crucial in be- tions struggled with certain social issues such as substance coming culturally competent. abuse and mental illness. The reason being is because in all One final thought; what are the main differences between my academics, counseling courses, seminars, and trainings, cultural competence and political correctness? At face there was never any mentioning of these populations suf- value, one could say that cultural competence is having ac- fering from substance abuse and mental illness. In addition, curate knowledge and perception about a culture, while po- mainstream media had not focused on these population as litical correctness is a conscientious effort to not offend any- having substance abuse and mental illness along with some one. With the latter comes a certain degree of anxiety due to of the activities that are related such as crime, domestic vio- being afraid of not offending anyone. However, if we allow lence, and incest. As we began to admit and treat these vari- ourselves to interact with other cultures, it will increase our ous cultures, I began to decrease my cultural encapsulation comfort level to the point we are aware of what is offensive by not only providing therapy but (Continued on Page 16)
6 fall 2018 11/2018C Boardonnections Folder Page 123 of 137 Memories and Life Lessons – Seeing the person behind the face Michael Geoghan, L.M.S.W., R.N., Executive Director (retired), Newaygo County Mental Health
Following the announcement of his In getting to know the folks I cared for, and as I earned their retirement as CEO of Newaygo Com- trust, they shared snapshots of their lives. One gentleman munity Mental Health, Connections for example, use to drive for Al Capone. Another was a for- asked Michael Geoghan if he would mer pool shark. Still another told me how it was growing up consider sharing some of his most in the South as a black man and having to use a “colored” memorable stories. He graciously washroom, and to eat in the back room of restaurants as the complied. What it reveals is none oth- er than a remarkable legacy of com- white patrons dined in the main dining rooms. Many of my passion. — Editor patient’s faces would brighten in recalling past memories, Michael Geoghan and yet others would tear up when remembering loved ones that had passed but were not forgotten. During my time earning to see the person behind the face was a process working in the nursing home, I became the “adopted grand- L that started with my parents teaching me, among many son” by several as they got to know me, my family, and my things, the “Golden Rule,” that is, treating others as you girlfriends (and as they had to “approve” of the latter). Last- would like to be treated I learned through both words and ing friendships developed with some of the patients I cared example, not only in how they honored one another in their for that carried over into my personal life. When a small marriage, but in how they responded to those they served number were able to return to their homes, they would invite through their church, work, and friendships. me to visit them; but I also witnessed the first of many of their deaths – people I had cared for and cared about. My first job in the healthcare field was working as an orderly in an extended care facility. My primary duties were to at- After acquiring my RN degree, on my first job as an RN tend to the care of the male residents. My primary interests charge nurse on an acute care unit in an extended care fa- in pursuing that job were, in part, due to the reported hourly cility, I found out quickly that I was in over my head with- wage of $1.71 (which at the time was far better than what out enough medical/surgical or management experience to I was making as an assistant manager at a fast food restau- oversee other care staff such as LPNs and CNAs. Working rant); and in large part, a growing desire to help others. I as an RN on an acute care inpatient psychiatric unit, I had must admit I really had no idea what I was getting into at my first experiences working with persons struggling with the time. acute behavioral health care illnesses such as schizophrenia, manic depression (i.e., bipolar disorder), major depression, Some of my first memories of this job were when I first multiple personality disorder (DID), borderline personality, walked into the care facility and smelled the lingering odors etc. I decided to pursue an LMSW. of urine and feces, heard the crying and moaning of bed rid- den patients, and saw the harried looks on some of the care I also learned a lot working as a RN in correctional settings, staff as they answered a patient’s light. My initial orienta- in both a medium security prison, and a county jail. I was tion and training was to shadow the orderly on the first shift. trained as a correctional officer at the Michigan Reforma- My training was primarily “OTJ,” being taught the duties by tory (MR) in Ionia, during which time I experienced a “lock whomever I was assigned to. My first mentor, if you will, down” in the middle of the night due to an attempted escape. was a young male orderly who was also enrolled in the nurs- While there, I learned about all the various weapons prison- ing program at a local hospital. It was during that time that ers make while “doing time.” I was trained how to defend I first became aware of and interested in becoming a nurse myself were I to be confronted with a physically aggressive – a professional career that was predominantly staffed by inmate, including use of take down and physical restraint women. After my enrollment into the Nursing Program, I techniques. I was exposed to a “culture of incarceration.” met a young lady who was in the class ahead of me who The majority of my correctional health care experience was would later become my wife. The work was hard, but as I in the county jail where I cared for men and women from got to know the folks I took care of, I began to see it less and all walks of life. I managed an ambulatory clinic in a 250 less as a burden and more like an honor to care for them – if bed jail, working independently under the clinical oversight but for a few hours a day – to show kindness and respect in of physicians and using established clinical protocols. I re- an environment that sometimes left them forgotten. corded an average of 17 inmates (Continued on Page 14)
fall 2018 7 11/2018 Board Folder ConnectionsPage 124 of 137 On Community and Healing (From Page 4) developing brain to impaired executive functioning and based on shared identity, and common experiences. From poor emotional self-regulation. Implicit, non-conscious a mental health promotion point of view, any activity that memories of trauma, abuse, or profound neglect trigger the brings people together based on some sense of community, embodied brains of vulnerable individuals to send signals as a context in which to provide formal support and servic- and release chemicals which result in compulsive, addictive es, or promote informal peer support, may be considered a behavior. Particularly under adverse circumstances, such community-level intervention. In this sense, a community vulnerable individuals can seem to find some measure of re- intervention may be based lief only through ingesting substances or engaging in neuro- on both shared pain and chemical inducing behaviors (cutting, gambling, shopping, struggle, as well as shared A community sex, video games) just to be able to live in their own skin. strengths. From an ecologi- cal point of view, we can intervention Community Level Intervention envisage intervening any- may be What is the relevance of all this for the work of public com- where along a continuum munity mental health associations? The SDOH perspective from small group, through based on reframes our understanding of the forces that generate in- informal association, for- both shared creasing demand for mental health services in our commu- mal organization, neigh- nities, beyond individual psychopathology. It also begins to borhood, to the municipal pain and suggest more impactful levels of intervention beyond indi- level. struggle, vidual treatment of persons listed on a mental health agen- Intervening at the commu- cy’s roster of clients. This is not to disparage the impor- as well nity level is not a new idea tance of individual treatment for (although its application to as shared any particular individual. Indeed, mental health specifically Treatment readily available, high quality, af- strengths. may be to some degree). fordable mental health treatment may be There is a very rich, multi- is usually a necessary element in disciplinary, community development tradition, international necessary, an individual’s recovery of men- in scope. One particular variant that is worth exploring in tal health, and may be considered but is not the context of community mental health is John McKnight’s one of the social determinants of “asset-based” approach, which is very congruent with vari- sufficient. mental health. Treatment may be ous strengths-based approaches to mental health. In a nut- necessary, but is not sufficient. shell, McKnight advocates building community (and hence The root and ongoing maintenance of good individual men- individual) resilience by weaving together and leveraging tal health is a health-supporting community context which informal associations and formal organizations that already invites the knowledge and use of community level interven- exist in a community in novel combinations (i.e.,creating tions partnerships), based on perceived needs and community-de- What is Community? fined priorities, and harnessing and applying the collective expertise and energy of its members toward these commu- Before we begin exploring more concretely what effec- nity-defined goals. tive community interventions look like, it is important to acknowledge there are different meanings of the notion of An Example of a Municipal–level Community community, and by implication, different types of commu- Intervention nity-level mental health interventions. From a sociological Let me give an example of a municipal-level intervention point of view community may have distinct, multiple and/or along these lines, from London, Ontario, the community I overlapping meanings. Community may refer to, for exam- have been living in for the past 32 years. London is a city ple, a specific geographical place (a neighborhood or town), with a population of almost 390,000, located about 60 miles an interest group (the chamber of commerce or neighbor- due east of Port Huron. About 10 years ago, municipal com- hood association), an affinity group (a community theater munity and social services staff were empowered by senior association), a recreation association (local running club), administrators to work with various community and so- an identity group (LGBTQ), a cultural/ethno group, or a re- cial service providers, both public and private, to promote ligious community. We can talk about a sense of community greater coordination of family and children’s services. All – a feeling among people of belonging and being included community-level stakeholders serving social service needs
8 fall 2018 11/2018C Boardonnections Folder Page 125 of 137 of families and children were invited to be part of a com- Centers were created. Three more came on line within the prehensive process. The existing system was to be analyzed last year, and one more is slated to open very soon. for gaps, unnecessary duplication, barriers, etc. Over time These Family Centers create a new, non-stigmatizing insti- more than 170 organizations became involved from various tutional setting or context in which mental health promot- sectors including child care, child welfare, public health, the ing synergies may be generated through creative partner- school system, mental health, recreation, religious, public ships and authentic engagement of community members. As library, and informal associations. The result was the for- an excellent example of this, the children’s mental health mation of the London Child and Youth Network (CYN).7 A agency I work for –Vanier Children’s Services – has recently multi-pronged effort evolved over several years involving begun offering infant/parent mental health clinics at each of hundreds of people. Work conducted with and by commu- the seven Family Centers on a rotating basis. These early nity members, and supported by municipal staff, included an identification, early intervention clinics are staffed by just analysis of community strengths and risk factors, neighbor- one highly skilled Child and Family Therapist, a member hood by neighborhood, using various available data sources. of Vanier’s Early Years team who is trained in “Circle of By consensus, the community identified four priority areas: Security,” an evidence-based infant/parent attachment in- • Ending Poverty tervention model. The neurobiology research over the past • Making Literacy a Way of Life few years has demonstrated irrefutably how an infant born • Leading the Nation in Healthy Eating & Healthy into an environment of “toxic stress” is at very high risk of 8 Physical Activity developing mental illness. In partnership with day care and other child and family support staff, community members • Creating a Family-Centered Service System who exhibit symptoms of toxic stress and poor infant/par- Each area has multi-year work plans and evaluation frame- ent attachment are referred to the Child and Family Thera- works with community-level indicators identified to monitor pist for counselling and support. The clinician also offers progress. (Go to the CYN website to learn more about this consultation, support and guidance to other Family Center initiative, including performance measures and outcomes.) staff members, so that they may recognize and respond ap- It is worth noting that there has been much research and propriately when signs of toxic stress and poor attachment many innovative practices developed for the purposes of are evident. guiding communities in effectively conducting these kinds In Bronfenbrenner’s of community-level inter- framework (page 16), ventions. Perhaps the most There are many different levels the creation of Child and prominent example of this Youth Network would currently comes under the and intersecting opportunities be an example of inter- heading of collective im- vening at the exosystem pact. (An internet search for community mental health level.9 The creation of a of this term will turn up interventions. network of Family Cen- a great deal of applied re- ters as part of the CYN search and practical tools.) initiative would be an example of an intervention at the The CYN’s Family-Centered Service System priority de- intersection of the meso- and exosystem level. The locat- serves special attention. A number of at-risk neighborhoods ing of the infant/parent mental health clinics on site would were identified though analysis of census, municipal plan- be an example of an intervention within an intervention, at ning, and school-system data. Substantial resources were the intersection of the meso-and microsystem level. These made available to begin creating a network of multi-service, examples illustrate that there are many different levels and Family Centers, physically integrated within existing or intersecting opportunities for community mental health in- newly built publicly-funded elementary schools. The partic- terventions. (Continued on Page 10) ular configuration of services offered and partners engaged at any given Family Center depended on the particular needs of the community, but typically included child care, men- 8Clinton, J., Feller, A., & Williams, R. (2016). “The Importance of Infant tal health, and public health services. Initially four Family Mental Health.” Paediatrics & Child Health, 21(5), 239–241. 9One would expect that the macrosystem in Canada is more amenable to the marshalling and application of public funds for interventions such as this, as 7 http://londoncyn.ca/ compared to most places in the U.S. at this moment in time. fall 2018 9 11/2018 Board Folder ConnectionsPage 126 of 137 On Community and Healing (From Page 9)
My Sister’s Place: Healing a Marginalized of watching this program evolve in fits and starts over the Community course of about 15 years. Susan is particularly gifted at en- gaging authentically with people and speaking and acting A second example of a community-level intervention I from deeply held principles and values. I have observed her would like to describe is also based in London, Ontario. speak extemporaneously about MSP, sometimes alone but My Sister’s Place (MSP) is a transitional support program most often with the women who form community there, to for women who experience mental illness, substance mis- groups large and small, religious and secular, charitable and use, and chronic poverty. This is arguably the most margin- business organizations. A turning point came when the ma- alized and stigmatized population in London. Many of the triarch of a local entrepreneurial family heard Susan speak, women who visit MSP engage in street-level survival sex was deeply moved, and decided to fund the purchase and work. Many are Indigenous women. MSP started out as an renovation of a beautiful Victorian-era mansion near the initiative by a few feminist community activists who saw a city’s core to become the home of MSP. As it stands now, need and acted, including members of the Sisters of St. Jo- about one-third of MSP staff salaries are supported by the seph, and women with lived experience. While MSP is now publicly-funded CMHA, one-third are supported by other incorporated as a program community funders including the United Way and the City within Middlesex branch of of London, and one-third through fund-raising. Virtually the Canadian Mental Health all program and infrastructure costs are supported by com- Association (CMHA), munity fund-raising. CMHA also runs a program for men which is the publicly-fund- who experience mental illness and chronic poverty, based ed, adult community mental on the same principles and values which I will discuss fur- health agency in the Lon- ther below. The community of London has stepped up (with don area, it got started when the aid of very intentional and skilled community relations one paid community mental work) to support this initiative through millions of dollars in health worker reached out donations and hundreds of thousands of hours of volunteer to the Sisters and a hand- power. ful of women’s advocates, and began reflecting on Many of the women who have come to MSP have been sup- the problem and imagining ported in transforming their lives from conditions of chronic what might done.10 This poverty, addiction, and incarceration to find stable housing led to a series of participa- and employment. Some have gone from chronic homeless- tory, action-research projects which gave central voice to the ness to earn university degrees and find meaningful work women of lived experience these activists wanted to serve. helping others based on their own lived experience. Many Over time, a program of formal and informal supports and others continue to struggle, but have a safe place and sense services was built up, with many community partners. The program was initially housed within one of the properties The principle is to support owned by the Sisters, and eventually moved to a rented old house in the core of the city. Initially, there was only one po- people by creating a safe, sition, and then eventually a few workers’ positions funded. radically inclusive space... Much of the work is done through partnerships.
On the strength of the leadership and charisma of the pro- of community. The emphasis is on peer support and “sis- gram director, the strength of community partnerships, the terhood.” In addition to clinical supports, programs include quality of engagement with the women, and the impact of a theater group, a music group, and a social enterprise in the program on participants, MSP began to gain greater which women make exquisite jewelry, a portion of the pro- and greater notice in the community. Full disclosure: Susan ceeds go to the women and a portion to program support. Macphail, the founding Director of MSP (until she retired The principle is to support people by creating a safe, radi- this past July) happens to be my spouse. I had the privilege cally inclusive space, accepting people where they are, in their pain or brokenness, while also recognizing, emphasiz- 10 For an excellent and inspiring guide (based on a complexity theory per- ing, and building on their strengths, skills, and abilities. An- spective) to what is possible when a few committed people pour sustained and creative energy into a project like MSP, see Getting to Maybe (2007) other way of putting this is that, at MSP women are healed by Westley, Zimmerman, & Patton. through community.
10 fall 2018 11/2018C Boardonnections Folder Page 127 of 137 What is a Healing Community? follow any particular formula or model, but they are always highly intentional, by which I mean developed collabora- I want to pause for a moment and reflect on that last idea tively with a broad array of community partners, based on – to be “healed through community.” As many others writ- critical reflection, informed by research, including participa- ing on health and healing have observed, the etymological tory research and evidence which includes the lived experi- root of the word health is akin to whole. So at an individual ence of those who would be served, and ongoing develop- level, to be healthy is to have various facets of our human mental evaluation.11 being, – physical, mental, emotional, and spiritual, become conscious, integrated and congruent. From psychodynam- The healing community is radically inclusive and welcom- ic (depth psychology) and mindfulness points of view, we ing. The community is welcomed and present in its diver- know that we must have self-compassion and self-accep- sity. Individuals are welcomed in their strength and in their tance of our imperfections, lest we repress and project our woundedness. For example at My Sister’s Place, no one is fears and insecurities about what we might become on oth- banned or exiled from the community. This is unusual, as ers, and consequently rejecting and lashing out at the “oth- many agencies that provide services to people experiencing er” – the mentally ill, the homeless, the addict, the refugee, chronic mental illness and poverty routinely ban persistently etc. If an individual’s mental health is shaped, enabled, or aggressive or difficult to serve community members. In order constrained by the community, then for healing to happen, for this principle to be operationalized, staff members must be the community must strive to be whole, that is, inclusive temperamen- The healing community is of various facets of its social being. A community that is tally suited, unduly exclusive or too homogenous is not a potential con- well super- radically inclusive text for healing. An unduly inward looking community that vised and sup- and welcoming. demands rigid conformity and the squelching of individual ported, and uniqueness and aspiration is not a healing context. I know well trained The community is of no more insightful accounting of this essential dialectal in principles welcomed and present tension between individual and community than a little book of trauma and in its diversity. by Jean Vanier, the founder of l’Arche – the network of inter- violence in- national communities for people with intellectual disabili- formed care. Individuals are ties – entitled Becoming Human (1998). Vanier writes, welcomed in their strength Relatedly, in a “It is not easy to strike a balance between closedness, healing com- and in their woundedness. having a clear identity that fosters growth in certain munity mem- values and spirituality, and openness to those who do bers are actively engaged to envision together and articulate not live with the same values… being too open can the values they want to see embodied. At My Sister’s Place dilute quality of life and stunt growth to maturity and safety is a shared value. So many marginalized community wisdom; being too closed can stifle. It requires the members have suffered trauma and abuse so that they feel wisdom, maturity, and inner freedom of community profoundly unsafe and are easily triggered, which some- members to help the community find the harmony times activates violent behavior in self-defense. Commu- that not only preserves and deepens life and a real nity members help each other to remember and abide by this sense of belonging but also gives and receives life. value of safety, with the support of skilled staff members. In Then the community truly becomes an environment the event of an aggressive or threatening incident, the trig- for becoming human, helping all to openness, free- gered community member may be required to “step away” dom and commitment to the common good (p. 65).” for a period of time, but he or she is supported in reconciling with and reintegrating into the community as soon as pos- Principles of Community-Level Mental Health sible. Intervention The healing community reflects the diversity of the com- Working from the premise that healing in community can munity, including people of different ages and stages of life, happen in many ways at many levels, let me try to pull to- different professions, ethnicities, religious beliefs, sexual gether the various threads of this discussion by reflecting orientations, etc. In the healing (Continued on Page 12) more broadly and attempting to formulate some general principles for community-level mental health work. 11Patton, M. Q. (2011). Developmental evaluation: Applying complexity Effective community mental health interventions may not concepts to enhance innovation and use. New York, NY, US: Guilford Press. fall 2018 11 11/2018 Board Folder ConnectionsPage 128 of 137 On Community and Healing (From Page 11) community people interact in a variety of life domains. Bronfenbrenner continued to develop and apply his model There may be clinical supports and services, but also em- until his death in 2005, to understand how the multilayered ployment and educational support, recreation and artistic and interacting web of social and biological processes af- opportunities, community celebrations, etc. The emphasis is fects mental health.12 The image presented here is a basic on building on strengths, and generating opportunities for depiction of a very complex model. It is presented here pri- growth and development. marily as a conceptual tool that may be helpful in under- standing how individuals are embedded in sets of interacting Finally, it is also important to note in this age of social me- “microsystems” which bear on their mental health. (In any dia, that although social media may be a powerful tool for particular community, there may be a multitude or paucity of facilitating community connections and supporting mental mental health promoting microsystems.) Formal and infor- health, a genuine healing community of necessity involves mal interactions and linkages between microsystems consti- actual face-to-face, human interaction and contact. In my tute a “mesosystem.” From a complexity theory perspective, view, there are essential qualities of human community and a mesosystem would be seen as an emergent phenomenon of relationship that cannot be fully mediated through smart interacting microsystems. Mesosystems and microsystems phones. are in turn shaped, enabled, and/or constrained by the en- Conclusion compassing exosystem and macrosystem. Individuals are shaped by and shape microsystems, and through organized Toward the beginning of this piece I suggested that our tra- effort, can shape exo-and macrosystems. One can use this ditional medical-model influenced, individualistic mental framework to analyze the social ecology of particular places, health treatment approaches were not so much wrong as in- particular communities. To what extent does the social ecol- complete and insufficient. I argued for an understanding in- ogy of a particular community promote or inhibit resilience formed by the social determinants of health and social eco- and mental health? When we see more clearly the dynamic logical models, and interventions informed by community social embeddedness of individuals, perhaps we can imag- development approaches. It seems to me that as erstwhile ine more vividly and creatively community-level modes of healers, when we see individuals exclusively or primarily mental health promoting and protecting interventions. through the lens of psychopathology, we may see in them what we’re afraid of or reject in ourselves. We risk rejecting part of what makes them up as whole human beings, and treating them as other or alien. To avoid this as community mental health workers, self-awareness and self-acceptance is required. Healing in community then, is a matter of em- phasis and balance. In a healing community, the emphasis is on care more than cure, mutual support more than expert service. Instead of emphasizing the identity of patient or cli- ent, community mental health workers, administrators and policy makers working through the dimensions of commu- nity-level interventions emphasize and privilege the identity of neighbor and community member, and in doing so dig- nify and amplify their efforts.
(For those who want to dig deeper, continue reading) A Social Ecological Framework for Conceptualizing Community Level Intervention Addendum to “On Community and Healing” 12 For a current review of this model see “Different Uses of Bronfen- By James Madden brenner’s Ecological Theory in Mental Health Research: What is Their Value for Guiding Mental Health Policy and Practice.” Eriksson, M., Ghazi- A very useful framework for exploring possible levels of nour, M. & Hammarström, A. “Soc Theory Health” (2018). https://doi. intervention beyond the individual is Bronfenbrenner’s org/10.1057/s41285-018-0065-6. See also “Introduction to Special Issue on ecological theory, which he originally articulated in 1977. Social Ecological Approaches to Community Health Research and Action.” Many readers will be familiar with this model. Lounsbury, D.W. & Mitchell, S.G. Am J Community Psychol (2009) 44: 213. https://doi.org/10.1007/s10464-009-9266-4.
12 fall 2018 11/2018C Boardonnections Folder Page 129 of 137 Hindsight Is 20/20: Our Current Health Crisis
Dan Buettner Fellow, National Geographic In the Blue Zones project cities, Founder, Blue Zones we’ve seen double-digit drops in smoking rates and obesity rates, millions of dollars in health-care savings, and a drastic rise in lev- els of community engagement and well-being.
For 30 years, my life’s work has been identifying and At the beginning of this exploration, we were inter- then studying extraordinary populations around the ested in figuring out if DNA had anything to do with world and unlocking their secrets to longevity and hap- the exceptional health and longevity in these regions. piness. What we learned was that it’s not DNA and it’s not geography. As the Western-influenced lifestyle and Several longevity hot spots surfaced through my ex- diet come in, these “Blue Zones” regions are dying peditions—the Barbagia region of Sardinia, Italy; Ikaria, out. The reason most of these places had such incred- Greece; Okinawa, Japan; the Nicoya Peninsula in Cos- ible health outcomes was partially because they were ta Rica; and Loma Linda, California. People in these isolated, geographically, from the rest of the world. It “Blue Zones” regions not just live longer, but they live took a while for fast food, processed food, and large better. Besides having a large number of centenarians, quantities of meat to infiltrate their diets. But as we people in these areas remain active into their 80s and see in Okinawa, Japan, the newer generation has a 90s and do not suffer from the chronic diseases com- more modern lifestyle and eat a more Western-pat- mon in most parts of the industrialized world. Armed tern diet. And now they are starting to have the health with a team of demographers and scientists and a problems of the Western world. Their geographic loca- grant from the National Institute on Aging, we set out tion hasn’t changed—their lifestyle has. to reverse-engineer longevity, or establish why these It’s a mistake and misunderstanding of research to populations live the healthiest and longest lives in the think that you can go to a Blue Zones region and find world. a special anti-aging ingredient there to mix into your Several common denominators, or longevity lessons, smoothie or rub onto your face. That’s not at all how it were distilled into the “Power 9:" works. You only have to look at the Blue Zones region of Loma Linda, CA to understand that the Blue Zones Move naturally throughout the day are not geographic locations. Loma Linda, CA, a town Have and cultivate a strong sense of purpose about 60 miles away from Los Angeles, is surround- Downshift every day to relieve stress ed on all sides by unremarkable California suburban towns. But Loma Linda residents live about a decade 80% Rule: stop eating when you are 80 percent full longer than other Americans, with much lower rates Plant Slant: Make beans, whole grains, veggies, and of chronic diseases and afflictions like dementia. Sev- fruit the center of your diet enth Day Adventists in Loma Linda have largely pro- Wine @ 5: Enjoy wine and alcohol moderately with tected their lifestyle. The cafeteria at Loma Linda Uni- friends and/or food versity is vegetarian, residents fought the introduction of fast food chains to the town, they remain actively Belong: Be part of a faith-based community or orga- involved in their faith and church community, and they nization are physically active into their 80s and 90s. Love Ones First: Have close friends and strong fam- In the Blue Zones project cities, we’ve seen double- ily connections digit drops in smoking rates and obesity rates, millions Right Tribe: Cultivate close friends and strong social of dollars in health-care savings, and drastic rise in lev- networks els of community engagement and well-being. (Continued on Page 15)
fall 2018 13 11/2018 Board Folder ConnectionsPage 130 of 137 Memories and Life Lessons (From Page 7) per day. I assessed and treated (within established physician of police force are you?” I simply turned to face him and protocol) both physical and behavioral healthcare needs, in- said, “Canine Squad,” and turned back around for the re- cluding acute appendicitis, delirium tremors (DTs), prenatal mainder of the ride. Upon our return to the station, while care, hypertensive crisis, heart disease, diabetes, tonsillitis, I was changing clothes and cleaning up, a booking officer body lice, scabies, liver disease, STDs, psychotic and de- came into the command officer’s office and said to both the pressive disorders, anxiety disorders, and other conditions. command officer and myself, “You have to hear this!” So, I counseled and provided health education to both inmates we went to the intercom outside of the booking office and and deputies. An enduring lesson was becoming able to see listened in on the conversation the man we brought in was each inmate as a person, many of whom were in jail from having with another booking officer. “I tell you, officer, that living in a generational culture of criminal activity, living in dog was talking!” We all had a laugh and I couldn’t help but poverty, little to no education, unemployed and /or underem- wonder what that man would say when he was arraigned ployed, or making poor choices. before the judge. Some of these indelible memories have a lighter side. As a Another time, while seeing inmates during a scheduled med civilian deputy, I was invited to observe, and in some cases, clinic, a young man new to the jail asked me a question participate in law enforcement activities. One such activity while waiting to be seen in the clinic waiting room. “Doc,” was when I volunteered to participate in an undercover sting (I received the nick name “Doctor Death” as a joke from operation which took place around Halloween. I dressed up the deputies) said the young inmate, “I heard you did time, as a werewolf and was planted at a party where the land is that true?” I paused before answering him and then said owner had been alleged to be selling alcohol to minors. My “Yes.” The young man then asked, “For what?” I looked at assignment was simply to infiltrate and observe until such him and said, “For impersonating a nurse,” and walked into time that the deputies would converge on the scene and bust the exam room. The young man responded “Really? How the party. big of a “bit” (i.e., sentence) did you do?” To which the older inmates started laughing and teasing the young man as they At the time, there were only a limited number of command knew I was telling a tale. officers who knew that I was participating. When the depu- ties converged on the scene and started to gather all of the I have many more stories that I could share, as I am sure partiers, I of course was one of them, and in playing the part, each of you have as well. Each of my experiences came with I was less than cooperative and ended up being ordered to a lesson in human behavior. Yes, unfortunately I often saw “assume the position” against a squad car, where I was pat- people at their worst, both the inmates and deputies, but I ted down, handcuffed, and placed in the back of the squad also saw moments of compassion and caring amidst this bro- car. Later, the arresting officer was informed by his com- kenness; and in those times, I found meaning and purpose in mand officer who it was he had just arrested, at which time not only what others do, but in my role as a health care pro- he drove me to the outside perimeter of the area while pro- fessional. I was able to see the person behind the behavior fusely apologizing to me for having treated me as such. I and to remember, “There but for the grace of God go I.” As assured him that he was just doing his job and reminded him it was and is indeed by His grace that I can do what He has that I was not cooperating and therefore, “got what I asked called me to do. Not by my strength or goodness, rather by for.” His and His alone. However, this particular story did not end at that point. Si- Carl Rogers once said, “True empathy is always free of any multaneous to the sting operation, the local law enforce- evaluative or diagnostic quality. This comes across to the re- ment was conducting driver “stop and checks” for intoxi- cipient with some surprise. If I am not being judged, perhaps cated drivers. Shortly after my “release from custody,” and I am not so evil or abnormal as I have thought.” while driving with the undersheriff back to the station, we A longtime friend and spiritual mentor once told me “We received a call for assistance in transporting to jail an intoxi- are but turtles on a fence post,” to which he added, “How cated driver that had been detained by another deputy. So, does a turtle get on a fence post? It has to be placed on that with me still made up in my werewolf makeup and attire, I fence post.” Thus I believe we are called, and through faith sat in the front seat of the command car and the drunk driver and trust in the one who calls us, we can see the real face of was placed in the back seat. While en-route back to the sta- our fellow man in times of triumph, but especially in times tion, the Undersheriff and I were engaged in a conversation. of failure. The drunk driver, seeing my side profile, asked, “What kind
19 14 fall 2018 11/2018C Boardonnections Folder Page 131 of 137 Hindsight (From Page 13)
It isn’t enough to simply try and adopt the Power 9 les- sons individually. Our environment dictates so much of our habits and our health, and we’ve set up most to the of our communities in the United States to accommo- Respond date our sedentary lifestyles—sitting in our cars and Surgeon General’s Call to Action on our couches—and to fill up on processed, high-cal- on community, health and prosperity orie foods. Stemming from extensive research, the Blue Zones BEHAVIORAL HEALTHCARE EXECUTIVE, 10.19.18 Project came to life—an initiative that works with com- By Ron Manderscheid, PhD, Executive Director munities to introduce high-impact changes to make NACBHDD and NARMH the healthier choice the easier choice. Based on the Power 9 longevity principles, permanent and semi-per- I am absolutely delighted to report that U.S. Surgeon manent changes are created aimed at affecting entire General Jerome Adams, MD, MPH, is in the early phas- communities and future generations. es of preparing a new Surgeon General’s Call to Action. The results have been stunning. Albert Lea, MN was This effort will focus on how we can improve commu- the first Blue Zones Project city, and in just a year, nity health, wellbeing, safety and prosperity. Now, we residents added 2.9 years to their lives and city health- have an opportunity to provide input on this endeavor. care claims dropped by 29 percent. In other Blue Zones Project cities, which we administer with a part- Why is this report so important? We have known for nership with Sharecare, we’ve seen double-digit drops quite some time that most issues with health, wellbe- in smoking rates and obesity rates, millions of dollars ing, safety and prosperity have their origins in how our in health-care savings, and drastic rise in levels of com- communities function. In healthcare, we call these com- munity engagement and well-being. munity factors the “social and physical determinants of health”, and we appreciate the exceptionally important Even as Silicon Valley and researchers spend billions trying to find the magic bullet to living longer and bet- role they play in physical and mental health and well- ter, the best way to improve health and longevity are being. low-tech. We won’t find the answer to our current health crisis in a test tube or a line of code. Instead, we need to go backward to move forward. We need to eat and live as our great-grandparents did.
This article first appeared in the 2018 Milken Institute Power of Ideas blog. It is reprinted here with the permis- sion of the Milken Institute. http://powerofideas.milkeninstitute.org/global-confer- ence/2018/hindsight-is-2020-our-current-health-crisis http://powerofideas.milkeninstitute.org/global-confer- ence/2018/ Milken Institute is an international organization. “Our mis- sion is to increase global prosperity by advancing collabora- tive solutions that widen access to capital, create jobs and improve health.” http://www.milkeninstitute.org/ To learn more about Blue Zones which was founded by Dan Buettner, see: Read more: https://www.behavioral.net/blogs/ron-manderscheid/policy/ https://www.bluezones.com/ surgeon-general-s-call-action-community-health-and-prosperity https://www.bluezones.com/2018/08/secret-to-longer- life-is-low-tech/
fall 2018 15 11/2018 Board Folder ConnectionsPage 132 of 137 Cultural Competency (From Page 6) by learning more about their cultural backgrounds as well as difference makers, there must be a mutual acculturation to their culture’s perceptions of substance abuse and mental ill- retain these individuals. In other words, rather than expect- ness. In addition, I began to learn how to greet clients in their ing the new hire to adapt to the work culture, the culture indigenousness languages. I noticed an immediate impact in must also adapt to the new hire culture. my ability to engage them and the high level of respect that One final thought, many of you are probably familiar with developed between me and my clients. I began to examine Motivational Interviewing (MI). With MI, come stages of the cultural makeup of my staff. It became apparent that the change. Starting with Pre-Contemplation (unaware of the cultural makeup of the staff did not match our diverse client need to change), Contemplation (contemplating chang- population. Consequently, there was a conscientious effort es), Planning (strategy to change), Action (producing the to increase our staff’s diversity and as a result, we gradually change), and Maintenance (maintaining and improving on became the provider of choice for various cultures. In addi- the change). I encourage you to assess your level of cultural tion, we noticed that our clients’ retention and satisfaction competence by using the MI Stages of Change. I suspect that rates increased. many of you are in the Pre-Contemplation Stage of Change This brings me to a crucial point; what are the main crite- and it could possibly be due to your social conditionings. As ria used by Behavioral Health Key Decision Makers to hire healthcare professionals, we challenge our clients to change their staff? Typically, most employers post a job description some of their thinking and behaviors; however, we do not that provides a general overview of the position. As a result, challenge ourselves. Whether it is conscious or unconscious, there are several applicants. Afterwards, the recruitment we tend to engage in clinical hypocrisy. process commences. So the question is raised again, what Conclusion are the hiring criteria? Do some Key Decision Makers have a hidden agenda, and if so, for what purpose? The purpose of writing this was to stimulate, challenge, in- spire, and promote critical thinking among behavioral health Recently, I developed a model to enhance cultural compe- professionals and key decision makers regarding your abil- tence in the behavioral health workforce by examining the ity to deliver optimal care to our culturally diverse clients. I following: wanted to provide a catalyst for self-growth, self-improve- a) Talent/Skills Natural Set. ment, self-care, and self-esteem. Finally, I am very receptive b) Cultural Uniqueness (Race, Religious Belief, Dress to engaging in healthy and stimulating dialogues with read- Attire, Name, etc.). ers who are interested in furthering their knowledge in this important subject matter. c) Appreciation of Uniqueness. d) Qualifications (Academic & Credentials). Visit Dr. Lumumba’s website at: counselingenterprise.com e) Opportunity to be hired, grow, and produce. With this model, key decision makers are implored to base References their decision to hire someone on other than their academic Hayes, P. A. (1996) Addressing the complexities of culture and qualifications and credentials. There are some very talent- gender in counseling. Journal of Counseling and Development, ed applicants who are automatically dismissed as potential 74, 332–338. hires based on their names, dress attire, or because of their Jun, H. (2010) Social justice, multicultural counseling, and accent. Recruiters have access to this information via tel- practice:Beyond a conventional approach. Los Angeles, CA: ephonic interviews, skype interviews, as well as other meth- Sage. ods. The sad part about these biases is that they hinder the King, R.D. (2012) Melanin: A key to freedom. Createspace Inde- company’s growth because they miss out on hiring these pendent Pub. Co. talented individuals. Some of these applicants could be dif- ference makers. I am challenging key decision makers to Morell, V. (1995) Ancestral Passions: The Leakey Family and the reassess your hiring and recruiting agendas and protocols. Quest for Humankind’s Beginnings. Rather than basing the hiring decision on qualifications, you Schumacher, J.A., & Madson, M.B. (2016) Fundamental of Mo- should ask what’s missing at our agency that could help us tivational Interviewing. New York, NY: Oxford University Press. with our delivery of care, increase our efficiency, increase Sue, D. W., & Sue, D. (2013) Counseling the culturally diverse: our proficiency, and increase and improve our cultural com- Theory and practice (6th ed.). Hoboken, NJ: Wiley. petence. In addition, once a decision is made to hire these
16 fall 2018 11/2018C Boardonnections Folder Page 133 of 137 Leadership (From Page 1) by Southwest Solutions. These transformations are an inte- vening is recognition of the need for a collective impact. (To gral part of the health and wellness of the residents. understand this more fully, see the companion article by James Madden, “On Community and Healing.”) It is becoming apparent, like all great sagas, this story will have many chapters. Perceived from a historical and cultural The Evolution of Community Mental Health – the Need perspective it is just beginning. Its central theme is about yet to Address the Mental Health of a Community another incredible transformation that is reshaping our institu- John provided some history, “In some ways you have to go back tions that are essential for healthcare as we appreciate more ful- to the mid-sixties when President Kennedy started the concep- ly what it means to be healthy. A more inclusive and therefore tualization of community mental health.” Within that frame you complete term may be “emotional well-being.” When this be- can understand the beginnings of Southwest Solutions that was comes our focus, being healthy is not just about our bodies, as founded in 1970 by Monsignor Clement Kern (1907-1983), important as that is, it is also about the places where we live and the legendary pastor of Most Holy Trinity in southwest De- work, having affordable housing in a safe and secure environ- troit. Kern was known as the “conscience of Detroit” because ment with access to essentials as well as a meaningful job and of his passionate commitment to helping the poor and disen- sufficient income. What needs to happen to diminish human franchised. The church was located near downtown Detroit and suffering and enhance our emotional well-being must include was attended by bankers, judges, elected officials, and business the strategies that address the various dimensions of poverty people. Kern made sure that those who were homeless or had in order to nurture a healing community. An understanding of a mental illness or drug addiction were also included. He not this social dimension helps clarify and guide the transitioning only developed a community within the church, he also worked of community mental health via the inclusion of a focus on the in the larger community. Clem Kern’s deep passion still ani- mental health of a community. If I live in a distressed neighbor- mates the organization. The mission and values instilled at the hood, my wellness requires more than treating the symptoms of start still compose who and why they are, it defines and assures a physical or psychological diagnosis. In fact, the former may their continued existence. What has changed is a growing ap- well be a significant factor in the latter. Community develop- preciation for the complexities that enhance the quality of life, ment is equally essential for health. In this story, Southwest success and self-sufficiency of individuals and families and as Detroit is ground zero but the mission, values, and strategies this understanding has evolved, so has the shape and form of are applicable in any community. the solutions that pursue this vision. Community Innovation SWSOL became a mental health agency in 1972. In the wake Before we venture further into the story of SWSOL, let me of deinstitutionalization, Southwest’s mission was to help the share some background John provided that has helped me un- mentally ill live in the community by providing psychiatric derstand community interventions thereby providing a frame- counseling and medication. John has been with Southwest So- work for the transformation I witnessed. The winter 2004 issue lutions since its beginning, when the agency had a staff of only of the Stanford Social Innovation Review (SSIR) included an ten people. He started as an administrative assistant and be- article entitled, “Leading Boldly” that distinguished between came head of the organization in 1981. To comprehend the evo- technical and adaptive social problems. Technical problems are lution of SWSOL we need to appreciate that John was a pioneer well defined and the solution is known in advance by a limited in understanding the efficacy of community development when number of organizations. Applying their expertise, the resolu- this critical dimension of mental health was only beginning to tion is described as isolated impact. An example of this is the be recognized. As such, he advocated for expanding the vision. development of a robust system of information technology that In addition to the traditional array of counseling solutions he provides data to guide decision making. It could similarly ap- believed that reintegrating the mentally ill and homeless into ply to the construction or remodeling of a physical structure the community required providing decent, affordable housing that houses these services. We can contract with competing or- and support services. It became imperative for the organization ganizations that have these skills to accomplish our tasks. In to actively participate in neighborhood revitalization and eco- contrast to this, the answers to adaptive problems are unknown nomic development. What began as a compassionate response and no individual entity has the resources or authority to bring to the needs of those with mental illness, utilizing the knowl- about the necessary changes. Improving community health is edge and understanding dominant in the 60s and 70s, soon an adaptive problem. In order to reach an effective solution, it grew into a multi-dimensional cluster of solutions designed requires learning by all the stakeholders involved in the prob- to address the emergent knowledge of the various dimensions lem as well as changes in behavior to create a solution. We need of emotional well-being. One way to frame this journey is the to adapt! The results of this collaborative work are captured in struggle to find a balance between people based strategies and the concept of collective impact. Southwest Solutions is aptly place based strategies, a struggle that is enjoined by every com- named as a response to an adaptive problem. The power of con- munity mental health agency that progresses. A head turner for (Continued on Page 18) fall 2018 17 11/2018 Board Folder ConnectionsPage 134 of 137 Leadership (From Page 17) those still immersed in a bio-medical model is how a response Southwest Counseling Solutions is a 501(c)(3) that employs initially focused on placing individuals housed in mental hospi- more than 250 staff persons. They represent the fields of psy- tals into the community has now adopted the long-term evalu- chiatry, psychology, social work, counseling and education. ative measure of making a significant contribution to reducing Focused on inclusiveness, they have more bilingual counseling poverty. However, this is exactly what has happened as SW- professionals than any other organization in Michigan, one in SOL pursued their mission that embraced the wedded values three of their counselors are bilingual. Their adult counseling of diversity, equity and inclusion. They discovered that people program for Spanish speaking consumers is highly effective, who participate in multiple services which constitute commu- with 98% avoiding hospital psychiatric services. In partner- nities of shared interests improve their lives faster. As more ship with Covenant Community Care, SWSOL has developed people achieve these connections, momentum builds and con- a model of integrated physical and mental health services. tributes to population health. By maintaining a focus on what is It is also one of Detroit’s largest providers of services to the essential for quality of life; community mental health has been homeless. In the last decade, they have placed into housing evolving by addressing the mental health of a community. It is more than 1,900 homeless persons, and their housing retention important to understand that many of the additional skills and rate after one year was at 94% which is one of the best in the activities that address the mental health of a community may nation. They are the lead agency to end homelessness in the be best acquired by partnering; this is an adaptive problem that city. The number of chronically homeless and homeless vet- requires the concerted efforts of multiple stakeholders. erans has declined significantly in the past few years through A PEEK AT THE COMPLEXITY the concerted and coordinated effort to address homelessness. Piquette Square is a 150-unit permanent supportive housing Today, Southwest Solutions is a family of nonprofit and for- project that provides comprehensive support services, includ- profit corporations that offers more than 50 vital and com- ing access to healthcare, employment, benefits, and education. munity-building programs and employs more than 350 staff. It is recognized as a national model in helping the veterans re- It is a foremost provider of human and housing services and build their lives and reintegrate into the community. Their Sup- real estate development. Its programs impact 12,000 people portive Services for Veteran Families, (SSVF) has helped over a year and are nationally known and recognized for achiev- 2,500 low-income veterans remain housed. In all its Centers ing outstanding results in improving lives and strengthening of Excellence, Southwest Counseling Solutions is consistently communities. The extraordinary growth of Southwest Solu- recognized for its leadership, expertise and excellence. At the tions and its national renown as an effective integrated-services same time, they are known for their collaboration with numer- and community-building organization stem from John’s vision ous community partners to expand and enhance the services in and knowledge linked to a style of leadership that enabled it all program areas. to happen: the power of convening. In sorting out and address- ing the various dimensions of emotional well-being, John has SOUTHWEST HOUSING SOLUTIONS successfully convened, not only those in need of services, but Southwest Housing Solutions began in 1979 and is a leader also previously “siloed” experts, aligning their knowledge and in the planning, development and management of affordable resources. Their ongoing collective impact is impressive. As housing and commercial property in Southwest Detroit. Their such, the corporate structures have mirrored the developing mission is to revitalize their community through collaborative, knowledge. Today there are three divisions: Southwest Coun- high-quality and innovative projects, and by promoting home seling Solutions, Southwest Housing Solutions, and Southwest ownership and resident-centered development initiatives. Their Economic Solutions. mixed-use projects stimulate commercial and cultural develop- A few moments of self-reflection may well be sufficient to ap- ment. preciate the complexity of the organizational structures that They are the leading nonprofit multi-family developer of afford- have emerged to address quality of life and success of individu- able housing in Wayne County, having developed or renovated als and families in southwest Detroit. We are complex! One’s nearly 1,400 units in multiple neighborhoods, including single- emotional well-being has many dimensions or facets, each be- family homes and multi-family apartments. More than 2,000 ing dependent on innumerable relationships/connections. people reside in their quality, affordable apartments and town- SOUTHWEST COUNSELING SERVICES homes. They have renovated and sold more than 650 homes in the metro area that were vacant, helping to reduce blight Southwest Counseling Solutions has served the Southwest and revitalize neighborhoods. They offer programs for home Detroit community since 1970. They help more than 7,500 buyer counseling, foreclosure prevention, financial coaching, individuals and families a year, improving their lives through mortgage lending, and no interest home repair loans. More than four Centers of Excellence: Adult Counseling Services; Early 2,500 families are homeowners due to their programs. One of Childhood and Family Literacy; Children, Youth and Families; every ten homes purchased in Detroit with a mortgage in 2016 and Supportive Housing. 18 fall 2018 11/2018C Boardonnections Folder Page 135 of 137 was assisted by their home buyer programs. mies, create jobs, serve residents with new goods and services, and cultivate community-based leadership. ProsperUS Detroit Southwest Housing Solutions is a trusted nonprofit partner with is the leading entrepreneurship program for aspiring minority a deep-rooted commitment to community development and a business owners in the city. More than 850 ethnic and immi- proven track record– grant entrepreneurs have graduated from their program since • $150 million of real estate development completed or it began in 2012, resulting in 150 new small businesses. Pros- in progress perUS has provided more than 1 million dollars in loans to 50 • 26 multistory buildings restored for residential and small businesses. retail use ProsperUS serves five neighborhoods: • 225,000 sq ft of commercial space created or • Cody Rouge managed for lease • Grandmont Rosedale • Neighborhood Preservation Team helps residents • Lower Eastside better the community • North End • Developer of Piquette Square, a 150-unit project for • Southwest Detroit homeless vets • Acquired, renovated and sold more than 400 REO The Center for Working Families (CWF) is based on a promis- homes that were vacant and are now owner-occupied ing national concept and is designed to help low-income fami- lies reach financial stability, access income supports, develop They manage more than 600 apartment units that they rent to educational and employment opportunities, build wealth, and low and moderate-income families and individuals – move up the economic ladder. Participants are assisted by a • Safe, affordable and quality housing in beautifully financial coach, workforce development coach and benefits renovated buildings coach. • Housing and support services for homeless or special Financial coaching helps participants manage income, reduce needs persons debt, review credit, and plan for a more successful economic • Permanent supportive housing for formerly homeless future. They offer one-on-one financial coaching and financial veterans at Piquette Square capability workshops. • A full range of services and opportunities for their They offer a variety of programs to help a family buy a home residents or keep their home. Their agency is HUD-approved, and their • Property management consulting services for other professional counselors are MSHDA certified and Neighbor- property owners Works trained and certified. They have English/Spanish bilin- Southwest Lending Solutions is a community-based lender gual counselors available. offering services to help prospective homeowners overcome The foreclosure intervention counseling provided by South- home financing challenges, plus highly competitive rates and west Economic Solutions serves homeowners throughout the terms. metro Detroit and tri-county area. SOUTHWEST ECONOMIC SOLUTIONS They offer home buyer education classes, pre-purchase coun- The mission of Southwest Economic Solutions is to provide seling and financial coaching through one-on-one sessions, opportunities for individuals and families to achieve greater group workshops, and community events. They offer special economic success. They promote and preserve homeowner- programs to help aspiring homeowners qualify for incentives ship and advance financial literacy, and have become a leader such as down payment assistance and low-interest home loans. in workforce development and adult literacy services. All their They also offer assistance for current Detroit homeowners to services are free for eligible individuals and families. apply for the City’s no-interest home repair loan program. Their Adult Learning Lab helps adults improve their literacy, To address workforce development, they offer several pro- math and computer skills so they can be better qualified for grams to help eligible participants obtain the skills, resources employment. and opportunities they need for gainful employment. Earn+ Learn is an innovative and comprehensive model of workforce ProsperUS Detroit is an entrepreneurial training and small development that involves multiple partners working together business lending program for Detroit residents, particularly to train, place and maintain participants in employment. those who are African-American, Arab-American or Latino. By helping emerging entrepreneurs develop successful busi- Homeless Veterans’ Reintegration Program (HVRP) helps nesses, ProsperUS will help strengthen neighborhood econo- (Continued on Back Cover) fall 2018 19 11/2018 Board Folder ConnectionsPage 136 of 137 Non-Profit Org. U.S. Postage PAID 426 S WALNUT Lansing, MI LANSING MI 48933 Permit No. 975 Telephone: 517-374-6848 www.cmham.org
Online editions of Connections can be found at: www.cmham.org: select “RESOURCES” on the home page, and choose “Connections” from the pull-down menu. Committed to diversity and inclusion, Connections is pleased to include authors of a variety of beliefs, opinions, and interpretations of facts and events. We do not make the determination of print-worthiness based solely on agreement with the Connections Editorial Board or the publisher, CMHAM. Individuals interested in contributing to Connections are invited to contact the editor at: [email protected].
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Leadership (From Page 19) homeless vets find meaningful employment through a broad are more apt to retain effectiveness and relevancy if we focus range of training, support and employment services. on game changers rather than on the existing iteration of a pro- gram. In doing this, why has precedent over what. Instead of PATH (Partnership Accountability Training Hope) assists wel- defending a program, we can ask, what are we doing to address fare applicants and recipients to become self-sufficient and in- this game changer? Are we making a difference? Where do we tegrated into the labor force, based on the workforce needs of excel? What’s missing? Michigan’s current and emerging economy. The seven game changers are: GAME CHANGERS Health This incredible expansion of services has all been the result of a growth in understanding the components that constitute Housing quality life, success and self-sufficiency of individuals and Income, Employment and Financial Empowerment families. This burgeoning knowledge has enabled SWSOL to Early Childhood and Education identify seven game changers. Retaining fidelity to the com- Transit plexity we are as human beings, there is recognition that each game changer has a cascading effect, that is, each has an im- Community Security and Stabilization pact beyond its particular area of emphasis. This means that Community Building and Engagement the various sectors and partners must align their strategies and A future article will focus more closely on these game chang- objectives. Likewise, it means integrating services to address ers and how they are indeed, having a significant impact on the interrelated needs of individuals and families, significantly Southwest Detroit! increasing the likelihood of their well-being and success. We
John VanCamp retired in 2018 after a 45-year career with Southwest Solutions – the last 37 as Chief Executive Officer. Connections Editor, Clint Galloway, researched Southwest Solutions – and subsequently saw first hand the impact the organization has had on the renaissance taking place in Detroit – when VanCamp guided him on a tour a few weeks ago. This article is a result of that research, the visit to the organization, and conversations with VanCamp.
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