The Way Forward: Federal Action for a System That Works for All People Living with SMI and SED and Their Families and Caregivers

Interdepartmental Serious Mental Illness Coordinating Committee

The Way Forward: Federal Action for a System That Works for All People Living With SMI and SED and Their Families and Caregivers

December 13, 2017

, 2017 TableDecember of Contents 13

Section Page

, 2017 , December 13 December

Introduction...... 1

Role of the ISMICC...... 2

The 2017 ISMICC Report to Congress...... 4

ISMICC Vision Statement...... 5

Families and Caregivers

WorksRecommendations for All From People the Non-Federal Living MembersWith SMI Summary and (See SED Chapter and 4 for Their Full

TheRecommendations) Way Forward:...... Federal Action for a System That 5

Families and Caregivers Caregivers and Families

Focus 1: Strengthen Federal CoordinationTheir and to ImproveSED Careand ...... SMI With Living 5 People All for Works

Coordinating Committee The Way Forward: Federal Action for a System That That System a for Action Federal Forward: Way The

Focus 2: Access and Engagement: Make It Easier to Get Good Care...... 5

Serious Mental Illness

Focus 3: Treatment and Recovery: Close the Gap Between What Works and WhatCommittee Is Coordinating

InterdepartmentalOffered...... 6

Serious Mental Illness Illness Mental Serious

Focus 4: Increase Opportunities for Diversion and Improve Care for People With

SMI and SED Involved in the Criminal and Juvenile Justice Systems ...... 7 Interdepartmental

Focus 5: Develop Finance Strategies to Increase Availability and Affordability of Care.. 7

References...... 9

Chapter 1: The Current Needs of Americans With Serious Mental Illnesses and Serious Emotional Disturbances...... 11

Serious Mental Illnesses...... 11

the Care of People With SMI and SED and SMI With People of Care the 55 ......

The Challenges and Opportunities for Improving the System That Supports Supports That System the Improving for Opportunities and Challenges The

Disparities and Closing the Treatment Gap Treatment the Closing and Disparities 54 ......

Key Advances in the Clinical Care of People With SMI and SED and SMI With People of Care Clinical the in Advances Key 52 ......

Challenges and Opportunities in Improving Children’s Mental Health Care Health Mental Children’s Improving in Opportunities and Challenges 51 ......

...... Presentations Stakeholder Non-Federal

51 Interdepartmental

Department of Justice: Support of Advances to Address Challenges of SMI and SED and SMI of Challenges Address to Advances of Support Justice: of Department 47 ..

. Illness Mental Serious

Interdepartmental Interdepartmental Interdepartmental ...... SED and SMI of 46

Department of Veterans Affairs: Support of Advances to Address Challenges Challenges Address to Advances of Support Affairs: Veterans of Department Committee Coordinating

Serious Mental Illness Illness Mental Serious Serious Mental Illness

Advances to Address Challenges of SMI and SED and SMI of Challenges Address to Advances 44 ......

. That System a for Action Federal Forward: Way The Substance Abuse and Mental Health Services Administration: Support of Support Administration: Services Health Mental and Abuse Substance Coordinating Committee Committee Coordinating Coordinating Committee

Works for All People Living With SMI and SED and Their Their and SED and SMI With Living People All for Works

Challenges of SMI and SED and SMI of Challenges 42 ...... Caregivers and Families

The Way Forward: Federal Action for a System That That System a for Action Federal Forward: Way The The Way Forward: Federal Action for a System That National Institute of Mental Health: Support of Advances to Address Address to Advances of Support Health: Mental of Institute National

Works for All People Living With SMI and SED and Their Their and SED and SMI With Living People All for Works Works for All People Living With SMI and SED and Their

...... Presentations Federal Families and Caregivers Caregivers and Families 40 Families and Caregivers

...... Disturbances Emotional 41

Chapter 2: Improving Practice Related to Serious Mental Illness and Serious Serious and Illness Mental Serious to Related Practice Improving 2: Chapter

...... References 30

...... Disturbances Emotional Serious 20

, 2017 , 13 December

Page Section , 2017 , 13 December December 13, 2017 (continued) Contents of Table

, 2017 DecemberAreas to Be 13 Explored by the ISMICC...... 57

Chapter 3: Setting the Stage for Evaluation of Federal Programs Related to SMI and SED...... 61

, 2017 , December 13 December Direct and Indirect Levers of Federal Influence...... 63

The ISMICC Role in Evaluating Federal Programs and Enhancing Coordination to Improve Outcomes...... 66

What Is Known to Date About Federal Programs...... 69

Future Work of the ISMICC to Evaluate Federal Programs...... 76 Families and Caregivers

ChapterWorks 4: Recommendations for All People From Non-FederalLiving With ISMICC SMI Members and...... SED and Their77 The Way Forward: Federal Action for a System That

Full Recommendations...... 78 Caregivers and Families Works for All People Living With SMI and SED and Their Their and SED and SMI With Living People All for Works

Coordinating Committee

Focus 1: Strengthen Federal Coordination That to Improve System Care a ...... for Action 78Federal Forward: Way The

Serious Mental Illness

Focus 2: Access and Engagement: Make It Easier to Get Good Care...... Committee 81 Coordinating

Interdepartmental Focus 3: Treatment and Recovery: Close the Gap Between What Works and WhatIllness Is Mental Serious

Offered...... 84

Interdepartmental Interdepartmental Focus 4: Increase Opportunities for Diversion and Improve Care for People

With SMI and SED Involved in the Criminal and Juvenile Justice Systems...... 87

Focus 5: Develop Finance Strategies to Increase Availability and Affordability

of Care...... 90

iii

Serious Mental Illness (SMI): Percentages, 2016 Percentages, (SMI): Illness Mental Serious 14 ......

Receipt of Mental Health Services in the Past Year Among Adults Age 18 or Older With With Older or 18 Age Adults Among Year Past the in Services Health Mental of Receipt 1.3.

...... 2016 Older: or 18 Age Adults 13

Past Year Substance Use Disorder (SUD) and Serious Mental Illness (SMI) Among Among (SMI) Illness Mental Serious and (SUD) Disorder Use Substance Year Past 1.2.

States, by Gender, Race/Ethnicity, Age Group: 2016 Group: Age Race/Ethnicity, Gender, by States, 12 ......

Past Year Serious Mental Illness (SMI) Among Adults Age 18 or Older in the United United the in Older or 18 Age Adults Among (SMI) Illness Mental Serious Year Past

1.1. Interdepartmental

Emotional Disturbances Emotional 1 ......

Estimates and Unmet Needs of Persons With Serious Mental Illnesses and Serious Serious and Illnesses Mental Serious With Persons of Needs Unmet and Estimates Serious Mental Illness Illness 1. Mental Serious Interdepartmental Interdepartmental Interdepartmental

Coordinating Committee Committee Figures Coordinating

Serious Mental Illness Illness Mental Serious Serious Mental Illness

...... SED and SMI With 70

Federal Programs Related to SMI and SED Programs That Can Support People People Support Can That Programs SED and SMI to Related Programs Federal 3.1.

Coordinating Committee Committee Coordinating Coordinating Committee That System a for Action Federal Forward: Way The

Works for All People Living With SMI and SED and Their Their and SED and SMI With Living People All for Works

Areas for the ISMICC to Explore During Future Meetings Future During Explore to ISMICC the for Areas 2.1. 58 ......

. Caregivers and Families

The Way Forward: Federal Action for a System That That System a for Action Federal Forward: Way The The Way Forward: Federal Action for a System That

Weighted Data From 2016 National Survey of Children’s Health Children’s of Survey National 2016 From Data Weighted 1.2. 22 ...... Works for All People Living With SMI and SED and Their Their and SED and SMI With Living People All for Works Works for All. People Living With SMI and SED and Their

Families and Caregivers Caregivers and Families Families and Caregivers

Mental Health Systems in 2016 in Systems Health Mental 15 ......

Populations Receiving Select Evidence-Based Practices in Selected State State Selected in Practices Evidence-Based Select Receiving Populations 1.1.

Tables

...... Report in Used Terms of Glossary B 104

...... Members A 94

, 2017 , 13 December

Page Appendices , 2017 , 13 December December 13, 2017 (continued) Contents of Table

, 2017 1.4. DecemberReceipt of 13 Mental Health Care and Specialty Substance Use Treatment in the Past Year Among Adults Age 18 or Older Who Had Past Year Serious Mental Illness and

Substance Use Disorders: Percentages, 2016...... 14 , 2017 ,

1.5. Past Year Major Depressive Episode Among Adolescents Ages 12 to 17 in the United 13 December States, by Race/Ethnicity: 2016...... 22

1.6. Past Year Substance Use Disorder (SUD) and Major Depressive Episode (MDE) Among Youth Ages 12 to 17: 2016...... 23

1.7. Past Year Treatment for Depression Among Adolescents Ages 12 to 17 With Major

Depressive Episodes in the United States: 2016...... 26

Families and Caregivers 3.1. WorksGovernment for All and PeoplePrivate Funding Living Sources With for Mental SMI Health and (MH)SED and and Substance Their

Use Disorder (SUD) Treatment...... 62

The Way Forward: Federal Action for a System That

Families and Caregivers Caregivers and Families

Works for All People Living With SMI and SED and Their Their and SED and SMI With Living People All for Works

Coordinating Committee The Way Forward: Federal Action for a System That That System a for Action Federal Forward: Way The

Serious Mental Illness

Coordinating Committee Committee Coordinating

Interdepartmental

Serious Mental Illness Illness Mental Serious

Interdepartmental Interdepartmental

Interdepartmental

Serious Mental Illness Illness Mental Serious Interdepartmental Interdepartmental Interdepartmental Coordinating Committee Committee Coordinating Serious Mental Illness Illness Mental Serious Serious Mental Illness Coordinating Committee Committee Coordinating Coordinating Committee That System a for Action Federal Forward: Way The Works for All People Living With SMI and SED and Their Their and SED and SMI With Living People All for Works Families and Caregivers Caregivers and Families The Way Forward: Federal Action for a System That That System a for Action Federal Forward: Way The The Way Forward: Federal Action for a System That Works for All People Living With SMI and SED and Their Their and SED and SMI With Living People All for Works Works for All People Living With SMI and SED and Their Families and Caregivers Caregivers and Families Families and Caregivers

, 2017 , 13 December

, 2017 , 13 December December 13, 2017

, 2017

IntroductionDecember 13

, 2017 , In 2003, the President’s New Freedom Commission on Mental Health concluded that America’s 13 December mental health service delivery system was in shambles. The Commission’s final report stated that “for too many Americans with mental illnesses, the mental health services and supports they need remain fragmented, disconnected and often inadequate, frustrating the opportunity for recovery.” A number of the recommendations of the President’s New Freedom Commission on Mental Health were not implemented or have only been partially realized. Since then, quality of life has not fundamentally changed for adults with serious mental illnesses (SMI) and children and youth with serious emotional disturbances (SED) and their families in the United States (Figure 1).

Figure 1. Estimates and Unmet Needs of Persons With Serious Mental Illnesses and

Serious Emotional Disturbances

Families and Caregivers

WorksThe for Health All CarePeople System LivingHas Failed Withto Address SMI the Needsand ofSED Persons and Their

TheWith Way Serious Forward: Mental Illnesses Federal (SMI) and ActionSerious Emotional for a DisturbancesSystem That(SED) Families and Caregivers Caregivers and Families

Works for All People Living With SMI and SED and Their Their and SED and SMI With Living People All for Works

Coordinating Committee The Way Forward: Federal Action for a System That That System a for Action Federal Forward: Way The

One in ten youths in SAMHSA’s Children's Mental Health Initiative

Serious Mental hadIllness attempted suicide prior to receiving services2

4.2% Committee Coordinating Approximate number of InterdepartmentalPercentage of the adult population, age 18

and over, living with SMI in the past year1 persons with SMI admitted

3 2 million annually to U.S. jails Illness Mental Serious

Sources

1 CBHSQ, 2017a Nearly one in four 2 CMHS/SAMHSA, 2016 Only about one in three Interdepartmental adults with SMI lived below the 3 Steadman et al., 2009 people with mental

4 4 CBHSQ, 2017b poverty line in the past year 5 SAMHSA, 2015 illness in jails or prisons 6 HHS, 2012 is currently receiving

7 Ibid. 5 any treatment

The suicide rate for individuals with mood disorders such as depression or bipolar 7% to 12 % disorder is 25 times higher Percentage of youth 6

than among the general population under age 18 with SED7

with SED. with

coordinate the administration of mental health services for adults with SMI or children children or SMI with adults for services health mental of administration the coordinate

Make specific recommendations for actions that federal departments can take to better better to take can departments federal that actions for recommendations specific Make •

including outcomes across a number of important dimensions; and dimensions; important of number a across outcomes including Evaluate the effect federal programs related to SMI and SED have on public health, health, public on have SED and SMI to related programs federal effect the Evaluate •

intervention, treatment and recovery, and access to services and supports; and services to access and recovery, and treatment intervention,

Report on advances in research on SMI and SED related to prevention, diagnosis, diagnosis, prevention, to related SED and SMI on research in advances on Report

• Interdepartmental

to: charged is ISMICC The

improve service access and delivery of care for people with SMI and SED and their families. their and SED and SMI with people for care of delivery and access service improve

Illness Coordinating Committee (ISMICC) to enhance coordination across federal agencies to to agencies federal across coordination enhance to (ISMICC) Committee Illness Coordinating Illness Mental Serious Interdepartmental Interdepartmental InterdepartmentalMental Serious Interdepartmental the authorizes 114-255) Law (Public Act Cures Century 21st The

Coordinating Committee Committee Coordinating Serious Mental Illness Illness Mental Serious Serious Mental Illness ISMICC the of Role

Coordinating Committee Committee Coordinating Coordinating Committee Act. That Education System a Disabilities for with Action Individuals the and Federal Act Forward: Way The and this prevents them from exercising their legal rights under the Americans with Disabilities Disabilities with Americans the under rights legal their exercising from them prevents this and

and discrimination, they don’t access services and supports that could improve their situations, situations, their improve could that Their supports and and SED services and access don’t SMI they With Living discrimination, and People All for Works

communities. When individuals and their families don’t seek help because of negative attitudes attitudes negative of because help seek don’t families their and individuals When communities. Caregivers and Families

The Way Forward: Federal Action for a System That That System a for Action Federal Forward: Way The The their Wayin Forward:valued and embraced Federal being from Actionconditions for ahealth Systemmental Thatserious with adults and Works for All People Living With SMI and SED and Their Their and SED and SMI With Living People All for Works Works youth, for Allchildren, Peoplepreventing Livingcare, health Withand SMIwork, andschool, SEDincluding andsetting, Theirevery of part

Families and Caregivers Caregivers and Families Families and Caregivers painful a remain discrimination and attitudes Negative

families and our communities. communities. our and families

the ISMICC) the

circumstances violence has led to unspeakable pain for for pain unspeakable to led has violence circumstances (submitted through public comments to to comments public through (submitted Marilyn —

SED die of suicide at extremely high rates, and in rare rare in and rates, high extremely at suicide of die SED disabled, mentally ill people like my son.” my like people ill mentally disabled,

community solutions to provide care for highly highly for care provide to solutions community remain all too common. Tragically, people with SMI and and SMI with people Tragically, common. too all remain

up entirely. We need a federal standard and and standard federal a need We entirely. up

or to access higher education, housing, or employment employment or housing, education, higher access to or

possible situations, become distraught, or give give or distraught, become situations, possible

emergency departments. Failure to succeed in school school in succeed to Failure departments. emergency

care, many family members are caught in im in caught are members family many care, -

unnecessary incarceration and long waits in hospital hospital in waits long and incarceration unnecessary and often deaths. Without access to adequate adequate to access Without deaths. often and

through hospitals or ERs, and homelessness, homelessness, and ERs, or hospitals through systems while contributing to poor outcomes such as as such outcomes poor to contributing while systems

is a travesty: incarceration, multiple cycles cycles multiple incarceration, travesty: a is

the primary solutions, overtaxing these services and and services these overtaxing solutions, primary the

since the closing of psychiatric care facilities facilities care psychiatric of closing the since

public education systems, and homeless services as as services homeless and systems, education public

greatly disabled by them. What has transpired transpired has What them. by disabled greatly 2017 , 13 December

services, criminal justice systems, hospital services, services, hospital systems, justice criminal services, psychotic thoughts not based in reality, and is is and reality, in based not thoughts psychotic

taking his medications but continues to have have to continues but medications his taking We have continued to defer to law enforcement enforcement law to defer to continued have We

mental hospitals over a 3-year period. He is is He period. 3-year a over hospitals mental

medical problems, and addiction challenges abound. abound. challenges addiction and problems, medical

“My adult son has cycled 13 times through through times 13 cycled has son adult “My , 2017 , 13 December December 13, 2017 comorbid unemployment, supports, social Poor

, 2017 The ISMICCDecember is chaired 13 by Dr. Elinore F. McCance-Katz, Assistant Secretary for Mental Health and Substance Use. This position brings a new level of authority, experience, and expertise to the coordination of efforts at the Department of Health and Human Services (HHS) to address

the needs of people with SMI and SED. Dr. McCance-Katz and other federal members on the

, 2017 , Committee will work across HHS and the federal government so Americans with SMI and SED are 13 December able to improve their lives and have access to the highest possible standard of care—care that is deeply informed by our knowledge of science and medicine.

The ISMICC is a historic chance to address Federal Department and Agency Representation SMI and SED across federal departments on the ISMICC and the systems that they represent. Each of the eight departments supports • Secretary of the Department of Health and Human Services programs that address the needs of people • Assistant Secretary for Mental Health and Substance Use • Attorney General, Department of Justice

with SMI and SED. Their collaboration • Secretary of the Department of Veterans Affairs will be Familiesinformed and andstrengthened Caregivers by the • Secretary of the Department of Defense

participation of non-federal members, • Secretary of the Department of Housing and Urban includingWorks national for experts All onPeople health Living DevelopmentWith SMI and SED and Their

• Secretary of the Department of Education

care research,The Waymental Forward:health providers, Federal • ActionSecretary of thefor Department a System of Labor That advocates, and people with mental health • Administrator of the Centers for Medicare & Medicaid Caregivers and Families

Services conditions and their families and caregivers. Their and SED and SMI With Living People All for Works

The ISMICC is currently authorized through • Commissioner of the Social Security Administration Coordinating Committee 2022, at which time the Secretary of HHS That System a for Action Federal Forward: Way The

will submit a recommendation to Congress

about whetherSerious to extend the Mental ISMICC. Illness

Coordinating Committee Committee Coordinating

The non-federalInterdepartmental ISMICC members have firsthand experience with the mental health service system, and knowledge of what barriers exist for people who are seeking help. Moreover,Illness the non- Mental Serious

federal members bring on-the-ground solutions and innovative ideas that can promote change

and improve lives, in partnership with the federal members.

Interdepartmental Interdepartmental Together, ISMICC members bring the experience needed to develop a better understanding of

what is working and what needs to be changed within the current systems of care. (See Appendix A for the full ISMICC membership.) This cross-sector, public-private partnership provides a

unique opportunity to share and generate solutions not previously considered or implemented.

By strengthening federal interdepartmental leadership and coordination, we can change federal policy to improve the availability and quality of care for people served. Improvement will come not just through the provision of more health care services, but through a more holistic approach—a true continuum of care that makes sense for each unique person. We seek to build a system where treatment and services work and individuals with SMI and SED can recover and live

happier, healthier, more productive, and more connected lives.

the individual needs of each person and their family and caregivers. caregivers. and family their and person each of needs individual the

to tailored and appropriate, navigate, to easy are that systems to lead will levels local and county, levels of government. A commitment to coordinate and collaborate at the federal, state, tribal, tribal, state, federal, the at collaborate and coordinate to commitment A government. of levels

efforts will help build new relationships and partnerships across public sectors, agencies, and and agencies, sectors, public across partnerships and relationships new build help will efforts Interdepartmental

that the work of the ISMICC will stimulate change across federal and non-federal sectors. Federal Federal sectors. non-federal and federal across change stimulate will ISMICC the of work the that

address the needs of people with SMI and SED and their families and caregivers. We anticipate anticipate We caregivers. and families their and SED and SMI with people of needs Illness the address Mental Serious

Interdepartmental Interdepartmental to Interdepartmentalpartnerships promote will and coordination cross-sector for model a as serve will ISMICC The

Coordinating Committee work. Committee Committee’s Coordinating

Serious Mental Illness Illness Mental Serious Serious the of progress Mentalthe further to needed Illnessas documents other and reports interim develop will

the lives of those with SMI and SED. The ISMICC ISMICC The SED. and SMI with those of lives the

Coordinating Committee Committee Coordinating Coordinating Committee That improving for System a for opportunities future Action identify will Federal and Forward: Way The

information on what the ISMICC has accomplished accomplished has ISMICC the what on information

availability and affordability of care of affordability and availability Their and SED and SMI With Living People All for Works

December 2022 and will provide more complete complete more provide will and 2022 December

Develop finance strategies to increase increase to strategies finance Develop 5. The final ISMICC report to Congress is due due is Congress to report ISMICC final The Caregivers and Families

The Way Forward: Federal Action for a System That That System a for Action Federal Forward: Way The The Way Forward: Federalsystems Action for a System That involved in the criminal and juvenile justice justice juvenile and criminal the in involved

periodically in the coming years. coming the in periodically

Works for All People Living With SMI and SED and Their Their and SED and SMI With Living People All for Works WorksSED and SMI forwith Allpeople for People care improve Living With SMI and SED and Their

revisit this report, its charge, and the areas of focus focus of areas the and charge, its report, this revisit Increase opportunities for diversion and and diversion for opportunities Increase 4.

Families and Caregivers Caregivers and Families Families and Caregivers to plan members ISMICC the science, emerging to between what works and what is offered is what and works what between

factors for the course of mental illnesses. Sensitive Sensitive illnesses. mental of course the for factors Treatment and recovery: Close the gap gap the Close recovery: and Treatment 3.

improve the ability to diagnose and identify risk risk identify and diagnose to ability the improve

good care good

Research is identifying new and powerful ways to to ways powerful and new identifying is Research Access and engagement: Make it easier to get get to easier it Make engagement: and Access 2.

important treatment advances are on the horizon. horizon. the on are advances treatment important

care

will guide the Committee’s work. We know that that know We work. Committee’s the guide will Strengthen federal coordination to improve improve to coordination federal Strengthen 1.

for fulfilling the Committee’s vision. The five areas areas five The vision. Committee’s the fulfilling for

Five ISMICC Areas of Focus of Areas ISMICC Five

The ISMICC identified five major areas of focus focus of areas major five identified ISMICC The

ahead.

with the ISMICC members. This report will set the stage for work by the ISMICC in the years years the in ISMICC the by work for stage the set will report This members. ISMICC the with 2017 , 13 December information presented in the first ISMICC meeting in August 2017 and from ongoing dialogue dialogue ongoing from and 2017 August in meeting ISMICC first the in presented information

The work of the ISMICC is just beginning. This 2017 ISMICC Report to Congress includes includes Congress to Report ISMICC 2017 This beginning. just is ISMICC the of work The , 2017 , 13 December December 13, 2017 Congress to Report ISMICC 2017 The

, 2017 ISMICCDecember Vision Statement 13

Federal interdepartmental leadership, with genuine collaboration and shared accountability of

all federal agencies, and in partnership with all levels of government and other stakeholders,

, 2017 , supports a mental health system that successfully addresses the needs of all individuals living 13 December with SMI or SED and their families and caregivers, effectively supporting their progress to achieve healthy lives characterized by autonomy, pride, self-worth, hope, dignity, and meaning.

Recommendations From the Non-Federal Members Summary1 (See Chapter 4 for Full Recommendations)

Focus 1: Strengthen Federal Coordination to Improve Care

1.1. FamiliesImprove ongoing and interdepartmental Caregivers coordination under the guidance of the Assistant

WorksSecretary forfor Mental All PeopleHealth and SubstanceLiving WithUse. SMI and SED and Their

1.2. TheDevelop Way and implement Forward: an interdepartmental Federal Action strategic for plan a toSystem improve the That lives of people

with SMI and SED and their families. Caregivers and Families Works for All People Living With SMI and SED and Their Their and SED and SMI With Living People All for Works

1.3. CoordinatingCreate a comprehensive inventory ofCommittee federal activities that affect the provision of services

for people with SMI and SED. That System a for Action Federal Forward: Way The

1.4. SeriousHarmonize and improve Mental policies to support Illness federal coordination.

1.5. Evaluate the federal approach to serving people with SMI and SED. Committee Coordinating Interdepartmental

1.6. Use data to improve quality of care and outcomes. Illness Mental Serious

1.7. Ensure that quality measurement efforts include mental health. Interdepartmental

1.8. Improve national linkage of data to improve services.

Focus 2: Access and Engagement: Make It Easier to Get Good Care

2.1. Define and implement a national standard for crisis care.

1 These recommendations reflect the views of the non-federal ISMICC members. Federal members were consulted regarding factual concerns and federal processes, but the final list of recommendations are the product of the non-federal members. These recommendations do not represent federal policy, and the federal departments represented on the ISMICC have not reviewed the recommendations to determine what role they could play in the future activities of the departments. The recommendations should not be interpreted as recommendations from the federal government.

recovery services. recovery

3.8. Develop a priority research agenda for SED/SMI prevention, diagnosis, treatment, and and treatment, diagnosis, prevention, SED/SMI for agenda research priority a Develop

3.7. Advance the national adoption of effective suicide prevention strategies. prevention suicide effective of adoption national the Advance

3.6.

Make housing more readily available for people with SMI and SED. and SMI with people for available readily more housing Make

throughout the nation. the throughout

3.5.

youth transition-age and youth, children, for care of systems effective Implement

care for people with SMI and SED. and SMI with people for care Interdepartmental

3.4. of systems our all in expectation the care health whole-person trauma-informed, Make

3.3. Make coordinated specialty care for first-episode psychosis available nationwide. available psychosis first-episode for care specialty coordinated Illness Make Mental Serious Interdepartmental Interdepartmental Interdepartmental

Coordinating Committee expectation. national a adults Committee young Coordinating 3.2.

Serious Mental Illness Illness Mental Serious and Serious youth, Mentaltransition-age youth, children, Illnessamong intervention early and screening Make

3.1.

Coordinating Committee Committee Coordinating CoordinatingSED. and SMI with Committeepeople for That care of System continuum a for comprehensive Action a Provide Federal Forward: Way The

Focus 3: Treatment and Recovery: Close the Gap Between What Works and What Is Offered Is What and Works What Their Between and Gap the SED Close and Recovery: SMI and With Treatment 3: Living Focus People All for Works

Families and Caregivers Caregivers and Families 2.10.

The Way Forward: Federal Action for a System That That System a for Action Federal Forward: Way The The Way Forward:settings. Federalcare primary all Actionin occur to for a Systemscreening SED and ThatSMI Expect

2.9. Works for All People Living With SMI and SED and Their Their and SED and SMI With Living People All for Works Works for All People Living With SMIcaregivers. andand SEDmembers andfamily TheirSupport

Families and Caregivers Caregivers and Families Families and Caregivers 2.8. Maximize the capacity of the behavioral health workforce. health behavioral the of capacity the Maximize

2.7. Use telehealth and other technologies to increase access to care. to access increase to technologies other and telehealth Use

2.6. Prioritize early identification and intervention for children, youth, and young adults. young and youth, children, for intervention and identification early Prioritize

2.5. Establish standardized assessments for level of care and monitoring of consumer progress. consumer of monitoring and care of level for assessments standardized Establish

2.4. Reassess civil commitment standards and processes. processes. and standards commitment civil Reassess

and other privacy laws, including 42 CFR Part 2, in the context of psychiatric care. psychiatric of context the in 2, Part CFR 42 including laws, privacy other and

caregivers about the Health Insurance Portability and Accountability Act of 1996 (HIPAA) (HIPAA) 1996 of Act Accountability and Portability Insurance Health the about caregivers 2017 , 13 December

2.3. Educate providers, service agencies, people with SMI and SED and their families, and and families, their and SED and SMI with people agencies, service providers, Educate

community-based alternatives to hospitalization. to alternatives community-based

2.2. , 2017 , 13 December December and 13capacity , 2017bed psychiatric adequate includes that care of continuum a Develop

, 2017 3.9. DecemberMake integrated 13 services readily available to people with co-occurring mental illnesses and substance use disorders, including medication-assisted treatment (MAT) for opioid use

disorders.

, 2017 , 3.10. Develop national and state capacity to disseminate and support implementation of the 13 December national standards for a comprehensive continuum of effective care for people with SMI and SED.

Focus 4: Increase Opportunities for Diversion and Improve Care for People With SMI and SED Involved in the Criminal and Juvenile Justice Systems

4.1. Support interventions to correspond to all stages of justice involvement. Consider all points included in the sequential intercept model.

4.2. Develop an integrated crisis response system to divert people with SMI and SED from the

Familiesjustice system. and Caregivers

4.3. WorksPrepare and for train All all Peoplefirst responders Living on how With to work SMI with andpeople SED with SMI and and TheirSED.

The Way Forward: Federal Action for a System That

4.4. Establish and incentivize best practices for competency restoration that use community- Caregivers and Families

based evaluation and services. Their and SED and SMI With Living People All for Works

Coordinating Committee

4.5. Develop and sustain therapeutic justice docketsThat in federal,System state,a for and local courtsAction for anyFederal Forward: Way The

person with SMI or SED who becomes involved in the justice system. Serious Mental Illness

4.6. Require universal screening for mental illnesses, substance use disorders, and otherCommittee Coordinating

behavioral health needs of every person booked into jail. Interdepartmental 4.7. Strictly limit or eliminate the use of solitary confinement, seclusion, restraint, Illness or other Mental Serious

forms of restrictive housing for people with SMI and SED.

4.8. Reduce barriers that impede immediate access to treatment and recovery services upon Interdepartmental release from correctional facilities.

4.9. Build on efforts under the Mentally Ill Offender Treatment and Crime Reduction Act, the

st 21 Century Cures Act, and other federal programs to reduce incarceration of people with mental illness and co-occurring substance use disorders.

Focus 5: Develop Finance Strategies to Increase Availability and Affordability of Care

5.1. Implement population health payment models in federal health benefit programs.

5.2. Adequately fund the full range of services needed by people with SMI and SED.

Interdepartmental

Works for All People Living With SMI and SED and Their Their and SED and SMI With Living People All for Works Works for All People Living With SMI and SED and Their

5.8. Families and Caregivers Caregivers and Families Familiesnationwide. program and Caregivers(CCBHC) Clinic Health Behavioral Community Certified the Expand

adults with SMI. with adults

5.7. Fund adequate home- and community-based services for children and youth with SED and and SED with youth and children for services community-based and home- adequate Fund

care.

5.6. Provide reimbursement for outreach and engagement services related to mental health health mental to related services engagement and outreach for reimbursement Provide

care services. care

5.5. Pay for psychiatric and other behavioral health services at rates equivalent to other health health other to equivalent rates at services health behavioral other and psychiatric for Pay

5.4.

Eliminate financing practices and policies that discriminate against behavioral health care. health behavioral against discriminate that policies and practices financing Eliminate 2017 , 13 December

comparable to those for physical illnesses. physical for those to comparable

and substance abuse services they are entitled to, and that benefits are offered on terms terms on offered are benefits that and to, entitled are they services abuse substance and

5.3. , 2017 , 13 December Decemberhealth mental 13the , 2017receive SED and SMI with people that ensure to parity enforce Fully

, 2017 ReferencesDecember 13

Center for Behavioral Health Statistics and Quality (CBHSQ). (2017a). 2016 National Survey on

Drug Use and Health: Detailed Tables. (NSDUH 2016, Table 8.6B). Rockville, MD: Substance

, 2017 , Abuse and Mental Health Services Administration. 13 December

Center for Behavioral Health Statistics and Quality (CBHSQ). (2017b). 2016 National Survey on Drug Use and Health: Detailed Tables. (NSDUH 2016, Table 8.6A). Rockville, MD: Substance Abuse and Mental Health Services Administration.

Center for Mental Health Services (CMHS), Substance Abuse and Mental Health Services Administration (SAMHSA). (2016). The evaluation of the comprehensive community mental health services for children with serious emotional disturbances program, report to Congress, 2015 (SAMHSA Publication No. PEP16-CMHI2015). Retrieved from https://www.samhsa.gov/

sites/default/files/programs_campaigns/nitt-ta/2015-report-to-congress.pdf. Families and Caregivers President’sWorks New Freedom for All Commission People onLiving Mental Health.With (2003).SMI andAchieving SED the Promise:and Their

Transforming Mental Health Care in America. Retrieved from http://govinfo.library.unt.edu/ The Way Forward: Federal Action for a System That

mentalhealthcommission/reports/FinalReport/downloads/FinalReport.pdf. Caregivers and Families

Steadman, H. J., Osher, F. C., Robbins, P. C., Case,Their B.,and & Samuels,SED S.and (2009). SMI PrevalenceWith of seriousLiving People All for Works

Coordinating Committee mental illness among jail inmates. Psychiatric Services,That 60(6),System 761-765.a for Action Federal Forward: Way The

Substance Abuse and Mental Health Services Administration (SAMHSA). (2015). Screening and

assessmentSerious of co-occurring Mental disorders in the Illness justice system. (HHS Publication No. (SMA)-15-

4930). Rockville, MD: Substance Abuse and Mental Health Services Administration. Committee Coordinating

U.S. DepartmentInterdepartmental of Health and Human Services (HHS) Office of the Surgeon General and National Action Alliance for Suicide Prevention. (2012). 2012 national strategy for suicideIllness Mental Serious

prevention: Goals and objectives for action. Washington, DC: U.S. Department of Health &

Human Services. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK109917 . Interdepartmental

Interdepartmental

, 2017 , 13 December

, 2017 , 13 December December 13, 2017

, 2017 ChapterDecember 1: The 13 Current Needs of Americans With Serious

Mental Illnesses and Serious Emotional Disturbances

, 2017 , December 13 December

This report focuses on issues related to adults 2 with serious mental illnesses (SMI) and children Defining SMI and youth with serious emotional disturbances Serious mental illness (SMI) refers to individuals 18 or (SED).2 older, who currently or at any time during the past year have had a diagnosable mental, behavioral, or emotional disorder of sufficient duration to meet diagnostic criteria specified in the diagnostic manual of the American Serious Mental Illnesses Psychiatric Association and that has resulted in functional impairment, that substantially interferes with or limits

one or more major life activities.

The definition of SMI includes one or more Families and Caregivers Major life activities include basic daily living skills (e.g.

diagnoses of mental disorders combined eating, bathing, dressing); instrumental living skills (e.g., with significantWorks impairment for All People in functioning. Living Withmaintaining SMI a household, and SEDmanaging andmoney, gettingTheir

Schizophrenia, bipolar illness, and major around the community, taking prescribed medication);

The Way Forward: Federal Actionand functioning for ina social, System family, and vocational/educaThat - depressive disorder are the diagnoses most Caregivers and Families tional contexts.

commonly associated with SMI, but people

with one or more other disorders may also fitTheir and SED and SMI With Living People All for Works

Coordinating Committee the definition of SMI if those disorders result in That System a for Action Federal Forward: Way The

functional impairment.

About Serious1 in 25 adults has anMental SMI in a given year.Illness In 2016, 4.2 percent of U.S. adults age 18

or older (an estimated 10.4 million adults) had an SMI in the past year (CBHSQ, 2017a). ThisCommittee Coordinating

estimateInterdepartmental includes new and existing cases of SMI. The percentage of SMI in the past year was higher for sexual minority adults (13.1 percent) than for sexual majority adults (3.6 percent)Illness Mental Serious

(Medley et al., 2016). Across racial and ethnic groups, people of two or more races (7.5 percent) and Non-Hispanic Whites (4.8 percent) had higher percentages of SMI in the past year than the Interdepartmental

national average (4.2 percent) (Figure 1.1). In 2016, women accounted for 65.4 percent of adults with SMI (CBHSQ, 2017a).

The percentage of SMI in the past year also varies across age groups, with those 50 and older (2.7 percent) having lower rates than those aged 18 to 25 (5.9 percent) or those aged 26 to 49 (5.3 percent). The lower prevalence in older adults may be impacted by the increased risk of earlier death among people with SMI.

2 For the precise wording of the definition, see https://www.samhsa.gov/sites/default/files/federal-register-notice-58-96-definitions.pdf. Note that impairment resulting from a primary diagnosis of substance use disorder does not qualify a person as having a serious mental illness. This report does not address Alzheimer’s disease or related disorders that are listed in the Diagnostic and Statistical Manual of Mental Disorders and cause functional impairment. The ISMICC has noted the need for consistent

definitions of SMI and SED and is considering how best to address these definitional issues moving forward.

Now known as the National Academy of Medicine of Academy National the as known Now 3

(Kessler, Chiu, Demler, & Walters, 2005). About a quarter of adults with SMI (25.4 percent, an an percent, (25.4 SMI with adults of quarter a About 2005). Walters, & Demler, Chiu, (Kessler,

Nearly three-quarters of adults with SMI are diagnosed with two or more mental disorders disorders mental more or two with diagnosed are SMI with adults of three-quarters Nearly diagnose and treat these complex and interrelated disorders (SAMHSA, 2002). (SAMHSA, disorders interrelated and complex these treat and diagnose

to equipped settings in care integrated receive to need individuals These care. room emergency to poorer health outcomes overall and utilization of high-cost services such as inpatient and and inpatient as such services high-cost of utilization and overall outcomes health poorer to

co-occurring disorders often experience difficulty seeking and receiving services, which leads leads which services, receiving and seeking difficulty experience often disorders co-occurring Interdepartmental

care is essential to improved health outcomes, especially for chronic illnesses.” chronic for especially outcomes, health improved to essential is care People with with People

problems and illnesses are frequently intertwined, and coordination of all these types of health health of types these all of coordination and intertwined, frequently are illnesses Illness and problems Mental Serious Interdepartmental Interdepartmental Interdepartmentalhealth general and substance-use, mental, this, of Because … illnesses. neurological and diabetes,

other, as well as a substantial number of general medical illnesses such as heart disease, cancers, cancers, disease, heart as such illnesses medical general of number substantial a as well Committee as other, Coordinating substance-use problems and illnesses seldom occur in isolation. They frequently accompany each each accompany frequently They isolation. in occur seldom illnesses and problems substance-use

stated by the Institute of Medicine of Institute the by stated

Serious Mental Illness Illness Mental Serious Seriousand “Mental 2005), MentalCorrigan, and Page, IllnessEngland, (Daniels, 3

Adults with SMI often have multiple chronic conditions and general health issues. health general and conditions chronic multiple have often SMI with Adults

Coordinating Committee Committee Coordinating CoordinatingAs Committee That System a for Action Federal Forward: Way The

Rockville, MD: Substance Abuse and Mental Health Services Administration. Services Health Mental and Abuse Substance MD: Rockville, tables.

Source: Center for Behavioral Health Statistics and Quality. (2017). (2017). Quality. and Statistics Health Behavioral for Center Results from the 2016 National Survey on Drug Use and Health: detailed detailed Health: and Use Drug on Survey National 2016 the Their from Results and SED and SMI With Living People All for Works Families and Caregivers Caregivers and Families The Way Forward: Federal Action for a System That That System a for Action Federal Forward: Way The The Way Forward: Federal Action for a System That Works for All People Living With SMI and SED and Their Their and SED and SMI With Living People All for Works Works for All People Living With SMI and SED and Their Families and Caregivers Caregivers and Families Families and Caregivers

, 2017 , 13 December

United States, by Gender, Race/Ethnicity, Age Group: 2016 Group: Age Race/Ethnicity, Gender, by States, United

1.1. Figure , 2017 , 13 December the Decemberin Older or 18 13 , 2017Age Adults Among (SMI) Illness Mental Serious Year Past

, 2017 estimatedDecember 2.6 million 13 adults) have a substance use disorder (Figure 1.2) (CBHSQ, 2017b), and approximately one in six (16.1 percent) misused opioids in the past year (CBHSQ, 2017c). Adults with SMI and substance use disorders “show more severe symptoms of mental illness, more

frequent hospitalizations, more frequent relapses, and a poorer course of illness than patients

, 2017 , with a single diagnosis, as well as higher rates of violence, suicide, and homelessness” (Bellack, 13 December Bennett, Gearon, Brown, & Yang, 2006). Nearly half of people with SMI used tobacco in the past year (49 percent) (CBHSQ, 2017d). A growing body of research shows that quitting smoking can improve mental health and addiction recovery outcomes (SAMHSA, n.d.-a); for example, smoking cessation is associated with a decreased risk of anxiety and mood disorders (Cavazos-Rehg et al., 2014).

Figure 1.2. Past Year Substance Use Disorder (SUD) and Serious Mental Illness (SMI)

Among Adults Age 18 or Older: 2016

Families and Caregivers

Works for All People Living With SMI and SED and Their

The Way Forward: Federal Action for a System That

Families and Caregivers Caregivers and Families

Works for All People Living With SMI and SED and Their Their and SED and SMI With Living People All for Works

Coordinating Committee The Way Forward: Federal Action for a System That That System a for Action Federal Forward: Way The

Serious Mental Illness

Coordinating Committee Committee Coordinating

Interdepartmental Source: Adapted from Figure 69 of: Substance Abuse and Mental Health Services Administration. (2017). Key substance useIllness and mental Mental Serious health indicators in the United States: Results from the 2016 National Survey on Drug Use and Health (HHS Publication No. SMA17-5044,

NSDUH Series H-52). Retrieved from http://www.samhsa.gov/data.

Relatively few adults with SMI receive effective treatments. Treatments that are Interdepartmental

demonstrated to be effective for SMI may include some combination of prescription medications, other supports (e.g., inpatient treatment, respite care, assertive community treatment,

coordinated specialty care, supported employment), and psychotherapy (e.g., cognitive behavioral therapy, cognitive remediation therapy). About two-thirds of adults with SMI (64.8 percent, an estimated 6.7 million adults) (CBHSQ, 2017e) reported receiving mental health treatment in 2016 (Figure 1.3). Most treatment is offered in outpatient settings, with only 7.6 percent (an estimated 789,000 adults) receiving inpatient mental health treatment/counseling in the past year (CBHSQ, 2017f). Nearly a third (32.6 percent, 2.2 million adults) of those who get treatment receive medications only, with no psychosocial or psychotherapeutic services (CBHSQ, 2017g). Among adults with co-occurring SMI and substance use disorders, nearly two-thirds (63.2 percent) received mental health care, but only 14.3 percent received specialized substance use treatment

(Figure 1.4).

. http://www.samhsa.gov/data from Retrieved H-52). Series NSDUH

(HHS Publication No. SMA17-5044, SMA17-5044, No. Publication (HHS Health and Use Drug on Survey National 2016 the from Results States: United the in indicators health

Source: Key substance use and mental mental and use substance Key (2017). Administration. Services Health Mental and Abuse Substance of: 73 Figure from Adapted

Interdepartmental

Serious Mental Illness Illness Mental Serious Interdepartmental Interdepartmental Interdepartmental Coordinating Committee Committee Coordinating

Serious Mental Illness Illness Mental Serious Serious Mental Illness

Coordinating Committee Committee Coordinating Coordinating2016 Percentages, Committee Disorders: That Use Substance System a and for Illness Action Mental Federal Forward: Way The the Past Year Among Adults Age 18 or Older Who Had Past Year Serious Serious Year Past Had Who Older or 18 Age Adults Among Year Past the

Receipt of Mental Health Care and Specialty Substance Use Treatment in in Treatment Use Substance Specialty and Care Health Mental of Receipt Works for All People Living With SMI and SED and Their Their and SED and SMI With 1.4. Living Figure People All for Works Families and Caregivers Caregivers and Families The Way Forward: Federal Action for a System That That System a for Action Federal Forward: Way The The Way Forward: Federal Action for a System That

Works for All People Living With SMI and SED and Their Their and SED and SMI With Living People All for Works Works for All People Living With SMI and SED and Their

Detailed tables. Rockville, MD: Substance Abuse and Mental Health Services Administration. Services Health Mental and Abuse Substance MD: Rockville, tables. Detailed

Source: Adapted from Table 8.33 of: Center for Behavioral Health Statistics and Quality. (2017). (2017). Quality. and Statistics Health Behavioral for Center of: 8.33 Table from Adapted Families and Caregivers Caregivers and Families health: Familiesand use drug on andsurvey national Caregivers 2016

, 2017 , 13 December

Older With Serious Mental Illness (SMI): Percentages, 2016 Percentages, (SMI): Illness Mental Serious With Older

1.3. Figure , 2017 , 13 December or 18 December Age Adults 13, 2017Among Year Past the in Services Health Mental of Receipt

, 2017 EffectiveDecember treatment 13 models exist, but are not widely available.States report annually on the implementation of select evidence-based practices (EBPs) in their systems. EBPs are practices that are based on rigorous research that has demonstrated effectiveness in achieving the

outcomes that the practices were designed to achieve. State mental health systems often serve

, 2017 , those with mental health conditions, including SMI and SED, who are Medicaid eligible and 13 December whose conditions require levels of care not paid for by private insurance. The percentage of the population who have access to these EBPs remains low and varies widely across states, recognizing that not all EBPs are appropriate for all people with SMI or SED (Table 1.1). For example, assertive community treatment, an intensive team-based care model that is a long-established best practice for adults with SMI, is provided to only 2.1 percent of the people served in state systems nationwide. Similarly, the individual placement and support model of supported employment, which should be provided to all adults with SMI who have a goal of employment, also is provided

to only 2.1 percent of adults in state systems.

Table 1.1.Families Populations and CaregiversReceiving Select Evidence-Based Practices in Selected State

WorksMental for HealthAll People Systems Livingin 20164 With SMI and SED and Their

The Way Forward: Federal Action for a System That Percent of State MH Caregivers and Families

Population Who Receive Practice in States

Evidence-Based Practice Target PopulationTheir for Serviceand SED and thatSMI Report DataWith Living People All for Works

Coordinating Committee Medication management Adults and youth with SMI/SEDThat System a for 32.0% Action Federal Forward: Way The Illness self-management Adults with SMI 19.0%

Dual diagnosis treatment Adults with SMI and SUD 10.5%

AssertiveSerious community treatment Mental Adults with SMI Illness 2.1%

Supported employment Adults and transition-age youth 2.1% Committee Coordinating

Interdepartmentalwith SMI Supported housing Adults and transition-age youth 3.1% Illness Mental Serious

with SMI

Therapeutic foster care Children and youth with SED 1.5%

Multi-systemic therapy Children and youth with SED 3.6% Interdepartmental Functional family therapy Children and youth with SED 6.9%

Family psychoeducation Families of people with SMI 1.9%

Most counties in the United States face shortages of mental health professionals. In 96 percent of the counties in the nation, there is a shortage of psychiatrists who prescribe medications for people with SMI (Thomas, Ellis, Konrad, Holzer, & Morrissey, 2009). From 2003 to 2013, the number of practicing psychiatrists decreased by 10 percent when adjusted for population size (Bishop, Seirup, Pincus, & Ross, 2016). Many psychiatrists are shifting to private practice, accepting only cash for reimbursement. In part, this may reflect low reimbursement

4 From SAMHSA Uniform Reporting System Data - https://wwwdasis.samhsa.gov/dasis2/urs.htm. These figures only represent a

subset of states that provided data.

such as building psychiatric respite bed capacity, may help to address these capacity issues. issues. capacity these address to help may capacity, bed respite psychiatric building as such

report they have adequate numbers of inpatient beds to meet needs. Use of a variety of strategies, strategies, of variety a of Use needs. meet to beds inpatient of numbers adequate have they report

and the number of beds per 100,000 population varies substantially across states, but few states states few but states, across substantially varies population 100,000 per beds of number the and

who responded) have shortages of psychiatric hospital beds. The configuration of available beds beds available of configuration The beds. hospital psychiatric of shortages have responded) who

Program Directors Research Institute (NASMHPD, 2017b) found that most states (35 of the 46 46 the of (35 states most that found 2017b) (NASMHPD, Institute Research Directors Program

proceedings (NASMHPD, 2017a). A report by the National Association of State Mental Health Health Mental State of Association National the by report A 2017a). (NASMHPD, proceedings

waiting for competency restoration services needed to restore competency to participate in legal legal in participate to competency restore to needed services restoration competency for waiting shortages have led to long delays in gaining access to treatment and an increase in individuals individuals in increase an and treatment to access gaining in delays long to led have shortages

bed areas, many In systems). justice juvenile or criminal the in involvement of because provided who are in need of longer periods of inpatient care, such as people in forensic care (care that is is that (care care forensic in people as such care, inpatient of periods longer of need in are who

bed capacity to respond to the needs of people experiencing both psychiatric crises and those those and crises psychiatric both experiencing people of needs the to respond to capacity bed Interdepartmental

numbers of inpatient psychiatric hospital beds. hospital psychiatric inpatient of numbers It is critical that every state have adequate adequate have state every that critical is It Most states report insufficient psychiatric crisis response capacity as well as insufficient insufficient as well as capacity response crisis psychiatric insufficient report Illness states Most Mental Serious

Interdepartmental Interdepartmental Interdepartmental 2013). 2013).

services have also generated notable outcomes in this area (Center for Health Care Strategies, Strategies, Care Health for (Center area this in outcomes notable generated also have Committee services Coordinating

Serious Mental Illness Illness Mental Serious Serioussupport peer family and Mental Youth 2011). IllnessCarter, & (Repper outcomes health improved for activation

recovery and resiliency through the generation of hope, engagement in treatment services, and and services, treatment in engagement hope, of generation the through resiliency and recovery Coordinating Committee Committee Coordinating Coordinatingpromote to demonstrated been have Committee services That support Peer System 2016). a for Vecchio, del & Action (Myrick Federal possible Forward: Way The

mental health system and should be included as a part of a full continuum of services, whenever whenever services, of continuum full a of Their part a and as SED included be and should SMI and With system health Living mental People All for Works reimbursement by Medicare (CMS, 2015). Peer support can play an important role in a functioning functioning a in role important an play can support Peer 2015). (CMS, Medicare by reimbursement

professional counselors and marriage and family therapists, whose services are not eligible for for eligible not are services whose therapists, family and marriage and counselors professional Caregivers and Families

The Way Forward: Federal Action for a System That That System a for Action Federal Forward: Way The The Waylicensed Forward:including Federalproviders, service Actionhealth formental of a Systemcategories are Thatthere Also, 2009). Works for All People Living With SMI and SED and Their Their and SED and SMI With Living People All for Works WorksMorrissey, for& AllHolzer, PeopleKonrad, LivingEllis, With(Thomas, SMItherapists andfamily and SED andmarriage and Their counselors,

Families and Caregivers Caregivers and Families Familiesprofessional and licensed Caregivers workers, social nurses, psychiatric practice advanced psychologists, as One county in five also has a shortage of non-prescriber mental health professionals, defined defined professionals, health mental non-prescriber of shortage a has also five in county One

health is widely accepted as a mechanism that can address shortages in some geographic areas. areas. geographic some in shortages address can that mechanism a as accepted widely is health

health physician assistants, are examples of strategies to address the shortage. Tele-mental Tele-mental shortage. the address to strategies of examples are assistants, physician health

medications, and educating more advanced practice registered nurses and psychiatric-mental psychiatric-mental and nurses registered practice advanced more educating and medications,

extent of their training, broadening the scope of practice of psychologists to prescribe some some prescribe to psychologists of practice of scope the broadening training, their of extent

Expanding the workforce by allowing advanced practice registered nurses to practice to the full full the to practice to nurses registered practice advanced allowing by workforce the Expanding

hospitalizations (National Council Medical Director Institute, 2017). 2017). Institute, Director Medical Council (National hospitalizations

long wait times for scheduled appointments, often leading to emergency department visits and and visits department emergency to leading often appointments, scheduled for times wait long

(Thomas & Holzer, 2006). The lack of access to psychiatric services creates several issues, such as as such issues, several creates services psychiatric to access of lack The 2006). Holzer, & (Thomas

need for child psychiatrists is even greater than the shortage of psychiatrists for adults with SMI SMI with adults for psychiatrists of shortage the than greater even is psychiatrists child for need 2017 , 13 December

Director Institute, 2017). The greatest shortages are in poorer and more rural counties. The The counties. rural more and poorer in are shortages greatest The 2017). Institute, Director

for psychiatric services (Bishop, Press, Keyhani, & Pincus, 2014; National Council Medical Medical Council National 2014; Pincus, & Keyhani, Press, (Bishop, services psychiatric for

payers, cuts to federal and state funding for public sector programs, and inadequate rate setting setting rate inadequate and programs, sector public for funding state and federal to cuts payers, , 2017 , 13 December Decembercare managed 13, 2017 Medicaid-contracted and programs Medicaid state from services psychiatric for

, 2017 AdultsDecember with SMI are 13 more likely to be jailed or “Successful reentry into the community is a involved with the criminal justice system. It is challenge for returning inmates with SMI. They estimated that approximately two million people with are more likely than returning inmates without

SMI are admitted annually to U.S. jails (Steadman, SMI to experience homelessness and are less

, 2017 , Osher, Robbins, Case, & Samuels, 2009). Among likely to find employment.” 13 December these admissions, 72 percent also meet criteria for — Conclusions from a systematic review by the Agency for Healthcare Research and Quality co-occurring substance use disorders (Hyde, 2011). (AHRQ, 2012) In 2016, among U.S. adults age 18 or older with SMI, 9.5 percent were on probation and 9.7 percent were on parole or supervised release (CBHSQ, 2017h). By comparison, 2.9 percent of the general U.S. adult population is currently under some form of criminal justice supervision (SAMHSA, 2015). Too few jails and prisons offer screening and treatment programs for mental and substance use disorders, leading to longer incarceration stays (SAMHSA, 2015). All states require efforts to restore legal competence after a person is determined to be incompetent to stand trial, a

process that typically takes place in state hospitals. However, a lack of available hospital beds for

competencyFamilies restoration and can Caregiverslead to waits for pretrial jail detainees that may average weeks, or even a yearWorks or longer for (Fuller, All People Sinclair, Lamb, Living Cayce, With & Snook, SMI 2017). and Only SEDabout one and in three Their people

with mental illness in jails or prisons receives any treatment (Bronson & Berzofsky, 2017). These factors

contribute,The in Wayturn, to Forward:higher rates of Federalrecidivism. SpecialtyAction courts for for a people System with mental That or substance

use disorders are promising, but their availability is extremely limited. Caregivers and Families Works for All People Living With SMI and SED and Their Their and SED and SMI With Living People All for Works

Coordinating Committee Many adults with SMI are unemployed. Only 36That percent (CBHSQ,System a 2017a)for of peopleAction with SMIFederal Forward: Way The

have full-time employment, while most would prefer to work (McQuilken, Zahniser, Novak,

Starks, SeriousOlmos & Bond, 2003). Mental SMI also is a major Illness driver of disability: 24.55 percent of adult

disability applications in Federal Fiscal Year 2016 to the Social Security Administration wereCommittee based Coordinating on mentalInterdepartmental health, as were 64.56 percent of childhood disability applications (Social Security Administration, 2017). Illness Mental Serious

Nearly twice as many adults with SMI have incomes below the poverty level as in the

general population (22.8 percent, compared to 13.5 percent) (CBHSQ, 2017i; U.S. Census Interdepartmental

Bureau, n.d.). SMI is common among people experiencing homelessness. The Department of Housing

and Urban Development (HUD) and SAMHSA (SAMHSA, n.d.-b) estimate that about one in five people (nearly 108,000 people)(HUD, 2016) experiencing homelessness has an SMI, and a similar percentage have a chronic substance use disorder. The Office of National Drug Control Policy reports that approximately 30 percent of people who are chronically homeless live with an SMI (Office of National Drug Control Policy, n.d.).

Most adults with SMI have private insurance or Medicaid. About one-quarter (24.9 percent)

of adults with SMI were enrolled in Medicaid at some time during 2015, while slightly more than

communities. communities. In many jurisdictions, civil commitment criteria focus primarily on the immediate immediate the on primarily focus criteria commitment civil jurisdictions, many In

Most civil commitment statutes fall short of adequately protecting patients or or patients protecting adequately of short fall statutes commitment civil Most

(Davis, Lin, Liu, & Sites, 2017). Sites, & Liu, Lin, (Davis,

million prescriptions) of the total opioid prescriptions distributed in the United States each year” year” each States United the in distributed prescriptions opioid total the of prescriptions) million

study concluded: “Adults with mental health conditions receive 51.4 percent (60 million of 115 115 of million (60 percent 51.4 receive conditions health mental with “Adults concluded: study

people with any mental health condition represent only 17.9 percent of the population, a recent recent a population, the of percent 17.9 only represent condition health mental any with people

Adults with mental illness receive a disproportionate share of opioid prescriptions. opioid of share disproportionate a receive illness mental with Adults While While

nationwide (HCUP, 2014b). 2014b). (HCUP, nationwide billion $27.7 cost disorders mood or schizophrenia with people for Hospitalizations 2014a).

with schizophrenia or mood disorders made 10.8 million visits to emergency departments (HCUP, (HCUP, departments emergency to visits million 10.8 made disorders mood or schizophrenia with Interdepartmental

diagnosed people 2014, In 2017). Owens, & Stocks, (Moore, percent 44 approximately increased

2006 and 2014, the rate of mental health/substance abuse-related emergency department visits visits department emergency abuse-related health/substance mental of rate the 2014, and 2006

often incurred at hospitals, due to emergency department visits and hospitalizations. Between Between hospitalizations. and visits department emergency to due hospitals, at Illness incurred often Mental Serious

Interdepartmental Interdepartmental Interdepartmentalare costs medical High 2010). al., et (Boyd disorders use substance or mental have system care health medications or services. A high proportion of the most costly patients served by the health health the by served patients costly most the of proportion high A services. or Committee medications health Coordinating

Serious Mental Illness Illness Mental Serious Seriousbehavioral for not Mentalconditions, health Illnesschronic for spending medical from result disorders mental . It is noteworthy that most of these higher costs for people with with people for costs higher these of most that noteworthy is It . 2014) Paulus, & Norris Melek, (

times for people with mental illness, even if their conditions are not among the most serious serious most the among not are conditions their if even illness, mental with people for times

Mental illnesses lead to high medical costs. medical high to lead illnesses Mental Coordinating Committee Committee Coordinating Coordinatingthree to two by increased are costs Committeecare Health That System a for Action Federal Forward: Way The Works for All People Living With SMI and SED and Their Their and SED and SMI With Living People All for Works

for the general populations (Hor & Taylor, 2010). 2010). Taylor, & (Hor populations general the for Caregivers and Families

The Way Forward: Federal Action for a System That That System a for Action Federal Forward: Way The Thethan Wayhigher times Forward:20 rate a Federalsuicide, by dies 20 Actionin 1 for aschizophrenia, Systemwith Thatdiagnosed adults Among

times higher than among the general population. population. general the among than higher times

Works for All People Living With SMI and SED and Their Their and SED and SMI With Living People All for Works Works for All People Living 25 Withbe to SMI estimated and is SEDdisorder andbipolar or Their depression

ISMICC)

by suicide for people with mood disorders such as as such disorders mood with people for suicide by

—

Families and Caregivers Caregivers and Families Familiesthe to comments public andthrough Caregivers(submitted Anne

for Suicide Prevention (HHS, 2012), the rate of death death of rate the 2012), (HHS, Prevention Suicide for

prison.”

According to the Surgeon General’s National Strategy Strategy National General’s Surgeon the to According

– dreams that didn’t include mental illness or or illness mental include didn’t that dreams –

44,000 suicides occurred in 2015 (CDC, 2017). 2017). (CDC, 2015 in occurred suicides 44,000 Like all mothers, I had dreams for my children children my for dreams had I mothers, all Like

Control and Prevention [CDC], 2015); more than than more 2015); [CDC], Prevention and Control He needed help. Instead, he got punishment. punishment. got he Instead, help. needed He

prison. He died alone, afraid, and powerless. powerless. and afraid, alone, died He prison. States about every 13 minutes (Centers for Disease Disease for (Centers minutes 13 every about States

hung himself in a solitary confinement cell in a a in cell confinement solitary a in himself hung

death by suicide. by death A suicide occurs in the United United the in occurs suicide A

“My 39-year old son killed himself today. He He today. himself killed son old 39-year “My

Adults with SMI are at particularly high risk of of risk high particularly at are SMI with Adults

percent) in comparison to primary care providers (24.3 percent) (Zhu, Zhang, & Polsky, 2017). 2017). Polsky, & Zhang, (Zhu, percent) (24.3 providers care primary to comparison in percent)

state-level market, plan networks included mental health care providers at a much lower rate (11.3 (11.3 rate lower much a at providers care health mental included networks plan market, state-level

of the 2016 Affordable Care Act Marketplaces demonstrated that, of those practicing in a given given a in practicing those of that, demonstrated Marketplaces Act Care Affordable 2016 the of 2017 , 13 December

usual source of care or delay medical care because of cost (Sherrill & Gonzales, 2017). An analysis analysis An 2017). Gonzales, & (Sherrill cost of because care medical delay or care of source usual

still face challenges in accessing treatment. For example, many individuals with SMI still lack a a lack still SMI with individuals many example, For treatment. accessing in challenges face still

1 in 10 (12.5 percent) had no insurance (CBHSQ, 2017i). However, individuals with insurance may may insurance with individuals However, 2017i). (CBHSQ, insurance no had percent) (12.5 10 in 1 , 2017 , 13 December Decemberthan more year, 13the , of 2017 period some For year. the during insurance private had percent) (51.5 half

, 2017 threat ofDecember harm to self 13 or others and do not consider patient history or capacity to make informed decisions “If assisted outpatient treatment had been available to my paranoid schizophrenic son, about the need for or benefits of treatment (Goldman, countless heartaches and dangers could have

2014). This results in many patients being unable to been averted over the course of the 25 years

, 2017 , access care when decompensated until they have done he has endured this cruel disease. No, instead 13 December something which may lead to their arrest. Although we have had to wait until our psychotic loved ones became a danger to self or others. There virtually all states have legal provisions for the use are red flags that maybe only family members of assisted outpatient treatment (AOT), this form of can see, but still we have to wait until it is too court-ordered outpatient treatment is realistically late. My son has been homeless, dangerous, available in few areas in the nation currently. AOT can and now in prison. I have not heard from him in 3 years because I “know” he’s been off meds, be valuable to help ensure that people with SMI who but he has a right to refuse treatment! He is lost! are at high risk of damaging behavior are engaged at And I can get no information because of HIPAA. some level with treatment services. SAMHSA currently We need assisted outpatient treatment, revised is working with the HHS Assistant Secretary for HIPAA, and more hospital beds instead of jail

cells.” PlanningFamilies and Evaluation and and Caregivers the National Institute of — Judy (submitted through public comments to the

Mental Health to evaluate the effect of various aspects ISMICC)

of AOTWorks implementation for All in 17People communities Living throughout With SMI and SED and Their

the UnitedThe States. Way Other Forward: strategies may Federal be considered Action for a System That

to address some of these issues, such as advance directives and other forms of consumer-directed Caregivers and Families care planning such as wellness recovery actionTheir plans.and SED and SMI With Living People All for Works

Coordinating Committee Caregivers of people with mental illness face complexThat situationsSystem a andfor a high Action burden of Federal Forward: Way The

care. A study of unpaid caregivers by the National Alliance for Caregiving estimates that nearly

8.4 millionSerious Americans provide Mental care to an adult Illness with an emotional or mental health issue, mainly related to SMI (NAC, 2016). It found that, for nearly one in five mental health caregivers, takingCommittee Coordinating

care of a loved one is equivalent to a full-time job. Approximately one in three caregivers provides

care forInterdepartmental more than 10 years (NAC, 2016). Many people with SMI are financially dependent on family and friends. Caregivers also bear a significant emotional burden, and often reportIllness feeling Mental Serious

isolated and stigmatized because of their loved one’s illness. This stress can lead to physical health

problems, as nearly 4 in 10 caregivers report difficulty taking care of their own health, and about Interdepartmental half cite caregiving as a cause of worsening health (NAC, 2016). Caregivers also face logistical

challenges in coordinating care for their loved one, such as finding appropriate providers,

managing medications, handling paperwork and finances, and accessing community services

IDEA, see http://idea.ed.gov/explore/view/p/,root,regs,300,A,300.8,.html. see IDEA,

dapted from Federal Register, Vol. 58, No. 96, pages 29422-29425; for detail on the criteria for emotional disturbance under under disturbance emotional for criteria the on detail for 29422-29425; pages 96, No. 58, Vol. Register, Federal from dapted A 5

role functioning (family, school, peers, community, or school) (Williams, Scott, & Aarons, 2017). 2017). Aarons, & Scott, (Williams, school) or community, peers, school, (family, functioning role

concluded that 10 percent of children meet the criteria of significant impairment in one domain of of domain one in impairment significant of criteria the meet children of percent 10 that concluded

from 13 percent to 20 percent (CDC, 2013). A recent meta-analysis of U.S. epidemiological studies studies epidemiological U.S. of meta-analysis recent A 2013). (CDC, percent 20 to percent 13 from

population-level information, estimates of the number of children with a mental disorder range range disorder mental a with children of number the of estimates information, population-level Reviews of the literature have produced some estimates. According to a 2013 CDC review of of review CDC 2013 a to According estimates. some produced have literature the of Reviews

on the study design and ages of children and youth included. youth and children of ages and design study the on

estimates prevalence ranging between 6.8 and 11.5 percent, based on published studies that differ differ that studies published on based percent, 11.5 and 6.8 between ranging prevalence estimates

across age groups, as no national survey currently estimates the prevalence of SED. SAMHSA SAMHSA SED. of prevalence the estimates currently survey national no as groups, age across Many children and youth have an SED. an have youth and children Many

impairment functional assess to challenging been has It Interdepartmental

child. the of age the on depending varies naturally community and school, family,

reflects the nature of childhood; role functioning in in functioning role childhood; of nature the reflects

SED. The type of functional impairment in SED also also SED in impairment functional of Illness type The SED. Mental Serious tive language as the group moves forward. moves group the as language tive

developmental disorder are not considered to have have to considered not are disorder developmental

- Interdepartmental Interdepartmental Interdepartmentalalterna propose and issue this examine to plan

enced by adults. As a result, ISMICC members members ISMICC result, a As adults. by enced

Coordinating Committee intellectual/ an or disorder use Committee substance a is Coordinating - experi disorders as people young in address to

mental disorders. Those whose sole diagnosis diagnosis sole whose Those disorders. mental

Serious Mental Illness Illness Mental Serious Seriousimportant as just are that Mentaldisorders diagnosable Illness

developmental disabilities that co-occur with their their with co-occur that disabilities developmental “disturbance” also does not seem fitting for for fitting seem not does also “disturbance”

have substance use disorders and intellectual/ and disorders use substance have cognitive or behavioral aspects. The word word The aspects. behavioral or cognitive

Coordinating Committee Committee Coordinating Coordinatinghave often youth and children by experienced Committee That System a for Action Federal Forward: Way The

As with SMI, individuals with SED can also also can SED with individuals SMI, with As

not capture the reality that mental disorders disorders mental that reality the capture not Their and SED and SMI With Living People All for Works bance.” The use of the word “emotional” does does “emotional” word the of use The bance.”

adults, include bipolar disorder and schizophrenia. schizophrenia. and disorder bipolar include adults,

about the term “serious emotional distur emotional “serious term the about Caregivers and Families

others that are less commonly seen in children than than children in seen commonly less are that others

The Way Forward: Federal Action for a System That That System a for Action Federal Forward: Way The Theconcerns Wayhave Forward:ISMICC the of members FederalThe Action for a System That

than adults include disruptive behavior disorders, and and disorders, behavior disruptive include adults than

Works for All People Living With SMI and SED and Their Their and SED and SMI With Living People All for Works Works for All People activities. Living With SMI and SED and Their Diagnoses that are more commonly seen in children children in seen commonly more are that Diagnoses

the child’s role in family, school, or community community or school, family, in role child’s the

Families and Caregivers Caregivers and Families Families and Caregivers different. are some SMI, for as same the are SED for ment that substantially interferes with or limits limits or with interferes substantially that ment

of the diagnoses that contribute to meeting criteria criteria meeting to contribute that diagnoses the of - impair functional in resulted which year, past

mental, behavioral, or emotional disorder in the the in disorder emotional or behavioral, mental, and substantial functional impairment. While some some While impairment. functional substantial and

children and youth who have had a diagnosable diagnosable a had have who youth and children

diagnosable mental, behavioral or emotional disorder disorder emotional or behavioral mental, diagnosable

Serious emotional disturbance (SED) refers to to refers (SED) disturbance emotional Serious

to children and youth; it requires the presence of a a of presence the requires it youth; and children to

Defining SED Defining

The definition of SED is similar to SMI, but applies but SMI, to similar is SED of definition The

Serious Emotional Disturbances Emotional Serious

of care conversations (NAC, 2016). (NAC, conversations care of 2017 , 13 December

percent have been told they cannot speak to a provider and 69 percent feel they have been left out out left been have they feel percent 69 and provider a to speak cannot they told been have percent

patient’s condition. Parents caring for an adult child face these challenges more frequently, as 77 77 as frequently, more challenges these face child adult an for caring Parents condition. patient’s

report they are often excluded from care conversations and cannot speak to the provider about the the about provider the to speak cannot and conversations care from excluded often are they report , 2017 , 13 December Decembercaregivers 13many , 2017 management, disease day-to-day in involvement their Despite 2016). (NAC,

, 2017 The NationalDecember Comorbidity 13 Survey – Adolescent Supplement (NCS-A), was a large-scale national survey of youth ages 13 to 18 conducted between 2001 and 2004 (Merikangas, He, Burstein, Swanson, Avenevoli, Cui & Swendsen, 2010). Interviews of 10,123 youth used an instrument that

generated DSM-IV diagnoses. The overall prevalence of disorders with severe impairment and/

, 2017 , or distress was 22.2 percent. Lifetime prevalence of mood disorders (including major depressive 13 December disorder, dysthymia, and bipolar I and II) with severe impairment was the most common class of disorders (11.2 percent). Lifetime prevalence of behavior disorders (including conduct disorder and oppositional defiant disorder) with severe impairment was found at a rate of 9.6 percent, and the rate of anxiety disorder with severe impairment was 8.3 percent. By any measure, the problem is substantial, and addressing it is important for the healthy development of our nation’s youth.

Children and youth have a range of SED diagnoses. SAMHSA’s Children’s Mental Health Initiative (CMHI) provides funds to a limited number of public entities to promote recovery and resilience for children and youth who have an SED and their families by providing comprehensive

services for mental and substance use disorders using the system of care framework. Systems of

care refersFamilies to a coordinated and networkCaregivers of community-based services and supports organized to meet

the challengesWorks of childrenfor All and People youth and Living their families. With Among SMI youth and entering SED the and CMHI Their program

in 2015,The the five Way most Forward:common diagnoses Federal were mood Action disorders for (such a System as depression, That 29.3 percent), attention deficit hyperactivity disorder (ADHD, 24.9 percent), oppositional defiant disorder (15.8 Caregivers and Families

percent), adjustment disorders (15.3 percent), and post-traumatic stress disorder (PTSD) or acute

stress disorder (12.6 percent) (CMHS/SAMHSA, Their 2016).and Data SED from theand 2016 SMI National With Survey ofLiving People All for Works

Coordinating Committee

Children’s Health (NSCH), shown in Table 1.2, indicateThat reportedSystem diagnoses a for for youngerAction children,Federal Forward: Way The

ages birth to 11, as well as for older youth. It should be noted that the NSCH methodology involves asking Seriousa parent about the statementsMental made by Illness a doctor or health provider, an approach that may

be less precise and result in lower estimates than a diagnostic interview. Committee Coordinating

On average,Interdepartmental 15 percent of young children (ages 2-8) in the United States have a parent-reported mental, behavioral, or developmental disorder (MBDD) diagnosis, which includes ADHD,Illness Mental Serious

depression, anxiety problems, behavioral or conduct problems such as oppositional defiant disorder or conduct disorder, Tourette syndrome, autism spectrum disorder, learning disability, Interdepartmental

intellectual disability, developmental delay, or speech or other language problems.1 The

percentage of children with diagnosed MBDD is similar for small rural and urban areas, at 18.6

percent and 15 percent, respectively (Robinson et al., 2017).

. Rockville, MD: Substance Abuse and Mental Health Services Administration. Services Health Mental and Abuse Substance MD: Rockville, . tables detailed Health: and Use

Source: Based on Table 9.7B of: Center for Behavioral Health Statistics and Quality. (2017). (2017). Quality. and Statistics Health Behavioral for Center of: 9.7B Table on Based Results from the 2016 National Survey on Drug Drug on Survey National 2016 the from Results

Interdepartmental

the United States, by Race/Ethnicity: 2016 Race/Ethnicity: by States, United the Illness Mental Serious

Past Year Major Depressive Episode Among Adolescents Ages 12 to 17 in in 17 to 12 Ages Adolescents Among Episode Depressive Major Year Past Interdepartmental Interdepartmental Interdepartmental 1.5. Figure Coordinating Committee Committee Coordinating

Serious Mental Illness Illness Mental Serious Serious Mental Illness (Figure 1.5). (Figure

or African-American youth having lower rates and Non-Hispanic White youth having higher rates rates higher having youth White Non-Hispanic and rates lower having youth African-American or

Coordinating Committee Committee Coordinating Black CoordinatingNon-Hispanic with groups, ethnic Committee across That episodes System depressive a major for of rate Action the in Federal differences Forward: Way The

estimated 3.1 million youth) experienced a major depressive episode (CBHSQ, 2017j). There were were There 2017j). (CBHSQ, episode Their depressive and major a SED and experienced SMI youth) With million 3.1 Living estimated People All for Works

depressive disorder annually among youth. among annually disorder depressive In 2016, 12.8 percent of youth in this age group (an (an group age this in youth of percent 12.8 2016, In SAMHSA’s ongoing National Survey of Drug Use and Health estimates the rate of major major of rate the estimates Health and Use Drug of Survey National ongoing SAMHSA’s Caregivers and Families

The Way Forward: Federal Action for a System That That System a for Action Federal Forward: Way The The Way Forward: Federal Action for a System That Works for All People Living With SMI and SED and Their Their and SED and SMI With Living People All for Works Works for All People Living With Whites. SMI and SEDNon-Hispanic to andcompared Their adolescents

Families and Caregivers Caregivers and Families FamiliesHispanic among and disorders Caregiversmood of rates higher were there and adolescents, White Non-Hispanic disorder were lower among Non-Hispanic Black or African-American adolescents, compared to to compared adolescents, African-American or Black Non-Hispanic among lower were disorder

disorders), except that the rates of anxiety disorders were higher and rates of substance use use substance of rates and higher were disorders anxiety of rates the that except disorders),

racial and ethnic groups in the major classes of mental disorders (mood, anxiety, or behavior behavior or anxiety, (mood, disorders mental of classes major the in groups ethnic and racial

Racial and ethnic differences among youth. among differences ethnic and Racial The NCS-A study found few differences across across differences few found study NCS-A The

* Missing data excluded from denominator from excluded data Missing *

Doctor/health provider/educator ever said child had behavioral/conduct problems behavioral/conduct had child said ever provider/educator Doctor/health 10.1 7.1

Doctor/health provider ever said child had depression had child said ever provider Doctor/health 8.2 1.1

Doctor/health provider ever said child had anxiety problems anxiety had child said ever provider Doctor/health 12.4 4.4

(N=48,534,964) Condition (N=24,815,076)

Age 0-11 0-11 Age Age 12-17 Age 2017 , 13 December

Percentage by Age Category: Age by Percentage

1.2. Table , 2017 , 13 December December 13Health , 2017 Children’s of Survey National 2016 From Data Weighted

, 2017 Youth Decemberwith SED often 13 have multiple disorders. The NCS-A study found that 6 percent of youth had disorders in two or more major classes of mental disorders (i.e., mood, anxiety, or behavior disorders). Among youth with a past year major depressive episode, 12.1 percent (an

estimated 333,000) also had a substance use disorder (CBHSQ, 2017k). An estimated 333,000

, 2017 , adolescents ages 12 to 17 had both a substance use disorder and a major depressive episode in 13 December the past year (Figure 1.6). Children and youth with SED also have increased rates of co-occurring health conditions such as obesity (Pastor & Reuben, 2011), asthma (Goodwin et al., 2014), and the onset of cigarette smoking (Blum, Kelly, & Ireland, 2001).

Figure 1.6. Past Year Substance Use Disorder (SUD) and Major Depressive Episode

(MDE) Among Youth Ages 12 to 17: 2016

Families and Caregivers

Works for All People Living With SMI and SED and Their

The Way Forward: Federal Action for a System That

Families and Caregivers Caregivers and Families

Works for All People Living With SMI and SED and Their Their and SED and SMI With Living People All for Works

Coordinating Committee The Way Forward: Federal Action for a System That That System a for Action Federal Forward: Way The

Serious Mental Illness

Source: Adapted from Figure 66 of: Substance Abuse and Mental Health Services Administration. (2017). Key substance use andCommittee mental Coordinating

health indicatorsInterdepartmental in the United States: Results from the 2016 National Survey on Drug Use and Health (HHS Publication No. SMA17-5044,

NSDUH Series H-52). Retrieved from http://www.samhsa.gov/data. Serious Mental Illness Illness Mental Serious

Early intervention is crucial to address development of mental disorders. The vast majority Interdepartmental of individuals who will develop a mental health disorder in their lifetime do so before age 24

(Kessler et al., 2005). Strong prevention and early intervention efforts should occur at these ages, but occur far too rarely. There are many standards for assessing mental health conditions

in children and adolescents up to age 18 in pediatric care (U.S. Preventive Services Task Force, n.d.). There are also consensus-based guidelines for care of children and adolescents, such as Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents (Hagan, Shaw, & Duncan, 2017). These guidelines call for regular screening for a variety of mental health conditions, and include recommendations for pediatric screening of those up to age 21. Medicaid’s Early and Periodic, Screening, Diagnosis, and Testing (EPSDT) benefit requires mental health assessment of all covered children. Other expert groups have developed guidelines for screening for a broader array of mental health conditions in children and adolescents (Weitzman et al.,

2015). However, screening is recommended only when systems are in place to ensure accurate

2004). 2004).

Chapman, Whitfield, Felitti, Dube, Edwards & Anda, Anda, & Edwards Dube, Felitti, Whitfield, Chapman,

— — SJ SJ

Anda, Felitti, Chapman, Williamson & Giles, 2001; 2001; Giles, & Williamson Chapman, Felitti, Anda,

the lifelines he needed.” he lifelines the

likelihood of developing SED and later SMI (Dube, (Dube, SMI later and SED developing of likelihood

system had to work collaboratively to throw him him throw to collaboratively work to had system

types of adverse childhood experiences increase the the increase experiences childhood adverse of types

family and community. He is a survivor; but the the but survivor; a is He community. and family

other than depression (CMHS/SAMHSA, 2016). These These 2016). (CMHS/SAMHSA, depression than other his adoption and he is starting to mesh into our our into mesh to starting is he and adoption his

experiences. Here we are today, I am finalizing finalizing am I today, are we Here experiences. percent) had a family member with a mental illness illness mental a with member family a had percent)

were customized to his unique needs and life life and needs unique his to customized were

months before entering services, and nearly half (48.4 (48.4 half nearly and services, entering before months

as a team. We developed new approaches that that approaches new developed We team. a as someone who had shown signs of depression in the six six the in depression of signs shown had who someone

and supports that cut across all of his programs programs his of all across cut that supports and quarters of these youth (73.5 percent) lived with with lived percent) (73.5 youth these of quarters

used and we developed strategies, services, services, strategies, developed we and used

year, I sat down with every provider he had ever ever had he provider every with down sat I year, suspended or expelled from school. Nearly three- Nearly school. from expelled or suspended

failing miserably in all of his life domains. This This domains. life his of all in miserably failing

been had percent) (47.2 half nearly and frequently, the community, and in our home. He was still still was He home. our in and community, the

than one in five of these youth were missing school school missing were youth these of five in one than

supports we thought he needed in school, in in school, in needed he thought we supports Interdepartmental

to such violence during the prior six months. More More months. six prior the during violence such to and services the together pulled quickly We

and a general lack of a nurturing environment. environment. nurturing a of lack general a and in life, and one in five (21.7 percent) had been exposed exposed been had percent) (21.7 five in one and life, in

much out of control due to a number of abuses abuses of number a to due control of out much

had been exposed to domestic violence at some point point some at violence domestic to Illness exposed been had Mental Serious

was very very was he old, years 8 only At placement.

Interdepartmental Interdepartmental Interdepartmental youth and children percent) (39.7 10 in 4 that reported and his father was in a long-term community community long-term a in was father his and

2016). Caregivers of youth entering the CMHI program program CMHI the entering youth of Caregivers 2016).

no longer care for him. His mom was in jail jail in was mom His him. for care longer no Committee Coordinating

re both SMI and they could could they and SMI both re aunt and uncle my

a challenging life circumstances circumstances life challenging

Serious Mental Illness Illness Mental Serious Serious Mental Illness (CMHS/SAMHSA, “Three years ago, I took in my cousin because because cousin my in took I ago, years “Three Children and youth with SED often have have often SED with youth and Children

Coordinating Committee Committee Coordinating Coordinating Committee That System a for Action Federal Forward: Way The critical time. critical

important step toward achieving a system of care that ensures screening for youth during this this during youth for screening ensures Their that and care of SED system a and SMI achieving With toward step Living important People All for Works

ages 18-26. Behavioral and oral health should be included in these recommendations.” This is an an is This recommendations.” these in included be should health oral and Behavioral 18-26. ages Caregivers and Families

The Way Forward: Federal Action for a System That That System a for Action Federal Forward: Way The Theadults young Way for Forward:specifically Federalmedications Actionpreventive and for aservices, Systemcounseling That screenings, as such

Works for All People Living With SMI and SED and Their Their and SED and SMI With Living People All for Works Worksservices forpreventive Allclinical Peoplefor Livingrecommendations With SMI evidence-based and SEDstandardized andof set Their consolidated

and Medicine (IOM & NRC, 2014): “The U.S. Preventive Services Task Force should develop a a develop should Force Task Services Preventive U.S. “The 2014): NRC, & (IOM Medicine and

Families and Caregivers Caregivers and Families FamiliesEngineering, andScience, Caregiversof Academy National the by issued was recommendation following The

rarely takes place outside mental health clinics affiliated with early psychosis research programs. programs. research psychosis early with affiliated clinics health mental outside place takes rarely

illness) can substantially reduce the impact of these disorders. Yet screening for early psychosis psychosis early for screening Yet disorders. these of impact the reduce substantially can illness)

age at which screening for development of the most serious mental illnesses (i.e., psychotic psychotic (i.e., illnesses mental serious most the of development for screening which at age

been developed explicitly for 18- to 26-year-olds (Ozer, Scott, & Brindis, 2013). This is a critical critical a is This 2013). Brindis, & Scott, (Ozer, 26-year-olds to 18- for explicitly developed been

limited. Screening rates are very low (IOM & NRC, 2014). Screening tools and processes have not not have processes and tools Screening 2014). NRC, & (IOM low very are rates Screening limited.

As youth enter young adulthood, mental health screening and early intervention continues to be be to continues intervention early and screening health mental adulthood, young enter youth As

screening in pediatric care settings, and have limited resources to do so. do to resources limited have and settings, care pediatric in screening

of schools do not conduct universal screening, as they face many of the same challenges as as challenges same the of many face they as screening, universal conduct not do schools of

for children and adolescents can be conducted in schools (Essex et al., 2009), but the vast majority majority vast the but 2009), al., et (Essex schools in conducted be can adolescents and children for 2017 , 13 December

cultural variations in views of mental health needs (Wissow et al., 2013). Mental health screening screening health Mental 2013). al., et (Wissow needs health mental of views in variations cultural

of mental health care for children and youth, the stigmatizing nature of these conditions, and and conditions, these of nature stigmatizing the youth, and children for care health mental of

of access to mental health care. Low uptake of screening procedures likely reflects the shortage shortage the reflects likely procedures screening of uptake Low care. health mental to access of , 2017 , 13 December Decemberexpansion an by 13, 2017 accompanied be must efforts screening so follow-up, and treatment, diagnosis,

, 2017 EffectiveDecember treatments 13 are available. There are a wide range of evidence-based treatments for many mental disorders that children and youth experience (e.g., anxiety, depression, ADHD, autism, eating disorders, obsessive compulsive disorder [OCD], exposure to traumatic events,

disruptive behavior, substance abuse) (Silverman & Hinshaw, 2008). Psychotherapeutic or

, 2017 , psychosocial services such as cognitive behavioral therapy and social skills training are evidence- 13 December based interventions that may be provided independently or along with medications. Coordinated specialty care is an evidence-based approach to working with youth nearing or in early adulthood who experience a first episode of psychosis. Psychotropic medications are commonly given for disorders such as anxiety, depression, psychosis, ADHD, and OCD, among others, and should be used for children and youth in keeping with the latest research and guidelines. Prescribers should be careful, as psychotropic medications have been overused in some populations of young people in ways that are not supported by research or practice guidelines (American Academy of Child and Adolescent Psychiatrists, 2015). In addition, the system of care approach continues to evolve

to reflect advances in research and service delivery. The core values of community-based, family- driven,Families youth-guided, and and culturally Caregivers and linguistically competent services are widely accepted.

The guiding principles calling for a broad array of effective services, individualized care, and

coordinationWorks across for child-serving All People systems Living are extensively With usedSMI as theand standards SED of and care throughoutTheir

the nationThe (Stroul Way & Friedman, Forward: 2011). Federal Action for a System That

Families and Caregivers Caregivers and Families

Most children and youth with SED do not Their receive and SED and SMI With Living People All for Works “The last 10 months of our lives have been filled

treatment. Identifiable mental health problems are

Coordinating Committeewith a life-altering and horrific change as my be- common, but few children receive services for thoseThat loved System youngest a sonfor had a psychoticAction break and Federal Forward: Way The problems. The lack of services received by these young, was diagnosed with schizophrenia. Like many

multi-challengedSerious children Mentalis a services systems Illness and other families, we were naïve. We have been screaming for help and information, waiting social policy failure (McCue Horwitz et al., 2012). Committee Coordinating on services, and watching my son slowly fade

About 4 in 10 (40.9 percent) of youth ages 12 to 17 with Interdepartmental away. Things need to change. It is evident that

major depressive episodes (1.2 million youth) received mental illness is still treated with casual effort treatment of any kind in 2016 (Figure 1.7) (CBHSQ, and not as a true and serious medicalIllness illness.” Mental Serious

2017j). This is similar to the findings from the NCS-A — Charlene (submitted through public comments to the

ISMICC) study, that 36.2 percent of adolescents with mental Interdepartmental

disorders received treatment across diagnostic groups.

However, that study also reported that treatment rates were higher for adolescents with attention deficit hyperactivity disorder (59.8 percent) and

behavior disorders, such as oppositional defiant disorder and conduct disorder (45.4 percent), but lower for those with anxiety disorders (17.8 percent), while children and youth with mood disorders had received treatment 37.7 percent of the time (Merikangas, He, Burstein, Swendsen, Avenevoli, Case, & Olfson, 2011). Among youth in 2016 with a past year major depressive episode who received treatment for depression, only 18.9 percent saw or talked to a health professional

and also took prescription medication (CBHSQ, 2017l).

Interdepartmental

Works for All People Living With SMI and SED and Their Their and SED and SMI With Living People All for Works Families and Caregivers Caregivers and Families

The Way Forward: Federal Action for a System That That System a for Action Federal Forward: Way The The Way Forward: Federal Action for a System That

. http://www.samhsa.gov/data

Works for All People Living With SMI and SED and Their Their and SED and SMI With Living People All for Works Works for All People Living With SMIfrom and SED and Their States: Results from the 2016 National Survey on Drug Use and Health and Use Drug on Survey National 2016 the from Results States: (HHS Publication No. SMA17-5044, NSDUH Series H-52). Retrieved Retrieved H-52). Series NSDUH SMA17-5044, No. Publication (HHS

Source: Substance Abuse and Mental Health Services Administration. (2017). (2017). Administration. Services Health Mental and Abuse Substance

Families and Caregivers Caregivers and Families United Familiesthe in indicators andhealth mental Caregiversand use substance Key

, 2017 , 13 December

Major Depressive Episodes in the United States: 2016 States: United the in Episodes Depressive Major

1.7. Figure , 2017 , 13 December With December17 to 12 13Ages , 2017 Adolescents Among Depression for Treatment Year Past

, 2017 Transition-ageDecember youth 13 face particular challenges. “My son was treated for serious psychiatric Youth with SED encounter problems as they age from disorders as a child. At age 17, in an attempt to adolescence to adulthood, and undergo the transition from escape the discrimination of his peers, he re-

youth-oriented systems of care to the adult behavioral fused treatment. It was not long before he quick-

, 2017 , health system. Exact definitions of the transition period ly became aggressively psychotic. My husband 13 December ages have been described broadly (ages 14 to 30) to more and I were encouraged to file a beyond control petition in civil court, just 6 months prior to our narrowly (ages 17 to 25). Regardless of the exact age range, son’s 18th birthday—hoping to save his life and this is a developmentally critical stage, i.e., transition from us from his reckless and often dangerous be- childhood into adult responsibilities. It is also the age range havior. Instead, he was ordered to jail, punished during which many adult SMI diagnoses first become for behaviors that were symptoms of his untreat- apparent (Kessler et al., 2005; Hafner et al., 1994). Program ed brain disease! None of my son’s medical records and history transitioned to the adult sys- structures, eligibility criteria, expectations related to family tem. My son was homeless, desperate for food, participation in treatment and sharing of information, and and still refused treatment. When we petitioned expectations for adult functioning can change substantially, him to a hospital, he was not held long enough

based solely on the passage of a birthday (Davis, 2003; to stabilize. Many times, he threatened homicide

Davis &Families Koroloff, 2005). and For theseCaregivers and other reasons, or suicide. We have felt powerless, as we have

watched his brain disease deteriorate year after many ofWorks these youth for drop All out Peopleof services when Living they With SMIyear from and countless SED psychotic and episodes.” Their reach adulthood. The adult outcomes for most youth who The Way Forward: Federal Action— Reginafor a(submitted System through public That comments to the

enter adulthood with SED or SMI are bleak; many don’t ISMICC)

finish high school, college enrollment and completion Caregivers and Families is low, unemployment is high, and they are at increasedTheir and SED and SMI With Living People All for Works

Coordinating Committee risk of homelessness (Davis & Vander Stoep, 1997; RinaldiThat et al., 2010;System Wagnera for & Newman,Action 2012). As Federal Forward: Way The with the general population, substance use peaks during these ages, as does justice system involvement

(Sheidow, McCart, Zajac, & Davis, 2012; Davis, Banks, Fisher, Gershenson, & Grudzinskas, 2007).

Evidence-basedSerious practices such Mental as supported employment Illness and supported housing have been adapted

and shown promising results for transition-age youth. The coordinated specialty care modelCommittee also Coordinating

early adulthoodInterdepartmental (Kane et al., 2016). A review of health care and services for young adults by the

Instituteshows great of Medicine promise andfor people National who Research experience Council a first6 (2014) episode describes of psychosis the variety in late of evidence-based adolescenceIllness or Mental Serious

interventions and recommends steps for increasing the use of evidence-based approaches for young

adults. Interdepartmental

6 Now known as the National Academy of Medicine and the National Academies of Science, Engineering, and Medicine.

students (6.4 percent) (Kann et al., 2016). al., et (Kann percent) (6.4 students

suicide was higher among gay, lesbian, and bisexual students (29.4 percent) than heterosexual heterosexual than percent) (29.4 students bisexual and lesbian, gay, among higher was suicide

percent) than heterosexual students (14.8 percent) and that the prevalence of having attempted attempted having of prevalence the that and percent) (14.8 students heterosexual than percent)

considered attempting suicide was higher among gay, lesbian, and bisexual students (42.8 (42.8 students bisexual and lesbian, gay, among higher was suicide attempting considered

(Pilowsky & Wu, 2006). In addition, the CDC has found that the prevalence of having seriously seriously having of prevalence the that found has CDC the addition, In 2006). Wu, & (Pilowsky

to have attempted suicide in the previous year than those who had never been in foster care care foster in been never had who those than year previous the in suicide attempted have to

(HHS, 2012). One study found that adolescents in foster care were almost four times more likely likely more times four almost were care foster in adolescents that found study One 2012). (HHS,

often have a history of mental health and/or substance use disorders and traumatic experiences experiences traumatic and disorders use substance and/or health mental of history a have often

youth involved in the juvenile justice and child welfare systems are at higher risk for suicide, and and suicide, for risk higher at are systems welfare child and justice juvenile the in involved youth

percent) had attempted suicide prior to receiving services (CMHS/SAMHSA, 2016). In particular, particular, In 2016). (CMHS/SAMHSA, services receiving to prior suicide attempted had percent)

(9.1 10 in 1 almost and suicide, committing about thought had percent) (19.4 one-fifth almost

Youth with SED are at high risk for suicide. for risk high at are SED with Youth

Among youth entering the CMHI program in 2015, 2015, in program CMHI the entering youth Among Interdepartmental

had private insurance. Only 5.2 percent had no health insurance (CBHSQ, 2017m). (CBHSQ, insurance health no had percent 5.2 Only Illness insurance. private had Mental Serious

Interdepartmental Interdepartmental Interdepartmentalpercent) (60.1 10 in 6 while 2016, during time some at Program Insurance Health Children’s the

insurance.

More than one-third (34.9 percent) of children or youth were enrolled in Medicaid or or Medicaid in enrolled were youth or children of percent) (34.9 one-third than More Committee Coordinating Serious Mental Illness Illness Mental Serious Serious health have Mentaldo episode Illnessdepressive major year past with youth and children Most

Coordinating Committee Committee Coordinating Coordinating Committee That System a for 2012). Action Gates, & Federal (Durso Forward: Way The experiencing homelessness self-identify as LGBT LGBT as self-identify homelessness experiencing

Works for All People Living With SMI and SED and Their Their and youth of SED percent and 40 as SMI many as With that found Living survey People All for Works

ISMICC)

homelessness and SED (SAMHSA, n.d.-b). A national national A n.d.-b). (SAMHSA, SED and homelessness

(submitted through public comments to the the to comments public through (submitted Jeanne — Caregivers and Families

The Way Forward: Federal Action for a System That That System a for Action Federal Forward: Way The The Way Forward: Federal Actionfor risk forhigh at aare Systemyouth (LGBT) That transgender and an epidemic of national proportion.” national of epidemic an

available. SAMHSA notes that lesbian, gay, bisexual, bisexual, gay, lesbian, that notes SAMHSA available.

Works for All People Living With SMI and SED and Their Their and SED and SMI With Living People All for Works is Worksillness mental of for All Peoplecriminalization the yet crime Living With SMI and SED and Their

parent. Estimates of those with SED are not currently currently not are SED with those of Estimates parent. where this would happen. Mental illness is not a a not is illness Mental happen. would this where

gle disease, other than serious mental illness, illness, mental serious than other disease, gle

Families and Caregivers Caregivers and Families Families and Caregivers a by accompanied being most with 2016), (HUD,

- sin a of think cannot I treatment. access to able

experiencing homelessness are age 18 or under under or 18 age are homelessness experiencing

danger to themselves or others, before being being before others, or themselves to danger

(HUD) estimates that more than 120,000 people people 120,000 than more that estimates (HUD)

reached stage 4 in the disease, or became a a became or disease, the in 4 stage reached

Department of Housing and Urban Development Development Urban and Housing of Department or cancer, we would not be waiting until they they until waiting be not would we cancer, or

tal. If our children were stricken with diabetes diabetes with stricken were children our If tal. of people experiencing homelessness. homelessness. experiencing people of The The

- hospi a in be to need they realize to capacity

Children and youth account for nearly a quarter quarter a nearly for account youth and Children

ic to remember that, and they don’t have the the have don’t they and that, remember to ic

have loving families but are often too psychot too often are but families loving have -

(CMHS/SAMHSA, 2016). 2016). (CMHS/SAMHSA, People suffering from serious mental illness illness mental serious from suffering People

around the streets without care and treatment? treatment? and care without streets the around SAMHSA’s CMHI program live below the poverty line line poverty the below live program CMHI SAMHSA’s

of the same symptoms as dementia wander wander dementia as symptoms same the of

children and youth with SED who receive services from from services receive who SED with youth and children

20-year-old suffering from a disease with many many with disease a from suffering 20-year-old

the poverty line. Almost two-thirds (65.1 percent) of of percent) (65.1 two-thirds Almost line. poverty the

homeless in our streets. Why would we let a a let we would Why streets. our in homeless 2017 , 13 December

(Wagner et al., 2003) have family incomes below below incomes family have 2003) al., et (Wagner “Our mentally ill are filling up our jails and living living and jails our up filling are ill mentally “Our

special education students with emotional disturbance disturbance emotional with students education special

youth with major depressive episodes (CBHSQ, 2017m), and almost one in three (29.8 percent) of of percent) (29.8 three in one almost and 2017m), (CBHSQ, episodes depressive major with youth

Many children and youth with SED are living in poverty. in living are SED with youth and children Many , 2017 , 13 December Decemberpercent) (20.2 five 13in , 2017one than More

, 2017 While Decemberthe highest rates13 of death by suicide are among middle-aged adults, especially males, suicide rates have increased among Black or African-American children. While the suicide rate among young children has remained relatively stable, a recent study shows that the

number of Black or African-American children between the ages of 5 and 11 who die by suicide has

, 2017 , almost doubled since 1993. The research shows that from 1993 to 2012, a total of 657 U.S. children 13 December in that age group killed themselves; 84 percent were boys and 16 percent were girls. Over the nearly 20-year period, the rate among Black or African-American children significantly rose while the rate among White children dropped (Bridge et al., 2015).

Compared with early adolescents who died by suicide, children who died by suicide were more commonly male, Black or African-American, died by hanging, strangulation, suffocation, and died at home. Among suicide decedents with known mental health problems, childhood decedents more often experienced attention deficit disorder with or without hyperactivity and less often experienced depression/dysthymia compared with early adolescent decedents (Sheftall et

al., 2017). Families and Caregivers

Works for All People Living With SMI and SED and Their

The Way Forward: Federal Action for a System That

Families and Caregivers Caregivers and Families

Works for All People Living With SMI and SED and Their Their and SED and SMI With Living People All for Works

Coordinating Committee The Way Forward: Federal Action for a System That That System a for Action Federal Forward: Way The

Serious Mental Illness

Coordinating Committee Committee Coordinating

Interdepartmental

Serious Mental Illness Illness Mental Serious

Interdepartmental Interdepartmental

and jail inmates, 2011-2012. Washington, DC: Bureau of Justice Statistics. Justice of Bureau DC: Washington, 2011-2012. inmates, jail and

prisoners by reported problems health mental of Indicators (2017). M. Berzofsky, & J., Bronson,

States from 1993 to 2012. JAMA Pediatrics, 169(7), 673-677. 673-677. 169(7), Pediatrics, JAMA 2012. to 1993 from States Interdepartmental

Campo, J. V. (2015). Suicide trends among elementary school-aged children in the United United the in children school-aged elementary among trends Suicide (2015). V. J. Campo,

Bridge, J. A., Asti, L., Horowitz, L. M., Greenhouse, J. B., Fontanella, C. A., Sheftall, A. H., ...... H., A. Sheftall, A., C. Fontanella, B., J. Greenhouse, M., L. Horowitz, L., Asti, Illness A., J. Bridge, Mental Serious

Interdepartmental Interdepartmental Interdepartmental 481-490. 28(6), Health, Adolescent adolescents with mobility impairments and learning and emotional disabilities. Journal of of Journal disabilities. emotional and learning and impairments mobility with Committee adolescents Coordinating

Serious Mental Illness Illness Mental Serious Seriousamong factors Mentalprotective and behaviors IllnessHealth-risk (2001). M. Ireland, & A., Kelly, W., R. Blum,

Health Affairs, 35(7), 1271-1277. 1271-1277. 35(7), Affairs, Health

psychiatrists declined, 2003-2013, which may help explain poor access to mental health care. care. health mental to access poor explain help may which 2003-2013, declined, psychiatrists Coordinating Committee Committee Coordinating Coordinating practicing US of Population Committee (2016). S. J. That Ross, & A., System H. a for Pincus, K., J. Action Seirup, F., T. Federal Bishop, Forward: Way The

Works for All People Living With SMI and SED and Their Their and SED and SMI With Living People All for Works 71(2):176-181.

Psychiatrists and the Implications for Access to Mental Health Care. JAMA Psychiatry, Psychiatry, JAMA Care. Health Mental to Access for Implications the and Psychiatrists Caregivers and Families

The Way Forward: Federal Action for a System That That System a for Action Federal Forward: Way The The by Way Forward:Insurance of FederalAcceptance (2014). ActionH.A. Pincus, for& S. a SystemKeyhani, , J. M. ThatPress, T.F., Bishop,

to-improve-targeting-and-delivery-of-clinical-services-for-medicaid-populations

Works for All People Living With SMI and SED and Their Their and SED and SMI With Living People All for Works Works. for All People Living With SMI and SED and Their

https://www.chcs.org/resource/faces-of-medicaid-clarifying-multimorbidity-patterns- from

Families and Caregivers Caregivers and Families FamiliesRetrieved Inc. andStrategies, CaregiversCare Health for Center Jersey: New Hamilton, populations. medicaid

Clarifying multimorbidity patterns to improve targeting and delivery of clinical services for for services clinical of delivery and targeting improve to patterns multimorbidity Clarifying

Boyd, C., Leff, B., Weiss, C., Wolff, J., Hamblin, A., & Martin, L. (2010). Faces of medicaid: medicaid: of Faces (2010). L. Martin, & A., Hamblin, J., Wolff, C., Weiss, B., Leff, C., Boyd,

63(4), 426-432. 63(4), Psychiatry, General of Archives illness.

trial of a new behavioral treatment for drug abuse in people with severe and persistent mental mental persistent and severe with people in abuse drug for treatment behavioral new a of trial

Bellack, A. S., Bennett, M. E., Gearon, J. S., Brown, C. H., & Yang, Y. (2006). A randomized clinical clinical randomized A (2006). Y. Yang, & H., C. Brown, S., J. Gearon, E., M. Bennett, S., A. Bellack,

systems_of_care/AACAP_Psychotropic_Medication_Recommendations_2015_FINAL.pdf . .

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of Psychotropic Medications for Children and Adolescents Involved in Child-Serving Systems. Systems. Child-Serving in Involved Adolescents and Children for Medications Psychotropic of

American Academy of Child and Adolescent Psychiatry (2015). Recommendations About the Use Use the About Recommendations (2015). Psychiatry Adolescent and Child of Academy American

https://effectivehealthcare.ahrq.gov from Retrieved system. justice criminal the with involved . 2017 , 13 December

center systematic review protocol: Interventions for adults with serious mental illness who are are who illness mental serious with adults for Interventions protocol: review systematic center

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treatment-for-substance-use-disorders#preventinghomeless3 . . Caregivers and Families

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Works for All People Living With SMI and SED and Their

The Way Forward: Federal Action for a System That

Families and Caregivers Caregivers and Families

Works for All People Living With SMI and SED and Their Their and SED and SMI With Living People All for Works

Coordinating Committee The Way Forward: Federal Action for a System That That System a for Action Federal Forward: Way The

Serious Mental Illness

Coordinating Committee Committee Coordinating

Interdepartmental

Serious Mental Illness Illness Mental Serious

Interdepartmental Interdepartmental

Interdepartmental

, 2017 , 13 December

, 2017 , 13 December December 13, 2017

, 2017 ChapterDecember 2: Improving 13 Practice Related to Serious Mental

Illness and Serious Emotional Disturbances

, 2017 , December 13 December

This chapter highlights some key advances in research Federal Leaders Who Presented on Federal on serious mental illnesses (SMI) and serious Advances in Addressing the Needs of emotional disturbances (SED). It also includes People With SMI and SED strategies to improve services for people with SMI and SED that were highlighted in the first ISMICC meeting. Joshua Gordon, Director, National Institute of Mental Health (NIMH) This is an exciting time, and many innovations are available to help federal departments, states, and Paolo del Vecchio, Director, Center for Mental providers meet the needs of people with SMI and SED Health Services (CMHS), Substance Abuse

and their families. and Mental Health Services Administration

(SAMHSA) Families and Caregivers The firstWorks ISMICC formeeting All occurredPeople on LivingAugust 31, With2017, SMIJohn McCarthy and, Director,SED Serious and Mental Their Illness

at the Department of Health and Human Services Treatment Resource and Evaluation Center

headquartersThe atWay the Hubert Forward: H. Humphrey Federal Building Action in (SMITREC), for a SystemDepartment of Veterans That Affairs (VA) Caregivers and Families

Washington D.C. Federal and non-federal experts were invited to present information on relevant advancesTheir and RubySED Qazilbashand , AssociateSMI DeputyWith Director,Living People All for Works

Coordinating CommitteeBureau of Justice Assistance (BJA), Department for addressing the needs of people with SMI and SED.That System a for Action Federal Forward: Way The This chapter reflects the content of the presentations, of Justice

discussion during the meeting, and later input from National Experts Who Presented on Non-

ISMICCSerious members. Mental IllnessFederal Advances in Addressing the Needs

Coordinating Committee of People With SMI and SED Committee Coordinating

The advancesInterdepartmental included in this chapter come directly Lynda Gargan, Executive Director, National from the presentations of the federal leaders and Federation of Families for Children’sIllness Mental Mental Serious

national experts. All of the advances are relevant Health to SMI and SED populations. Each advance has a Lisa Dixon, Professor of Psychiatry, Columbia Interdepartmental

substantial evidence base and has been tested in real- University Medical Center; Director, Division world settings. The order in which the information is of Behavioral Health Services and Policy

Research summarized within the chapter corresponds to the

order of the ISMICC meeting presentations. Within Sergio Aguilar-Gaxiola, Professor of Clinical the chapter, attention is given to the areas outlined in Internal Medicine, University of California, the Congressional legislation regarding the ISMICC: Davis; Director, Center for Reducing Health Disparities; Director, Community Engagement • Prevention Program, Clinical and Translational Science Center • Diagnosis Joseph Parks • Intervention , Medical Director, National Council for Behavioral Health

• Treatment and recovery

that play a role in the development of SMI. of development the in role a play that

only one part. There is a need to understand the environmental factors and developmental factors factors developmental and factors environmental the understand to need a is There part. one only

The growth of genetic knowledge provides indicators for predicting risk. However, genetic risk is is risk genetic However, risk. predicting for indicators provides knowledge genetic of growth The

entire cycle of development. of cycle entire

to understand SMI across the the across SMI understand to

interventions. NIMH seeks seeks NIMH interventions. and (4) develop personalized personalized develop (4) and

development, throughout disease, (3) chart the illness illness the chart (3) disease,

and follow the course of of course the follow and Interdepartmental

that help predict risk risk predict help that

Serious Mental Illness biomarkers Illness identify (2) SMI, Mental Serious Interdepartmental Interdepartmental Interdepartmental of development the predict to

Coordinating Committee ability our enhance Committee and risk Coordinating priorities include: (1) identify identify (1) include: priorities

Serious Mental Illness Illness Mental Serious Serious Mental Illness NIMH that noted Gordon Dr. Coordinating Committee Committee Coordinating Coordinating(NIMH) Health Committee Mental of That Institute System a National for Director, Action Gordon, A. Federal Joshua Forward: Way The

Works for All People Living With SMI and SED and Their Their and SED and SMI With Living People All for Works Support of Advances to Address Challenges of SMI and SED SED and SMI of Challenges Address to Advances of Support

National Institute of Mental Health: Health: Mental of Institute National Caregivers and Families The Way Forward: Federal Action for a System That That System a for Action Federal Forward: Way The The Way Forward: Federal Action for a System That

Works for All People Living With SMI and SED and Their Their and SED and SMI With Living People All for Works Works for All People Living With SMI and SED and Their

Families and Caregivers Caregivers and Families Families and Caregivers Presentations Federal

that should be available to people with SMI and SED. and SMI with people to available be should that at the end of this chapter. this of end the at

Additional advances and innovations are listed listed are innovations and advances Additional the range of evidence-based practices and advances advances and practices evidence-based of range the

Moving forward, the ISMICC will update and consider consider and update will ISMICC the forward, Moving

2017. 2017.

to build on the foundation outlined in this chapter. chapter. this in outlined foundation the on build to at the ISMICC inaugural meeting, August 31, 31, August meeting, inaugural ISMICC the at

As with the other chapters in this report, we expect expect we report, this in chapters other the with As from experts invited by the ISMICC to present present to ISMICC the by invited experts from

The advances highlighted in this chapter come come chapter this in highlighted advances The

the ISMICC. ISMICC. the 2017 , 13 December

additional advances that ISMICC members identified as areas that warrant further exploration by by exploration further warrant that areas as identified members ISMICC that advances additional

The presentations do not cover the full breadth of current advances. The chapter ends with with ends chapter The advances. current of breadth full the cover not do presentations The

Access to services and supports supports and services to Access , 2017 , 13 December December 13, 2017 •

, 2017 Dr. GordonDecember remarked 13 that biomarkers may someday make it possible to chart the course of the illness. NIMH avoids studying simple individual diagnoses, but instead pools data on people with SMI across diagnostic domains. Researchers are looking at “deep phenotyping,” which includes

measurement of a combinations of factors such as behavior, brain activity, and symptoms. Using

, 2017 , this approach, researchers seek to group people with psychosis according to common anatomic 13 December

and/or biologic origins. This may better predict their disease course and response to treatment.

Families and Caregivers

Works for All People Living With SMI and SED and Their

The Way Forward: Federal Action for a System That

Families and Caregivers Caregivers and Families

Works for All People Living With SMI and SED and Their Their and SED and SMI With Living People All for Works

Coordinating Committee The Way Forward: Federal Action for a System That That System a for Action Federal Forward: Way The

Serious Mental Illness

Coordinating Committee Committee Coordinating

LongitudinalInterdepartmental studies that use multiple modalities—including neuroimaging and neuropsychological measures—allow the development of predictive tools and methodsIllness for Mental Serious

charting illness progression. The Recovery After an Initial Schizophrenia Episode (RAISE) project was a research initiative of the NIMH. RAISE studied coordinated specialty care (CSC), Interdepartmental

an integrated approach to care for patients who experience their first episode of psychosis,

including psychotherapy, family education and support, supported employment, education, and medication. Patients who received CSC had better outcomes. SAMHSA and NIMH are

collaborating closely to implement CSC in community settings via the Mental Health Block Grant 10 percent set-aside for early serious mental illness, including psychotic disorders. Several related NIMH research efforts aim to reduce treatment delays in first-episode psychosis by identifying people at high risk, improving the care of those high-risk people in community mental health centers, and developing novel approaches to treating youth and adults. The evidence shows that diagnoses are not sufficient predictors of response to treatment; an individualized approach is needed. Understanding the relationship between patterns of brain activity and treatment will

help develop novel treatments aimed at patterns of dysfunctional brain activity.

recovery supports. recovery

requires a multidisciplinary approach that often includes medication, therapy, and community community and therapy, medication, includes often that approach multidisciplinary a requires

of people with SMI and SED SED and SMI with people of

Meeting the complex needs needs complex the Meeting

and collaborative care. care. collaborative and

comprehensive, coordinated, coordinated, comprehensive,

provide services is through through is services provide most effective way to to way effective most

the that shows Research

Interdepartmental psychoeducation. family Interdepartmental

supported employment, and and employment, supported

Serious Mental Illness treatment, Illness community Mental Serious

Interdepartmental Interdepartmental Interdepartmental assertive management, practices such as medication medication as such practices

Coordinating Committee Committee evidence-based receive Coordinating Serious Mental Illness Illness Mental Serious Seriousnot do SED or SMI Mentalfor services health Illnessmental public receive who people most that show 2016

Coordinating Committee Committee Coordinating Coordinatingfrom Data treatments. Committeeevidence-based to That access of issue System a central the for on focused Action Vecchio del Federal Mr. Forward: Way The and Mental Health Services Administration (SAMHSA) Administration Services Health Mental and Paolo del Vecchio, Director, Center for Mental Health Services (CMHS), Substance Abuse Abuse Substance (CMHS), Services Their Health and Mental for SED and Center SMI Director, With Vecchio, del Living Paolo People All for Works

Families and Caregivers Caregivers and Families

The Way Forward: Federal Action for a System That That System a for Action Federal Forward: Way The The Way Forward:SED Federaland SMI of Action forChallenges a SystemAddress to ThatAdvances of Support

Substance Abuse and Mental Health Services Administration: Administration: Services Health Mental and Abuse Substance Works for All People Living With SMI and SED and Their Their and SED and SMI With Living People All for Works Works for All People Living With SMI and SED and Their

Families and Caregivers Caregivers and Families Families and Caregivers

appropriate services can be accessed efficiently. accessed be can services appropriate

identify those at highest risk, so that that so risk, highest at those identify

can ultimately make it possible to to possible it make ultimately can

outcomes. The use of data sets sets data of use The outcomes.

improve understanding of mortality mortality of understanding improve

jail or prison. The research aims to to aims research The prison. or jail

for suicide following release from from release following suicide for

who are particularly at high risk risk high at particularly are who

partners, NIMH is studying people people studying is NIMH partners,

the Department of Justice and other other and Justice of Department the 2017 , 13 December

treatment. In collaboration with with collaboration In treatment.

of suicide, and approaches for for approaches and suicide, of

which people are at high risk risk high at are people which , 2017 , 13 December December 13, 2017 predicting on focused also is NIMH

, 2017 Only 2 Decemberpercent of public 13 mental health clients have access to effective therapeutic approaches

such as cognitive behavioral

, 2017 , therapy. Similarly, few are receiving 13 December evidence-based approaches such as dialectical behavior therapy and cognitive remediation therapy. People with SMI need access to effective psychiatric care, including diagnostic examination, medication, and psychotherapeutic interventions.

Of the 70 percent of people with SMI who are unemployed and want to work, only 2 percent

receiveFamilies evidence-based and supported Caregivers employment. Similarly, few have access to supportive housing,

despiteWorks the link between for All housing People and reduced Living symptoms, With SMIdecreased and criminal SED justice and and Their juvenile

justice Thesystems Way involvement, Forward: and increased Federal employment. Action Jail fordiversion a System programs haveThat also demonstrated effectiveness. Major advances have been made in recent decades to promote peer Caregivers and Families

and family support, with 40 states including this as a billable Medicaid optional service. As a

part of recovery support services, and given theTheir elevatedand ratesSED of mortality,and SMI attention With to self-careLiving People All for Works

Coordinating Committee and general health by people with SMI and SED is alsoThat important.System a Studies for show theAction benefits ofFederal Forward: Way The

exercise, healthy diet, and other self-management activities.

CoordinatedSerious care approaches Mental are critical. Through Illness a partnership across the Centers for Medicare

& Medicaid Services (CMS), SAMHSA, and the Assistant Secretary for Planning and EvaluationCommittee Coordinating

(ASPE),Interdepartmental over 70 Certified Community Behavioral Health Clinics in eight states have enhanced Medicaid federal match to provide comprehensive, coordinated care as a result of the SectionIllness 223 Mental Serious

Demonstration Program to Improve Community Mental Health Services. Equally promising is the collaboration involving SAMHSA, ASPE, and NIMH to look at the impact of assisted outpatient Interdepartmental treatment on engagement in effective care in 17 representative communities throughout the

United States.

An estimated 50 percent of clients stop engaging in treatment in the first six months. People must be engaged in their care, and providers should be trained to deliver individualized and personalized approaches that address individual goals and strengths as well as culture, age, sexual

orientation, and geography.

SMI shows more encounters in non-mental health clinic settings than in mental health settings. settings. health mental in than settings clinic health non-mental in encounters more shows SMI

version of assertive community treatment. Data related to outpatient utilization for people with with people for utilization outpatient to related Data treatment. community assertive of version

of outpatient programs such as the Mental Health Intensive Case Management Program, VHA’s VHA’s Program, Management Case Intensive Health Mental the as such programs outpatient of

with SMI, the decrease may be associated with changes in treatment practices and the success success the and practices treatment in changes with associated be may decrease the SMI, with decreased, whereas receipt of non-psychiatric inpatient care has been relatively stable. For people people For stable. relatively been has care inpatient non-psychiatric of receipt whereas decreased,

has care psychiatric inpatient receiving patients VHA of percentage the 2016, through 1999 From Interdepartmental

coding.

Changes from 2015 to 2016 may be related to the transition from ICD-9 to ICD-10 diagnosis diagnosis ICD-10 to ICD-9 from transition the to related be may 2016 to 2015 from Changes

2016. The data also reflects a decrease in the prevalence of patients diagnosed with schizophrenia. schizophrenia. with diagnosed patients of prevalence the in decrease a reflects also Illness data The 2016. Mental Serious Interdepartmental Interdepartmental Interdepartmentaland 1999 between steadily increased disorder bipolar for care receiving people of number The Coordinating Committee Committee Coordinating

Serious Mental Illness Illness Mental Serious Serious Mental Illness care. services lasting a year or more, and provides outreach in an effort to bring them back into VHA VHA into back them bring to effort an in outreach provides and more, or year a lasting services

Initiative identifies people with schizophrenia or bipolar disorder who experience a gap in VHA VHA in gap a experience who disorder bipolar or schizophrenia with people identifies Initiative

Coordinating Committee Committee Coordinating CoordinatingRe-Engage SMI VA’s The psychoses. Committeeother or That disorder, bipolar System a for schizophrenia, Action with patients Federal about Forward: Way The

In response, the VA established the National Psychosis Registry in 1999, which generates data data generates which 1999, in Registry Their and Psychosis SED National the and SMI established VA With the Living response, In People All for Works they generate disproportionate expenditures and service utilization. service and expenditures disproportionate generate they Caregivers and Families

The Way Forward: Federal Action for a System That That System a for Action Federal Forward: Way The The Way Forward: Federal Action for a System That schizophrenia and bipolar disorder constitute a small proportion of the patient population, yet yet population, patient the of proportion small a constitute disorder bipolar and schizophrenia

Works for All People Living With SMI and SED and Their Their and SED and SMI With Living People All for Works Works with users for All(VHA) People LivingAdministration Health With Veterans SMI andconditions. SEDhealth andmental Theirwith veterans

Families and Caregivers Caregivers and Families Familiesof needs the andmeet to Caregiverscapacity its increased substantially has VA the that noted McCarthy Dr.

Center, Department of Veterans Affairs (VA) Affairs Veterans of Department Center,

John McCarthy, Director, Serious Mental Illness Treatment Resource and Evaluation Evaluation and Resource Treatment Illness Mental Serious Director, McCarthy, John

Support of Advances to Address Challenges of SMI and SED and SMI of Challenges Address to Advances of Support

Affairs: Veterans of Department

vulnerable population. vulnerable

address privacy rights and offer protections against the abuse and neglect that continue for this this for continue that neglect and abuse the against protections offer and rights privacy address

There is a critical need to standardize and increase data collection. Further work is needed to to needed is work Further collection. data increase and standardize to need critical a is There 2017 , 13 December

educational and health settings, and that children and youth have access to a range of services. of range a to access have youth and children that and settings, health and educational

happens before age 25 for 75 percent of people. It is critical that problems be identified early in in early identified be problems that critical is It people. of percent 75 for 25 age before happens , 2017 , 13 December Decemberonset 15; age 13before , 2017 happens illness mental of onset the people, of percent 50 estimated an For

, 2017 The VADecember has conducted 13 comprehensive suicide monitoring and analysis.

Among those who received

, 2017 , VHA care since 1999, suicide 13 December rates through 2006 were elevated, with the highest rates among those with bipolar disorder, but the rates have declined somewhat since then. Among VHA patients from 2001 through 2014, suicide rates have stayed

high among people with bipolarFamilies disorder, despite and VA Caregiversefforts such as the Mental Health Enhancement Initiative and the

development of suicide prevention coordinators on the crisis line. However, suicide rates have

decreasedWorks somewhat for for All VHA People users with Living schizophrenia, With and SMI overall and among SED people and with Theirmental or

substanceThe use Waydisorders. Forward: Suicide risks Federal are particularly Action high after for inpatient a System discharges, That especially

among people with depressive disorder, followed by bipolar disorder and schizophrenia. Caregivers and Families

Suicide prevention for people with SMI is an importantTheir and priority.SED REACHand VETSMI (RecoveryWith Living People All for Works

Coordinating Committee Engagement And Coordination for Health—Veterans That EnhancedSystem Treatment) a for uses a Action suicide Federal Forward: Way The

predictive model based on information in the VA’s electronic health record system to identify and engageSerious veterans at high Mental risk for suicide, particularly Illness among those with SMI. Strategic partnerships—such as the one between the Veterans Administration, CMS, SAMHSA, and Committee the Coordinating

Administration for Community Living—are critical given the substantial numbers of veterans

who dieInterdepartmental of suicide and who are not recent users of VHA care or otherwise connected with the VA. Serious Mental Illness Illness Mental Serious

Department of Justice: Interdepartmental

Support of Advances to Address Challenges of SMI and SED

Ruby Qazilbash, Associate Deputy Director, Bureau of Justice Assistance (BJA),

Department of Justice

With close to 11 million people being processed through jails each year, compared with approximately 625,000 being admitted into the nation’s prisons, jails house the majority of the inmate population with SMI. BJA policy focuses on helping local jails use validated screening

instruments consistently in order to understand and reduce SMI prevalence rates within a

for reoffending. for

those not connected to services, estimates suggest that more than half are at moderate to high risk risk high to moderate at are half than more that suggest estimates services, to connected not those

with SMI in that county were not connected to community treatment but likely needed it. Of Of it. needed likely but treatment community to connected not were county that in SMI with community. According to the national estimates previously mentioned, as many as 1,700 people people 1,700 as many as mentioned, previously estimates national the to According community.

969 people were flagged with an SMI, and of those, only 609 received follow-up treatment in the the in treatment follow-up received 609 only those, of and SMI, an with flagged were people 969

For example, in the Franklin County, Ohio, jail population, out of 10,523 bookings into the jail, jail, the into bookings 10,523 of out population, jail Ohio, County, Franklin the in example, For

or reentry from the jail or prison back into the community—are getting connected to that care. care. that to connected getting community—are the into back prison or jail the from reentry or

community following release. Yet only a fraction of people—at the point of court, jail diversion, diversion, jail court, of point the people—at of fraction a only Yet release. following community

the in time of length increases services, management case particularly services, community-based

people with mental illnesses stay longer in jail. Research shows that providing connections to to connections providing that shows Research jail. in longer stay illnesses mental with people Interdepartmental that show BJA by supported studies local and treatment, receiving are indicator health mental

Bureau of Justice Statistics surveys show that approximately one-third of inmates with a a with inmates of one-third approximately that show surveys Statistics Illness Justice of Bureau Mental Serious

Interdepartmental Interdepartmental Interdepartmental nation. the across systems of state the reflect communities

calls involving mental health issues take much longer to resolve than other calls. These individual individual These calls. other than resolve to longer much take issues health mental Committee involving calls Coordinating

Serious Mental Illness Illness Mental Serious Seriousservice Generally, calls. Mentalservice Illnesshealth-related mental in years recent in increases sharp reported mental health-related. Similarly, law enforcement agencies in Deschutes County, Oregon, have have Oregon, County, Deschutes in agencies enforcement law Similarly, health-related. mental

Coordinating Committee Committee Coordinating is Coordinatingcalls 10 in 1 that indicating report Committee Florida one That with System a increasing, be for to appears Action SMI with Federal people Forward: Way The crises, as well as for their family members. The volume of calls to law enforcement involving involving enforcement law to calls of volume The members. family their for as well as crises, Law enforcement agencies and officers have become first responders for people in mental health health mental in people for responders first Their become and have SED and officers and SMI agencies With Living enforcement Law People All for Works Families and Caregivers Caregivers and Families The Way Forward: Federal Action for a System That That System a for Action Federal Forward: Way The The Way Forward: Federal Action for a System That Works for All People Living With SMI and SED and Their Their and SED and SMI With Living People All for Works Works for All People Living With SMI and SED and Their Families and Caregivers Caregivers and Families Families and Caregivers

, 2017 , 13 December

community. , 2017 , 13 December the Decemberwithin 13services ,to 2017jails of out and in cycling are who people connect to and jail, jurisdiction’s

, 2017 December 13

, 2017 , December 13 December

Families and Caregivers

In 2012,Works BJA and the for Council All People of State Governments Living With Justice SMICenter andreleased SED a shared and framework Their

for reducingThe recidivism Way Forward: and promoting Federal recovery for Action adults with for behavioral a System health Thatneeds who are

under correctional supervision. The framework reflects a consensus with SAMHSA, the National Caregivers and Families

Institute of Corrections, and major associations Their representingand SED state directorsand SMI of corrections,With Living People All for Works

probationsCoordinating and parole, substance use services, Committee and mental health services. The outcome was that there is a need for risk and needs assessments for peopleThat under correctionalSystem a for controlAction who have Federal Forward: Way The

behavioral health needs. People with low criminogenic risk need to be connected to community

servicesSerious and medical care. PeopleMental with moderate Illness to high criminogenic risk need intensive

supervision with a combination of supports. The shared framework is part of the Justice andCommittee Coordinating

MentalInterdepartmental Health Collaboration Program funded by the Bureau of Justice Assistance, which is adding 55 new grantees in 2017 to help communities apply the framework and allocate Illness resources Mental Serious

appropriately.

Interdepartmental Interdepartmental

Developmental Disabilities will operationalize more supports to law enforcement agencies. enforcement law to supports more operationalize will Disabilities Developmental Center to Improve Law Enforcement Responses to People with Mental Illness and Intellectual and and Intellectual and Illness Mental with People to Responses Enforcement Law Improve to Center Assistance Technical and Training National a for appropriation Congressional 2017 A jurisdictions.

and memoranda of understanding. The sites accept site visits and are on call to help other other help to call on are and visits site accept sites The understanding. of memoranda and Interdepartmental

policies, their sites, learning six features toolkit The progress. evaluate and measures, outcome

about how to build a police and mental health collaboration, provide training, track data and and data track training, provide collaboration, health mental and police a build to how about The Police and Mental Health Collaboration Toolkit launched by BJA provides information information provides BJA by launched Toolkit Collaboration Health Mental Illness and Police The Mental Serious Interdepartmental Interdepartmental Interdepartmental

release, and (4) the recidivism rate for this population, compared to a general release cohort. release general a to compared population, this for rate recidivism the (4) and Committee release, Coordinating with SMI as compared to the general jail population, (3) the rate of connection to care upon upon care to connection of rate the (3) population, jail general the to compared as SMI with

Serious Mental Illness Illness Mental Serious Seriouspeople for jail in stay Mentalof length average Illnessthe (2) assessment), and screening necessitates (which

and track four measures: (1) the percent of people within the jail population who have an SMI SMI an have who population jail the within people of percent the (1) measures: four track and

Coordinating Committee Committee Coordinating Coordinatingquestions key answer to counties ask Committee That Questions” “Six System a initiative’s The for Initiative. Action Up Stepping Federal the Forward: Way The

least 384 county boards (representing 115 million people) have passed resolutions committing to to committing resolutions passed have Their people) and million 115 SED and SMI (representing boards With county Living 384 least People All for Works

systems and processes that connect people with SMI to services in the community. To date, at at date, To community. the in services to SMI with people connect that processes and systems Stepping Up works to increase community efforts to support law enforcement and create effective effective create and enforcement law support to efforts community increase to works Up Stepping Caregivers and Families The Way Forward: Federal Action for a System That That System a for Action Federal Forward: Way The The Way Forward: Federal Action for a System That

Works for All People Living With SMI and SED and Their Their and SED and SMI With Living People All for Works Works jails. in forSMI Allwith Peoplepeople of Livingprevalence Withthe SMIreducing on andfocuses SED andInitiative Up TheirStepping The Families and Caregivers Caregivers and Families Families and Caregivers

, 2017 , 13 December

, 2017 , 13 December December 13, 2017

, 2017

December 13Non-Federal Stakeholder Presentations

, 2017 , Challenges and Opportunities in Improving Children’s Mental Health Care 13 December

Lynda Gargan, Executive Director, National Federation of Families for Children’s Mental Health

Prevalence data show that approximately 20 percent of children under age 18 (approximately 7.5 million) will have a significant mental health issue sometime in life.

Dr. Gargan emphasized that stigma associated with mental illness is real. She compared the rally around families whose children developed catastrophic medical illnesses with the silence

and prejudice surrounding mental illness. To help our children, there is a need to reject stigma,

identifyFamilies children’s behavioral and Caregivers health Worksas a public forhealth All People Living With SMI and SED and Their

crisis, and support a system

that willThe help ourWay teachers Forward: Federal Action for a System That

teach. Children are not little Caregivers and Families adults, so data cannot be Their and SED and SMI With Living People All for Works

Coordinating Committee extrapolated from what works That System a for Action Federal Forward: Way The for adults, and then applied

to children. She noted the

exampleSerious of medications Mental Illness

that are dispensed without Committee Coordinating

longitudinalInterdepartmental data or Food and Drug Administration Illness Mental Serious

indications for children.

Prescriptions should not be the first line of response. Culturally responsive supports are needed. Interdepartmental Interdepartmental Peer support services constitute a valuable tool in supporting families. For families, a peer is a

person who possesses the lived experience of having parented a child who experiences mental/ behavioral health challenges. Because families trust families, peers offer guidance and support that cannot be matched by professionals. Peers act as cultural translators, navigators, and

advocates for families.

hospitalization. in reductions dramatic to led has This sites. 20 across adults young 800 advances from research to practice. For example, providers in New York State have enrolled over over enrolled have State York New in providers example, For practice. to research from advances The Mental Health Block Grant and the contributions of states and localities have promoted promoted have localities and states of contributions the and Grant Block Health Mental The Interdepartmental

Serious Mental Illness Illness intervention. based Mental Serious

Interdepartmental Interdepartmental Interdepartmental evidence- this of development additional support to further the the further to support additional

Coordinating Committee provide government local Committee and state Coordinating

Serious Mental Illness Illness Mental Serious Serious Mental Illness states, many In program. Grant

administered Mental Health Block Block Health Mental administered Coordinating Committee Committee Coordinating Coordinating Committee That System a for SAMHSA- the Action through Federal services Forward: Way The

Works for All People Living With SMI and SED and Their Their and SED and CSC SMI provide With to funds Living aside set People All for Works Congress has asked states to to states asked has Congress

outcomes associated with CSC, CSC, with associated outcomes Caregivers and Families

The Way Forward: Federal Action for a System That That System a for Action Federal Forward: Way The The Way Forward: Federal Action for a Systempositive the on ThatBased psychosis. Works for All People Living With SMI and SED and Their Their and SED and SMI With Living People All for Works Works for All People Living With SMI andearly SEDwith youth and Theirtransition-age on

Families and Caregivers Caregivers and Families Families and Caregivers focused and providers of team a by package of interventions delivered delivered interventions of package

coordinated specialty care (CSC), a a (CSC), care specialty coordinated

compared to those with a longer period of not being in treatment. Emerging evidence supports supports evidence Emerging treatment. in being not of period longer a with those to compared

psychosis. Research shows improved outcomes in people with a shorter duration psychosis psychosis duration shorter a with people in outcomes improved shows Research psychosis.

She reported on a recent example of an advance in the treatment of people with first-episode first-episode with people of treatment the in advance an of example recent a on reported She

person-centered approach. person-centered

integrated care that includes evidence-based pharmacologic treatment, recovery support and a a and support recovery treatment, pharmacologic evidence-based includes that care integrated

to achieve progress. This effort requires ongoing attention to engagement and a continuum of of continuum a and engagement to attention ongoing requires effort This progress. achieve to Dr. Dixon emphasized the need for partnerships of the federal, state, local, and private sectors sectors private and local, state, federal, the of partnerships for need the emphasized Dixon Dr.

, 2017 , 13 December Division of Behavioral Health Services and Policy Research Policy and Services Health Behavioral of Division

Lisa Dixon, Professor of Psychiatry, Columbia University Medical Center; Director, Director, Center; Medical University Columbia Psychiatry, of Professor Dixon, Lisa , 2017 , 13 December December 13, 2017 SED and SMI With People of Care Clinical the in Advances Key

, 2017 Upon entryDecember into the 13New York program, only about 40 percent of youth worked or were in school. This rate increased to 72 percent at the last or most recent follow-up. Studies show that most youth and adults want to work or go to school, and see that as an essential part of recovery. A

no-exclusion, integrated approach to evidence-based supported employment, with the goal of

, 2017 , competitive employment, has consistently been demonstrated as more effective than traditional 13 December

vocational rehabilitation and other rehabilitative approaches.

Families and Caregivers

Works for All People Living With SMI and SED and Their

The Way Forward: Federal Action for a System That

Families and Caregivers Caregivers and Families

Works for All People Living With SMI and SED and Their Their and SED and SMI With Living People All for Works

Coordinating Committee The Way Forward: Federal Action for a System That That System a for Action Federal Forward: Way The

Serious Mental Illness

Coordinating Committee Committee Coordinating

Early psychosisInterdepartmental treatment is critical, as is peer support. Peer support has an emerging evidence base demonstrating reduced use of acute services, decreased substance abuse, and increasedIllness Mental Serious

engagement.

Approximately 5-20 percent of people with SMI die by suicide. The highest risk follows discharge Interdepartmental from an emergency department or inpatient hospitalization. Effective strategies that reduce risk

during the post-discharge period include:

• Systematized safety planning prior to discharge,

• Follow-up outreach (phone, text, home visits), and

• Suicide-specific psychotherapies (e.g., cognitive therapy for suicide prevention, dialectical behavior therapy).

Knowledge about detecting and treating suicidality (i.e., selective prevention) is not routinely

employed in health care systems.

Reducing Disparities Project focused on reducing stigma and discrimination. and stigma reducing on focused Project Disparities Reducing

Each Mind Matters that includes materials tailored to specific ethnic groups, and the California California the and groups, ethnic specific to tailored materials includes that Matters Mind Each

experiencing disparities. Other examples include the statewide stigma reduction campaign called called campaign reduction stigma statewide the include examples Other disparities. experiencing

Mental Health Services Act generated over $2 billion for services last year, especially for those those for especially year, last services for billion $2 over generated Act Services Health Mental

of practices and programs used for diverse populations. An initiative in California called the the called California in initiative An populations. diverse for used programs and practices of

There is a need to work with community-based organizations to capture the effectiveness effectiveness the capture to organizations community-based with work to need a is There

that 50 to 90 percent of those in need of mental health treatment are not receiving services. receiving not are treatment health mental of need in those of percent 90 to 50 that especially for traditionally underserved populations. National data on the treatment gap reveals reveals gap treatment the on data National populations. underserved traditionally for especially

gap— treatment care—the accessing people of difficulty the on focused Aguilar-Gaxiola Dr. Interdepartmental

Center Science Translational and Clinical Program, Engagement

Davis; Director, Center for Reducing Health Disparities; Director, Community Community Director, Disparities; Health Reducing for Center Director, Davis; Sergio Aguilar-Gaxiola, Professor of Clinical Internal Medicine, University of California, California, of University Medicine, Internal Clinical of Professor Illness Aguilar-Gaxiola, Sergio Mental Serious

Interdepartmental Interdepartmental Interdepartmental Disparities and Closing the Treatment Gap Treatment the Closing and Committee Disparities Coordinating Serious Mental Illness Illness Mental Serious Serious Mental Illness Coordinating Committee Committee Coordinating Coordinating Committee That System a for Action Federal Forward: Way The Works for All People Living With SMI and SED and Their Their and SED and SMI With Living People All for Works Families and Caregivers Caregivers and Families The Way Forward: Federal Action for a System That That System a for Action Federal Forward: Way The The Way Forward: Federal Action for a System That Works for All People Living With SMI and SED and Their Their and SED and SMI With Living People All for Works Works for All People Living With SMI and SED and Their Families and Caregivers Caregivers and Families Families and Caregivers

, 2017 , 13 December

services is needed to address this issue. this address to needed is services

who do not have SMI. Strategic care integration, attention to health behaviors, and high-quality high-quality and behaviors, health to attention integration, care Strategic SMI. have not do who , 2017 , 13 December Decembercounterparts 13, 2017age-matched their than earlier years 10 roughly die SMI with people that show Data

, 2017 EngagingDecember people with 13 SMI and SED and their families in the treatment process is key. Engagement is an iterative process in which clinicians and investigators reach out to the client and his/her family and continually evaluate their efforts. Incorporating the family in a culturally

appropriate fashion within routine

, 2017 , clinical settings improves access 13 December to treatment, client participation in care, integration of care, and ultimately, clinical outcomes for populations with SMI and SED. Public health interventions should include audiovisual tools and social marketing campaigns to reduce stigma, promote evidence-

based treatment approaches, and disseminateFamilies community-defined and Caregivers

evidence. Public health messaging

shouldWorks be inclusive for and All respectful People Living With SMI and SED and Their

of diversity.The Way Forward: Federal Action for a System That

Families and Caregivers Caregivers and Families

The Challenges and Opportunities for ImprovingTheir and the SystemSED and SMI With Living People All for Works

Coordinating Committee

That Supports the Care of People With SMI andThat SED System a for Action Federal Forward: Way The

JosephSerious Parks, Medical Director, Mental National CouncilIllness for Behavioral Health

Dr. Parks indicated that many Committee Coordinating

effectiveInterdepartmental services are available for people with SMI. Peer support and Illness Mental Serious

population health management

services are especially important. Interdepartmental

available. available.

panels by secret shopper to see if someone actually answers the phone and if appointments are are appointments if and phone the answers actually someone if see to shopper secret by panels

identify possible parity concerns is also critical, as well as assessing the adequacy of provider provider of adequacy the assessing as well as critical, also is concerns parity possible identify

profit. Comparing payment rates in behavioral health to the rates in general medical care to to care medical general in rates the to health behavioral in rates payment Comparing profit.

the amount of the payment is sufficient to cover the actual cost of what is done, plus a reasonable reasonable a plus done, is what of cost actual the cover to sufficient is payment the of amount the

streams. The payments for behavioral health services need to be actuarially sound—meaning that that sound—meaning actuarially be to need services health behavioral for payments The streams.

coding and available billing billing available and coding

Procedural Terminology (CPT) (CPT) Terminology Procedural

that are not reflected in Current Current in reflected not are that

practices new for reimbursement

that they are unable to obtain obtain to unable are they that Interdepartmental

Community providers also report report also providers Community

Serious Mental Illness Illness loss. Mental Serious

Interdepartmental Interdepartmental Interdepartmental financial to due care providing

Coordinating Committee not or beds closing Committee hospitals Coordinating

Serious Mental Illness Illness Mental Serious Serious Mental Illness with treatment, psychiatric indicate a shortage of available available of shortage a indicate

Coordinating Committee Committee Coordinating Coordinating Committee That System a for Reports Action severe. Federal particularly Forward: Way The

Works for All People Living With SMI and SED and Their Their and SED and is SMI With shortage Living psychiatry The People All for Works

with SMI are uninsured. are SMI with Caregivers and Families

The Way Forward: Federal Action for a System That That System a for Action Federal Forward: Way The Thepeople of Way number Forward:substantial A Federalcommunity. Actionand state by forvary a Systemservices and Thattreatment of quality

Works for All People Living With SMI and SED and Their Their and SED and SMI With Living People All for Works and Worksavailability forthe All PeopleGenerally, crisis. in LivingSED and WithSMI with SMI people andof SEDneeds the andaddress Theirto resources

with SMI. Yet there are not enough psychiatrists to treat people. Additionally, there is a lack of of lack a is there Additionally, people. treat to psychiatrists enough not are there Yet SMI. with

Families and Caregivers Caregivers and Families Familiespeople of andneeds the Caregiversaddressing for treatments effective many are there that noted Parks Dr.

need it. need

they when and need they

are expected to figure out what what out figure to expected are

organize information. Yet they they Yet information. organize

functioning, and ability to to ability and functioning,

concentration, executive executive concentration,

have deficits in memory, memory, in deficits have

health disorders. They often often They disorders. health

and three or four physical physical four or three and 2017 , 13 December

behavioral health disorders disorders health behavioral

approximately three or four four or three approximately

people with SMI have have SMI with people , 2017 , 13 December December 13, 2017 most that is news bad The

, 2017 The newDecember Certified Community13 Behavioral Health Clinic (CCBHC) demonstration program may provide What Is a Certified Community Behavioral Health Clinic? strategies for addressing these issues. The CCBHC

program covers the full range of evidence-based Section 223 of the Protecting Access to Medi-

, 2017 , services, but it remains a demonstration program care Act (PAMA) creates and evaluates a 2-year 13 December operating in only eight states and limited to just two demonstration program for states to certify community behavioral health clinics. Certified years. clinics must meet specific criteria emphasizing high-quality care and integration across communi- Dr. Parks discussed the importance of level of care ty services to address the holistic needs of people assessment instruments that include scores for social with SMI and SED, and others. Learn more about determinants. These instruments may help address the CCBHC program at https://www.samhsa.gov/section-223. the bed crisis by reflecting appropriate lengths of stay. For example, after Missouri required the use of LOCUS (Level of Care Utilization System) and CALOCUS (Child and Adolescent Level of Care

Utilization System), which assess housing and other social determinants, insurers enhanced coverageFamilies for evidence-based and Caregivers services.

Finally,Works Dr. Parks outlinedfor All technical People ways Living to address With psychiatric SMI service and shortages, SED and such asTheir revising The Way Forward: Federal Action for a System That the Conrad 30 Waiver Program, which allows medical doctors to apply for a waiver for the 2-year Caregivers and Families

residence requirement upon completion of the J-1 exchange visitor program, so waivers provided

to psychiatrists do not count toward the ceilingTheir of 30and slots; revisingSED and the GroupSMI on EducationalWith Living People All for Works

Coordinating Committee

Affairs (Association of American Medical Colleges) That graduate medicalSystem a educationfor calculationAction forFederal Forward: Way The supporting psychiatry residents to be the same as for obstetrician- gynecologists or primary care physicians;Serious revising redistribution Mental requirements Illness for unused Medicare direct graduate medical

education training slots so the psychiatry slots cannot be reduced; and removing regulatory

barriers to telepsychiatry. Dr. Parks noted that success will largely be a question of willingnessCommittee to Coordinating

exert executiveInterdepartmental powers in areas such as payments rates and performance measurement.

Serious Mental Illness Illness Mental Serious

Areas to Be Explored by the ISMICC Interdepartmental

The federal and expert presentations described above provide an important overview of key areas of opportunity and innovation for application on the federal level and in the broader behavioral

health field. Table 2.1 summarizes other areas that the ISMICC will consider in the future.

Exploration of levels of care and their place in the treatment of SMI of treatment the in place their and care of levels of Exploration •

Medication development Medication •

Medication optimization Medication •

Medication treatment and management and treatment Medication •

Veterans Administration Uniform Mental Health Standards Standards Health Mental Uniform Administration Veterans •

(Schizophrenia Patient Outcomes Research Team) Research Outcomes Patient (Schizophrenia

STAR*D (NIMH-funded Sequenced Treatment Alternatives to Relieve Depression); PORT PORT Depression); Relieve to Alternatives Treatment Sequenced (NIMH-funded STAR*D Recovery

Findings from CATIE (NIMH-funded Clinical Antipsychotic Trials of Intervention Effectiveness); Effectiveness); Intervention of Trials Antipsychotic Clinical (NIMH-funded CATIE from Findings • and Treatment

Strategies and approaches included in the Stepping Up Initiative Up Stepping the in included approaches and Strategies •

Sequential intercept model intercept Sequential •

Trauma-informed officers Trauma-informed

• Re-entry programs with navigational assistance and links to community health community to links and assistance navigational with programs Re-entry •

Cognitive behavioral therapy, cognitive skills training (Reasoning and Rehabilitation Program) Rehabilitation and (Reasoning training skills cognitive therapy, behavioral Cognitive •

Forensic assertive community treatment community assertive Forensic •

Crisis intervention team training team intervention Crisis •

Civil commitment laws, including compulsory treatment compulsory including laws, commitment Civil •

Drug courts Drug

Interdepartmental • Interdepartmental

Mental health courts health Mental •

Justice Criminal

Jail diversion Jail •

Serious Mental Illness Illness Intervention: Mental Serious Family-based treatments Family-based •

Intensive behavioral peer intervention for attention deficit hyperactivity disorder hyperactivity deficit attention for intervention peer behavioral Intensive

Interdepartmental Interdepartmental Interdepartmental •

Behavioral parent training training parent Behavioral

Coordinating Committee • Committee Coordinating Behavioral classroom management; management; classroom Behavioral •

Multisystemic therapy Multisystemic Serious Mental Illness Illness Mental Serious Serious Mental Illness •

Division of Children’s System of Care) Care) of System Children’s of Division

Trauma-informed and trauma-specific services, including Promising Path to Success (New Jersey Jersey (New Success to Path Promising including services, trauma-specific and Trauma-informed •

Exposure and response prevention for obsessive-compulsive disorder obsessive-compulsive for prevention response and Exposure Coordinating Committee Committee Coordinating Coordinating Committee That System a for Action • Federal Forward: Way The

Coordinated specialty care for youth with first-episode psychosis first-episode with youth for care specialty Coordinated

Works for All People Living With SMI and SED and Their Their and SED and SMI With • Living People All for Works Interpersonal therapy for adolescents with depression with adolescents for therapy Interpersonal • Youth

CBT; trauma-focused CBT trauma-focused CBT; •

Families and Caregivers and Children Caregivers and Families

High-fidelity wraparound wraparound High-fidelity •

The Way Forward: Federal Action for a System That That System a for Action Federal Forward: Way The The Way Forward: Federal Action for a System That Intervention:

restraint and seclusion and restraint

National Association of State Mental Health Program Directors, core strategies for reduction of of reduction for strategies core Directors, Program Health Mental State of Association National Works for All People Living With SMI and SED and Their Their and SED and SMI With Living People All for Works Works for All People Living With SMI and SED and• Their

Coordinated specialty care for adults with first-episode psychosis first-episode with adults for care specialty Coordinated

Families and Caregivers Caregivers and Families Families and Caregivers • Dialogic therapy Dialogic •

Problem-solving therapy Problem-solving •

Brief interpersonal therapy therapy interpersonal Brief •

Social rhythm therapy therapy rhythm Social •

Cognitive remediation therapy remediation Cognitive •

Dialectical behavioral therapy therapy behavioral Dialectical •

Cognitive behavioral therapy (CBT); trauma-focused CBT trauma-focused (CBT); therapy behavioral Cognitive • Adults

Assertive community treatment community Assertive • Intervention:

Jail-based Mental Health Screening Health Mental Jail-based •

Implementation of American Psychiatric Association practice guidelines guidelines practice Association Psychiatric American of Implementation •

charting illness progression progression illness charting

Neuroimaging/neuropsychological measures to allow for the development of predictive tools for for tools predictive of development the for allow to measures Neuroimaging/neuropsychological •

understanding of environmental/developmental factors environmental/developmental of understanding 2017 , 13 December

Deep phenotyping/biomarkers to provide indicators for predicting genetic risk, along with with along risk, genetic predicting for indicators provide to phenotyping/biomarkers Deep • Diagnosis

Advances, Including Evidence-Based and Promising Practices Promising and Evidence-Based Including Advances, Area Focus

2.1. Table , 2017 , 13 December December 13 , 2017 Meetings Future During Explore to ISMICC the for Areas

, 2017 Table 2.1.December Areas 13 for the ISMICC to Explore During Future Meetings (continued)

Focus Area Advances, Including Evidence-Based and Promising Practices

Treatment and • Exploration of need for inpatient beds in different settings

, 2017 , Recovery • Telemedicine 13 December (continued) • Use of mobile applications and social media • American Diabetes Association and American Psychiatric Association consensus report on antipsychotic drugs and obesity and diabetes • Georgia model of crisis call center engagement and support • Family psychoeducation; family consultation; caregiver respite • Shared decision-making; supported decision-making; therapeutic alliance; advance directives • Assisted outpatient treatment • Wellness coaching to address co-occurring disorders • Peer-led engagement; peer groups; programs such as Hearing Voices Network • Complementary approaches (e.g., mindfulness, diet, exercise) • Supportive housing

• Supported employment Families• Supported and education Caregivers

• Housing first Access Worksto • Systemfor All of care People approach for children’sLiving behavioral With health SMI and SED and Their

Services and • Comprehensive coordinated care; integration approaches

SupportsThe Way• Standards Forward: included in the Federal Certified Community Action Behavioral for Health a SystemClinic demonstration That

• Specialized services and cultural competence training to address disparities among underserved Caregivers and Families

groups such as people of color, andTheir lesbian, and gay, bisexualSED and transgenderand SMI individualsWith Living People All for Works

• Health navigator programs such as the Peer Bridger Program and other family- and youth-led

Coordinating Committee programs That System a for Action Federal Forward: Way The

• Findings from Meadows Mental Health Policy Institute continuum of crisis services, and related adult

and child crisis stabilization services

Serious• Arizona model Mental for connecting law enforcement Illness to facility-based crisis stabilization

• Use of secret shopper surveys to assess network adequacy Committee Coordinating

• Level of care instruments such as LOCUS and CALOCUS

Interdepartmental

Additionally, advances in our understanding of genetic, environmental, and developmentalIllness Mental Serious

factors across the lifespan hold great promise for earlier diagnosis of SMI and SED. Research

on early intervention and treatment demonstrates the potential to improve the course of the Interdepartmental

illnesses. There have not been many significant recent advances in the biologic treatment of people with SMI. Decades of experience with second-generation antipsychotic medications have yielded

medications with much better tolerability, but little improvement in effectiveness. Even though this class of medications often avoids the more debilitating side effects of older antipsychotic medications (such as sedation, movement disorders, and cardiac conduction abnormalities), the newer medications have more silent side effects such as blood glucose elevation, blood lipid elevation, and obesity. One of the second-generation antipsychotic agents, clozapine, continues to stand out as potentially effective in individuals who have not responded to other medications. However, this medication is underutilized in the United States. SAMHSA has engaged in several

recent projects to develop interventions to highlight underutilization of clozapine.

Interdepartmental

The Way Forward: Federal Action for a System That That System a for Action Federal Forward: Way The The Way Forward: Federal Action for a System That Works for All People Living With SMI and SED and Their Their and SED and SMI With Living People All for Works Works for All Peoplecaregivers. and Livingfamilies Withtheir and SMISED and and SMI SEDwith andliving TheirAmericans serve

Families and Caregivers Caregivers and Families Familieseffectively to andneeded Caregiversresources the define and understand to work also will ISMICC The lifespan. of effective treatments and services to meet the needs of people with SMI and SED across the the across SED and SMI with people of needs the meet to services and treatments effective of

client and family involvement. The ISMICC will continue to explore and capture the broad range range broad the capture and explore to continue will ISMICC The involvement. family and client

approach that recognizes the importance of interdisciplinary and cross-sector support, as well as as well as support, cross-sector and interdisciplinary of importance the recognizes that approach

justice involvement, and other challenges. Many of the evidence-based practices include a team team a include practices evidence-based the of Many challenges. other and involvement, justice

health issues, intellectual or developmental disabilities, substance use, trauma, homelessness, homelessness, trauma, use, substance disabilities, developmental or intellectual issues, health

Many people have concurrent issues that are not adequately addressed, including physical physical including addressed, adequately not are that issues concurrent have people Many

pharmacotherapeutic interventions. pharmacotherapeutic

and other elements of SMI symptomology will result in new opportunities to develop better better develop to opportunities new in result will symptomology SMI of elements other and

We remain hopeful that advances in understanding the biologic underpinnings of psychosis psychosis of underpinnings biologic the understanding in advances that hopeful remain We

mood stabilizers, and anxiety medications are often used to augment the effects of antipsychotics. antipsychotics. of effects the augment to used often are medications anxiety and stabilizers, mood 2017 , 13 December

intensity of suicidal ideation in people with SMI, and other medicines such as antidepressants, antidepressants, as such medicines other and SMI, with people in ideation suicidal of intensity

even once every three months (for at least one product). Lithium and clozapine can reduce the the reduce can clozapine and Lithium product). one least at (for months three every once even

more agents are available in long-acting injection forms that can be administered monthly, or or monthly, administered be can that forms injection long-acting in available are agents more , 2017 , 13 December Decemberthat so 13, 2017mechanisms, delivery on focus a included have development drug in advances Recent

, 2017 ChapterDecember 3: Setting 13 the Stage for Evaluation of Federal

Programs Related to SMI and SED

, 2017 , December 13 December

The central charge of the ISMICC is to improve the lives of Americans with serious mental illnesses (SMI) and serious emotional disturbances (SED) and their families. This is to be achieved in part by enhancing coordination across federal departments to improve service access and delivery of care. Working with leaders of the eight departments that serve on the ISMICC, committee members will inform efforts to evaluate the effect that federal policies and programs related to SMI and SED have on public health outcomes. The ISMICC will develop specific recommendations for actions that federal departments can take to better coordinate the

administration of mental health services for adults with SMI and children and youth with SED. Those effortsFamilies begin andnow. OverCaregivers the next five years, the ISMICC will work in collaboration with

federal interdepartmental leadership to build shared accountability for a system that provides

the fullWorks range of treatments for All Peopleand supports Living needed byWith individuals SMI and and families SED living and with Their SMI and

SED. The Way Forward: Federal Action for a System That Families and Caregivers Caregivers and Families

This will be a challenging undertaking. ISMICCTheir membersand recognizeSED and that itSMI will requireWith Living People All for Works

partnerships with all levels of government and a diverse array of other stakeholders. Mental health Coordinating Committee care and treatment is not solely a federal responsibility, That but ratherSystem onea sharedfor acrossAction federal, Federal Forward: Way The

state, tribal, and local governments; private insurers; diverse provider organizations; advocates;

caregivers;Serious families; and people Mental with SMI and IllnessSED. Figure 3.1 illustrates this point by showing the complexity of funding for treatment of mental health and substance use disorders in the UnitedCommittee Coordinating

States. Interdepartmental In the course of their deliberations, ISMICC members have emphasized that this reviewIllness of federal Mental Serious

initiatives must rise above the level of simply looking at individual programs. The ISMICC vision

calls for federal interdepartmental leadership in collaboration with others to build responsive Interdepartmental and effective systems of care that meet the needs of people with SMI and SED and their families.

Members have stressed the importance of focusing not only on prevention and treatment, but also on key social determinants of health such as housing, employment, education, and

transportation.

recovery support services for people with SMI and SED. and SMI with people for services support recovery

contribute in important ways to supporting the delivery of effective prevention, treatment, and and treatment, prevention, effective of delivery the supporting to ways important in contribute

Administration, and the Indian Health Service. These departments all have programs that that programs have all departments These Service. Health Indian the and Administration,

ISMICC, such as the Administration for Children and Families, the Health Resources and Services Services and Resources Health the Families, and Children for Administration the as such ISMICC,

The same is true for other components of the HHS that are not specifically represented on the the on represented specifically not are that HHS the of components other for true is same The

population, but are more broadly focused and tied to their mission and authorizing legislation. legislation. authorizing and mission their to tied and focused broadly more are but population,

Education, Labor, Justice, and Social Security—have missions that are highly relevant to the target target the to relevant highly are that missions Security—have Social and Justice, Labor, Education, Five other agencies represented on the ISMICC—Housing and Urban Development (HUD), (HUD), Development Urban and ISMICC—Housing the on represented agencies other Five

components related to the health of the nation at large. large. at nation the of health the to related components

have that Services Medicaid & Medicare for Centers the and (SAMHSA) Administration Services

Services (HHS) has public health agencies such as the Substance Abuse and Mental Health Health Mental and Abuse Substance the as such agencies health public has (HHS) Services Interdepartmental

serves active duty military and their families, while the Department of Health and Human Human and Health of Department the while families, their and military duty active serves the Department of Veterans Affairs serves veterans and the Department of Defense (DoD) (DoD) Defense of Department the and veterans serves Affairs Veterans of Illness Department the Mental Serious

Interdepartmental Interdepartmental Interdepartmentalexample, For constituents. its and Congress to accountable held is it which through metrics its population of focus, its authorizing legislation and level of funding, and the performance performance the and funding, of level and legislation authorizing its focus, of population its

needs of people with SMI and SED. Programs differ according to each department’s mission, mission, department’s each to according differ Programs SED. and SMI with people Committee of needs Coordinating

Serious Mental Illness Illness Mental Serious Seriousthe address that Mentalprograms supports IllnessISMICC the on represented departments eight the of Each

slowly than all health spending through 2020. Health Affairs, 33(8), 1407-1415. 33(8), Affairs, Health 2020. through spending health all than slowly

Source: Coordinating Committee Committee Coordinating Coordinatingmore grow to projected disorders use substance and Committee mental on That Spending (2014). M. System C. a Chow, & for T., Yee, R., K. Action Levit, L., T. Mark, Federal Forward: Way The

Works for All People Living With SMI and SED and Their Their and SED and SMI With Living People All for Works

5.8 % % 5.8

Other Federal Other Caregivers and Families

12.6 % % 12.6 2.8 % % 2.8 Medicare

The Way Forward: Federal Action for a System That That System a for Action Federal Forward: Way The ThePrivate Other Way Forward: Federal Action for a System That

15.9 % % 15.9 10.1 % % 10.1 Other State & Local & State Other Out of Pocket of Out

28.5 % % 28.5 24.3 % % 24.3 Medicaid Works for All People Living With SMI and SED and Their Their and SED and SMI With Living People All for Works WorksInsurance Private for All People Living With SMI and SED and Their

Families and Caregivers Caregivers and Families Families and Caregivers

for MH/SUD by Source Source by MH/SUD for for MH/SUD by Source by MH/SUD for

Private Funding Private Government Funding Government

37.2 % 37.2 62.8 % % 62.8

, 2017 , 13 December

Substance Use Disorder (SUD) Treatment (SUD) Disorder Use Substance

3.1. Figure , 2017 , 13 December December and (MH) 13, Health 2017 Mental for Sources Funding Private and Government

, 2017 The reviewDecember of federal 13 initiatives must include the large federal health insurance and disability programs such as Medicare, Medicaid, the Children’s Health Insurance Program, and Social Security disability programs that serve a broad and diverse population, including many people

with SMI and SED. These insurance and disability programs are of critical importance and serve

, 2017 , as a major source of funding for treatment and recovery support services for people with SMI and 13 December SED. School-based services in affiliation with the Department of Education play a central role in the lives of children and youth with SED. HUD-funded housing is also critically important. ISMICC members have stressed that it is essential to include these programs in any meaningful analysis of population health outcomes for people with SMI and SED.

The formation of the ISMICC marks the first time in many years that an interdepartmental group has come together to coordinate their efforts related to the broad spectrum of issues that impact people with SMI and SED. It is the first time that such a group has been chaired by an Assistant Secretary for Mental Health and Substance Use. This newly created position brings a new level

of authority, experience, and expertise to the coordination of efforts at HHS to address the needs

of peopleFamilies with SMI and and SED. Caregivers The Assistant Secretary must work across HHS and the federal

governmentWorks so people for withAll SMIPeople and SED Living receive the With highest SMI possible and standard SED of and care—care Their that

is deeplyThe informed Way by Forward:our knowledge Federalof science and Action medicine. for a System That

These eight departments have made a commitment to align their policies, assess their Caregivers and Families

programming, and improve care for people withTheir SMIand and SED.SED Theirand collaborationSMI With will be Living People All for Works

Coordinating Committee informed and strengthened by the participation of That non-federal System ISMICC a for members, Action including Federal Forward: Way The

national experts on health care research, mental health providers, advocates, and people with mentalSerious health conditions andMental their families. Illness

Coordinating Committee Committee Coordinating

Direct Interdepartmentaland Indirect Levers of Federal Influence Serious Mental Illness Illness Mental Serious

As the ISMICC undertakes the challenging work of evaluating and recommending ways to

strengthen federal policies and programs, a key goal will be to ensure that changes made at the Interdepartmental federal level actually lead to better lives for people with SMI and SED throughout the nation.

As Figure 3.1 illustrates, there are many contributors to our complex national system for mental health care. All federal sources combined account for almost half of all spending on mental

and substance use disorders (46.9 percent; Mark, Levit, Yee & Chow, 2014). It is important to note that the data in Figure 3.1 includes little if any of the spending that occurs for housing, disability payments, vocational training, educational services, etc., much of which also reflects a combination of federal, state, tribal, local, and private resources.

The ISMICC process will examine the various approaches that can be used to improve population health for people with SMI and SED, using the broad range of direct and indirect levers of federal influence. The goal of this process is to improve collaboration of federal agencies that provide

services, such as:

enhanced access to supported employment and evidence-based treatment can can treatment evidence-based and employment supported to access enhanced

SMI and SED. Demonstration programs currently underway are assessing whether whether assessing are underway currently programs Demonstration SED. and SMI

Another is the direct income support and other services they provide to recipients with with recipients to provide they services other and support income direct the is Another

(SSI) programs is that they provide an entitlement to Medicare or Medicaid eligibility. eligibility. Medicaid or Medicare to entitlement an provide they that is programs (SSI)

of the Social Security Disability Insurance (SSDI) and Supplemental Security Income Income Security Supplemental and (SSDI) Insurance Disability Security Social the of

in the lives of adults with SMI and children and youth with SED. One facet of the role role the of facet One SED. with youth and children and SMI with adults of lives the in

Social Security disability programs. programs. disability Security Social These programs have long played a major role role major a played long have programs These •

disparities in local economies and circumstances. circumstances. and economies local in disparities services available in communities throughout the nation, but cannot always overcome overcome always cannot but nation, the throughout communities in available services

of types and range the influence greatly can policy CHIP and Medicaid women. earn too much to qualify for Medicaid. In some states, CHIP also covers pregnant pregnant covers also CHIP states, some In Medicaid. for qualify to much too earn

coverage, including behavioral health services, to uninsured children in families that that families in children uninsured to services, health behavioral including coverage, Interdepartmental

SED. CHIP, like Medicaid, is a federal/state partnership. CHIP provides low-cost health health low-cost provides CHIP partnership. federal/state a is Medicaid, like CHIP, SED.

used to create a responsive and effective system of services for people with SMI and and SMI with people for services of system effective and responsive a create to Illness used Mental Serious Interdepartmental Interdepartmental Interdepartmentalbeen has flexibility this which to extent the in widely differ States Medicaid. under

Home program, which often serves people with SMI and SED, an optional benefit benefit optional an SED, and SMI with people serves often which program, Home Committee Coordinating in some states) to tailor its service system. An example of this is the Medicaid Health Health Medicaid the is this of example An system. service its tailor to states) some in

Serious Mental Illness Illness Mental Serious Seriouscounties (and state Mentaleach allows and Illnessfederalism, of principles the of exercise creative

The mix of mandated and optional services provides extensive opportunities for the the for opportunities extensive provides services optional and mandated of mix The

Coordinating Committee Committee Coordinating Coordinatingnext. the to state one from Committee substantially vary That can services System for a for payment of Action methods Federal Forward: Way The

by the federal and state governments, the configuration of reimbursable services and and services reimbursable of Their configuration the and SED governments, and state and SMI federal With the by Living People All for Works

services relevant to people with SMI and SED. Because Medicaid is jointly operated operated jointly is Medicaid Because SED. and SMI with people to relevant services behavioral health services, and frequently offers the most comprehensive array of of array comprehensive most the offers frequently and services, health behavioral Caregivers and Families

The Way Forward: Federal Action for a System That That System a for Action Federal Forward: Way The The Way Forward: Federal Action for a System That a federal/state partnership for reimbursement of services, is the largest payer for for payer largest the is services, of reimbursement for partnership federal/state a

Medicaid and the Children’s Health Insurance Program (CHIP). Program Insurance Health Children’s the and Medicaid Medicaid, Medicaid, Works for All People Living With SMI and SED and Their Their and SED and SMI With Living People All for Works Works for All People Living With SMI and SED and Their•

Families and Caregivers Caregivers and Families Families and Caregivers Medicare program because of its great reach. great its of because program Medicare

of people with SMI and SED could have widespread benefits, particularly through the the through particularly benefits, widespread have could SED and SMI with people of

insurers. Making their policies and programs more effective at addressing the needs needs the addressing at effective more programs and policies their Making insurers.

and their ability to access care, but also because they often serve as a model for private private for model a as serve often they because also but care, access to ability their and

coverage. These programs are highly influential, not only for the impact on enrollees enrollees on impact the for only not influential, highly are programs These coverage.

services provided to eligible enrollees or works with intermediaries to provide health health provide to intermediaries with works or enrollees eligible to provided services

programs where the federal government directly reimburses health care providers for for providers care health reimburses directly government federal the where programs

Medicare, TRICARE, and the Indian Health Service. Health Indian the and TRICARE, Medicare, These are examples of of examples are These •

emulated in other systems. other in emulated

active duty service members and veterans and—importantly—serves as a model to be be to model a as and—importantly—serves veterans and members service duty active 2017 , 13 December

and ongoing outreach to people with SMI and SED. This work improves the care of of care the improves work This SED. and SMI with people to outreach ongoing and

in areas such as integration of health and behavioral health care, suicide prevention, prevention, suicide care, health behavioral and health of integration as such areas in

(VHA) and DoD health care facilities. care health DoD and (VHA) VHA and DoD have done promising work work promising done have DoD and VHA

Government-operated systems run by the Veterans Health Administration Administration Health Veterans the by run systems Government-operated , 2017 , 13 December December 13, 2017 •

, 2017 Decemberenable people 13 with SMI to avoid enrolling in the programs and move to competitive employment instead.

The federal government also provides a diverse mix of other services and functions that influence

, 2017 , the lives of people with SMI and SED and their families. A partial list of examples would include: 13 December

• Basic and applied research that helps us better understand the course of a disorder and the means to prevent, cure, or lessen its impact. This includes the work of the National Institute of Mental Health that aims to unravel the causes and course of SMI and to assess the effectiveness of models such as coordinated specialty care for first-episode psychosis.

• Surveys and other surveillance programs that provide information on the incidence, prevalence, and distribution of disorders. SAMHSA, the Agency for

Healthcare Research and Quality, and the Centers for Disease Control and Prevention

Familiesconduct ongoing and Caregivers major national surveys to help us understand patterns and Worksprevalence for ofAll a broad People range ofLiving health and With behavioral SMI health and disorders, SED and patterns Their of care,

as well as some of the contributing social factors.

The Way Forward: Federal Action for a System That

• Demonstrations and evaluations of prevention, treatment, and support models Caregivers and Families

that can improve the lives of peopleTheir withand SMISED and SED.and SAMHSA,SMI With the OfficeLiving of People All for Works

Coordinatingthe Assistant Secretary for Planning Committee and Evaluation, and the Centers for Medicare & Medicaid Services have collaborated on That relevant demonstrationSystem a for programs,Action such as Federal Forward: Way The

the Certified Community Behavioral Health Clinic (CCBHC) program that provides

Seriousalternative payment Mental models and more Illness integrated, comprehensive care for people with

SMI and SED. The Center for Medicare and Medicaid Innovation has implementedCommittee Coordinating

Interdepartmentaland is assessing an extensive roster of alternative delivery and payment programs, including many that impact health and behavioral health care for people withIllness SMI and Mental Serious

SED.

• Time-limited grant programs to fund development of promising models at Interdepartmental the state, tribal, and local levels. This widely used tool encourages widespread

implementation of promising models through time-limited federal funding. Examples include suicide prevention initiatives, efforts to develop trauma-informed systems, expansion of mental and substance use disorder treatment in federally qualified

health centers, and many others. A general concern with this strategy is whether gains achieved are retained over the longer term after the grant funding ends.

• Longer-term formula-funded programs. These include block grants and other funding streams that support critical infrastructure and system capacity. They may be used to ensure a focus on specific issues, such as the focus on intervening early for serious mental illness included in the Community Mental Health Services Block

Grant.

from new, innovative approaches to meet the needs across the full range of health, health, of range full the across needs the meet to approaches innovative new, from

being addressed at all, or not being adequately addressed? What areas could benefit benefit could areas What addressed? adequately being not or all, at addressed being

with SMI and SED and their families. Are there important gaps—areas that are not not are that gaps—areas important there Are families. their and SED and SMI with

and supports necessary to make possible an acceptable quality of life for people people for life of quality acceptable an possible make to necessary supports and

people with SMI and SED? SED? and SMI with people Consider and examine the full spectrum of services services of spectrum full the examine and Consider

1. How effective are federal policies and programs in addressing the needs of of needs the addressing in programs and policies federal are effective How

evaluation questions such as the following: the as such questions evaluation

A deeper examination of this broad array of federal programs should attempt to answer common common answer to attempt should programs federal of array broad this of examination deeper A

federally supported services. services. supported federally

of array the on perspective high-level a developing in step first a as Illness, Mental Serious to

on data from 2013, Mental Health: HHS Leadership Needed to Coordinate Federal Efforts Related Related Efforts Federal Coordinate to Needed Leadership HHS Health: Mental 2013, from data on and from a Government Accountability Office (GAO) report that was released in 2014 and based based and 2014 in released was that report (GAO) Office Accountability Government a from and Interdepartmental

The ISMICC proposes to examine the information obtained from the request to federal members, members, federal to request the from obtained information the examine to proposes Illness ISMICC The Mental Serious Interdepartmental Interdepartmental Interdepartmental evaluation. this of development the inform to order in SED and SMI with

ISMICC meeting, we have begun to collect information about federal programs serving people people serving programs federal about information collect to begun have we meeting, Committee ISMICC Coordinating

Serious Mental Illness Illness Mental Serious first Seriousthe Since process. Mentalextended an require Illnesswill evaluation this and formed newly is ISMICC The

Enhancing Coordination to Improve Outcomes Outcomes Improve to Coordination Enhancing

The ISMICC Role in Evaluating Federal Programs and and Programs Federal Evaluating in Role ISMICC The Coordinating Committee Committee Coordinating Coordinating Committee That System a for Action Federal Forward: Way The

Works for All People Living With SMI and SED and Their Their and SED and SMI With Living People All for Works in the years ahead. years the in Caregivers and Families

The Way Forward: Federal Action for a System That That System a for Action Federal Forward: Way The The Way Forward: Federal Action for a System That beneficial influences on practices at the community level, will be a major focus of the committee committee the of focus major a be will level, community the at practices on influences beneficial

Works for All People Living With SMI and SED and Their Their and SED and SMI With Living People All for Works as Worksserve can forthey All which Peoplein ways the Livingand Withprograms, SMIand andpolicies these SED andExamining TheirSED. and SMI

Families and Caregivers Caregivers and Families Familieswith people for and Caregiverssupports and services of system federal the of evaluation advance to agencies

undertaking. The ISMICC will support coordination across the participating departments and and departments participating the across coordination support will ISMICC The undertaking.

The evaluation of this diverse array of federal policies and programs will be an enormous enormous an be will programs and policies federal of array diverse this of evaluation The

while advocates tend to push for additional, more specific measures and reports. reports. and measures specific more additional, for push to tend advocates while

providers complain about the costs and burden associated with these requirements, requirements, these with associated burden and costs the about complain providers

delivery in ways that can improve responsiveness and effectiveness. However, many many However, effectiveness. and responsiveness improve can that ways in delivery

Medicaid, and other insurers. These requirements have the potential to shape service service shape to potential the have requirements These insurers. other and Medicaid,

variety of federal grants, as well as reimbursement funding streams from Medicare, Medicare, from streams funding reimbursement as well as grants, federal of variety

Quality measurement and reporting. and measurement Quality These are required for receipt of a wide wide a of receipt for required are These •

several such programs. programs. such several 2017 , 13 December

For example, SAMHSA and the Departments of Justice, Education, and Labor fund fund Labor and Education, Justice, of Departments the and SAMHSA example, For

and supports to aid implementation of effective models at state, tribal, and local levels. levels. local and tribal, state, at models effective of implementation aid to supports and

variety of topics relevant to people with SMI and SED, and provide education, tools, tools, education, provide and SED, and SMI with people to relevant topics of variety

Technical assistance and support. support. and assistance Technical Many technical assistance centers address a wide wide a address centers assistance technical Many , 2017 , 13 December December 13, 2017 •

, 2017 Decemberbehavioral 13 health, education, employment, income supports, housing, or other areas?

2. How effectively are federal departments collaborating and coordinating

policies and programs to enhance the quality of life for people with SMI and

, 2017 , SED? In addition to the ISMICC, what structures are in place to develop and sustain 13 December coordination on an ongoing basis? What accountability measures exist or are needed to ensure that efforts to improve policy and programmatic coordination are achieving desired public health outcomes?

3. Do current policies and programs have sufficient reach to serve all of the people with SMI and SED who could benefit? A concern is that programs may be designed, accidentally or intentionally, to restrict the number of people who can participate and consequently exclude vulnerable populations or those with limited access such as people in rural areas. This may occur inadvertently through

the construction of program eligibility criteria that fail to acknowledge all relevant

Familiescircumstances. and It Caregivers also may occur simply as the result of inadequate funding—a Worksuniversally for importantAll People consideration Living that With may be SMI difficult and to SEDaddress. and What Theircan be done

to expand the reach of policies and programs to all of those who are in need? The Way Forward: Federal Action for a System That

4. Are there important gaps in knowledge or information that make it difficult Caregivers and Families

to assess the extent to which weTheir are achievingand SED goalsand related SMI to publicWith healthLiving People All for Works

Coordinating Committee outcomes for people with SMI and SED?That Given theSystem contexta for of our complexAction systemFederal Forward: Way The in which federal, state, tribal, local, and private players hold important roles, there are

many important concerns about which information is not yet readily available to assess

Seriouskey issues or progress Mental in resolving problems.Illness What can be done to improve access to

public health indicators in such areas? For example, the need to involve the criminalCommittee Coordinating

Interdepartmentaljustice system is widely viewed as a sign of failure of community treatment systems, yet we have no way to obtain comprehensive information on such incidents.Illness In other Mental Serious

cases, programs that serve people with SMI and SED do not collect information that

allows identification of that segment of program participants. Interdepartmental 5. How effectively do policies and programs meet the needs of the people they serve or impact? As currently constructed and operated, do they advance the goal of

improving care and quality of life for people with SMI and SED? Do they incorporate adaptations to cultural, linguistic, and local circumstances? Do they address health

disparities and vulnerable populations in the areas served? Has the effectiveness of the

Interdepartmental

release? upon benefits of reinstatement and incarceration, or institutionalization

there be better guidance related to termination of Medicaid or disability benefits upon upon benefits disability or Medicaid of termination to related guidance better be there

jointly funded programs could improve access and outcomes? and access improve could programs funded jointly For example, could could example, For Illness Mental Serious

9. Interdepartmental Interdepartmental Interdepartmentalimplementing states or regions for guidance clearer where areas there Are Coordinating Committee Committee Coordinating

Serious Mental Illness Illness Mental Serious Serious Mentalprogressing? Illnessnot is person the if manner person-centered to the population served to track progress over time, and to adapt the intervention in a a in intervention the adapt to and time, over progress track to served population the to

measurement-based care? care? measurement-based Is the program using validated rating scales appropriate appropriate scales rating validated using program the Is

8. Coordinating Committee Committee Coordinating Coordinating of principles the apply Committeeprogram the That does System programs, a for treatment Action direct For Federal Forward: Way The

Works for All People Living With SMI and SED and Their Their and SED and SMI With Living People All for Works

assurance initiatives so that operations and outcomes can be improved over time? over improved be can outcomes and operations that so initiatives assurance and ensure that they receive needed services? Are there active, meaningful quality quality meaningful active, there Are services? needed receive they that ensure and Caregivers and Families

The Way Forward: Federal Action for a System That That System a for Action Federal Forward: Way The The Way Forward: Federal Action for a System That registries used as a tool to maintain contact with participants, monitor their progress, progress, their monitor participants, with contact maintain to tool a as used registries

Works for All People Living With SMI and SED and Their Their and SED and SMI With Living People All for Works WorksAre forprogram? Allthe in People Livingparticipation and Withprogram the SMIof andreach the SEDincrease andto steps Their

Families and Caregivers Caregivers and Families Familiesactive take it Does and them? Caregivers receiving are who services from benefit could who those of

management in its operations? its in management Is there an approach to monitoring the proportion proportion the monitoring to approach an there Is

7. Does the policy or program apply the principles of population health health population of principles the apply program or policy the Does

adaptation to cultural, linguistic, and local circumstances? local and linguistic, cultural, to adaptation

being implemented in a manner consistent with those models, with appropriate appropriate with models, those with consistent manner a in implemented being

success in meeting the needs of people with SMI and SED. Are policies and programs programs and policies Are SED. and SMI with people of needs the meeting in success

A good deal is known about practices and models of care that have a track record of of record track a have that care of models and practices about known is deal good A

about what has been shown to improve outcomes for people with SMI and SED? and SMI with people for outcomes improve to shown been has what about

6. Does the policy or program reflect the state of the science and our knowledge knowledge our and science the of state the reflect program or policy the Does

cyclical illnesses? illnesses? cyclical 2017 , 13 December

create incentives to work and provide the necessary support for people with episodic or or episodic with people for support necessary the provide and work to incentives create

design align with the nature of SMI and SED? For example, do disability programs programs disability do example, For SED? and SMI of nature the with align design

improvements in response to evaluation recommendations? Does current program program current Does recommendations? evaluation to response in improvements , 2017 , 13 December Decemberundergone 13program , the 2017 Has it? evaluate to plans there are or evaluated, been program

, 2017 10.December Are there 13 areas in which data collection could be harmonized across departments to improve our knowledge of changes in key outcome measures? Many program measures are set through regulation or law and may be difficult to

change, but others could be changed administratively to allow better comparisons

, 2017 , across departments and programs. This could facilitate the collection of data 13 December relevant to tracking progress on public health outcomes relevant to the SMI and SED populations.

11. Could existing large-scale federal data collection efforts be better used to provide information about population health outcomes relevant to the SMI and SED populations? Could reasonable and affordable changes to these data collection efforts be feasible and beneficial? Several federal databases are relevant to people with SMI and SED and could provide information about gaps to address, such as Medicaid and Medicare claims data, electronic health record data from the

VHA, and data from surveys such as the National Survey on Drug Use and Health

Familiesand the Medical and CaregiversExpenditure Panel Survey. Is it feasible to use these data to monitor

Worksthe effectiveness for All People of efforts toLiving improve Withthe care SMI and qualityand ofSED life for andSMI and Their SED

Thepopulations Way Forward: over time? Federal Action for a System That

It will be critical to identify gaps that occur either through the absence of essential policies or Caregivers and Families

programs, or through programs that fail to reachTheir all and of thoseSED in need.and The 21SMI st CenturyWith Cures Living People All for Works

Coordinating Committee

Act created new programs and initiatives to addressThat the needs ofSystem peoplea for with SMI andAction SED. If Federal Forward: Way The

Congress provides funding to implement or continue these programs, the ISMICC can examine

them toSerious assess what is working Mental and where additional Illness improvements are called for.

This work will require a level of commitment from the departments that participate in the Committee Coordinating

ISMICCInterdepartmental process, and will benefit from the expertise and guidance of the full membership. A key concern will be how to ensure that improvements developed at the federal level are implementedIllness Mental Serious

comprehensively throughout the states, tribes, and localities across the nation. Given the complex and multilayered federal, state, and local funding streams that support services needed by the Interdepartmental

SMI and SED populations, careful attention to principles of implementation science will be very

important.

Vocational Rehabilitation Services Rehabilitation Vocational •

Student Support and Academic Enrichment Formula Grant Formula Enrichment Academic and Support Student •

State Vocational Rehabilitation Services Program Services Rehabilitation Vocational State •

State Supported Employment Program Employment Supported State

• Special Education – Personnel Development to Improve Services and Results for Children with Disabilities with Children for Results and Services Improve to Development Personnel – Education Special •

Services for School Aged Children: (Part B of IDEA) of B (Part Children: Aged School for Services

• School Climate Transformation Grants Transformation Climate School •

Project SERV (School Emergency Response to Violence) to Response Emergency (School SERV Project

•

IDEA Technical Assistance and Dissemination and Assistance Technical IDEA

Interdepartmental • Interdepartmental

IDEA Parent Information Parent IDEA

•

Elementary and Secondary School Counseling Program Counseling School Secondary and Elementary •

Serious Mental Illness Illness (IDEA) Act Mental Serious

Early Intervention Program for Infants and Toddlers with Disabilities (Part C of Individuals with Disabilities Education Education Disabilities with Individuals of C (Part Disabilities with Toddlers and Infants for Program Intervention Early

Interdepartmental Interdepartmental Interdepartmental •

Department of Education of Department

Coordinating Committee Committee Coordinating

TRICARE

Serious Mental Illness Illness Mental Serious Serious Mental Illness •

Naval Hospital Jacksonville, Substance Abuse Rehabilitation Program (SARP) Program Rehabilitation Abuse Substance Jacksonville, Hospital Naval •

Overcoming Adversity and Stress Injury Support (OASIS) Support Injury Stress and Adversity Overcoming

Coordinating Committee Committee Coordinating Coordinating Committee That System a for Action Federal • Forward: Way The

In-Transition •

Direct Care (DC) System Mental Health Services Health Mental System (DC) Care Direct Works for All People Living With SMI and SED and Their Their and SED and SMI With Living • People All for Works

Army Behavioral Health Residential Treatment Facilities Treatment Residential Health Behavioral Army

Families and Caregivers • Caregivers and Families

The Way Forward: Federal Action for a System That That System a for Action Federal Forward: Way The The Way Forward: Federal Action for a System ThatDefense of Department

Works for All People Living With SMI and SED and Their Their and SED and SMI With Living People All for Works Works for All People Living WithSED SMIand SMI andWith SEDPeople and Support Their Can That

Federal Programs Related to SMI and SED Programs Programs SED and SMI to Related Programs Federal 3.1. Table

Families and Caregivers Caregivers and Families Families and Caregivers

nationally.

and begin the process of a broader evaluation of federal policies and programs, and their impact impact their and programs, and policies federal of evaluation broader a of process the begin and

In the months ahead, the ISMICC will, with staff support, continue existing data collection efforts efforts collection data existing continue support, staff with will, ISMICC the ahead, months the In

2014 GAO report cited above. above. cited report GAO 2014

Another source of basic descriptive information for many of these programs is available from the the from available is programs these of many for information descriptive basic of source Another

programs, and that data collection process is ongoing. is process collection data that and programs,

SMI and SED. An initial call has gone to all the departments for basic information about these these about information basic for departments the all to gone has call initial An SED. and SMI

programs that serve a broader population but provide services that are important to people with with people to important are that services provide but population broader a serve that programs 2017 , 13 December compiled by committee staff. This list includes programs that focus on SMI and SED, as well as as well as SED, and SMI on focus that programs includes list This staff. committee by compiled

Table 3.1 is a listing of programs in each of the eight departments that serve on the ISMICC, ISMICC, the on serve that departments eight the of each in programs of listing a is 3.1 Table , 2017 , 13 December December 13, 2017 Programs Federal About Date to Known Is What

, 2017 Table 3.1.December Federal 13 Programs Related to SMI and SED Programs That Can Support People With SMI and SED (continued)

Department of Health and Human Services

, 2017 , Administration for Children and Families 13 December • National Center on Domestic Violence, Trauma, and Mental Health • Temporary Assistance for Needy Families • Title IV-E Foster Care Administration for Community Living • Advanced Research Training Program in Employment and Vocational Rehabilitation of Persons with Psychiatric Disabilities • Aging and Disability Resource Centers • Creating a Multidimensional Model of Engagement for Young Adult with Psychiatric Disabilities in Adult System Team- Based Community Outreach and Support Services • Customized Employment for Individuals with Serious Psychiatric Disabilities

• Development Center to Enhance Evidence-Based Supportive Employment with a Technology-Based Management

SystemFamilies and Caregivers • EmpoweringWorks Parents: for National All ResearchPeople Center Living for Parents withWith Disabilities SMI and andtheir Families SED and Their

• Enhancing the Community Living and Participation of Individuals with Psychiatric Disabilities The Way Forward: Federal Action for a System That • Evaluating the Impact of Employment Services in Supportive Housing Caregivers and Families

• Identifying Enabling Environments Affecting Adults with Psychiatric Disabilities

• Increasing Community Participation Among Adults withTheir Psychiatric and DisabilitiesSED Throughand IntentionalSMI PeerWith Support Living People All for Works

Coordinating Committee • Increasing Community Participation in Adults with Schizophrenia That System a for Action Federal Forward: Way The • Integrated Program to Improve Competitive Employment in Dually Diagnosed Clients

• Integrated Scaling Approach: A Model for Large Scale Implementation of Effective Interventions for Employment.

• ManualSerious and Training Program toMental Promote Career Development Illness Among Transition Age Youth and Young Adults with

Psychiatric Conditions Committee Coordinating • RecoveryInterdepartmental 4 US – Development of a Photovoice-Based Social Media Program to Enhance the Community

Participation and Recovery of Individuals with Psychiatric Disabilities

• Rehabilitation Research and Training Center on Improving Employment Outcomes for Individuals with PsychiatricIllness Mental Serious

Disabilities

• Rehabilitation Research and Training Center on Self-Directed Recovery and Integrated Health Care Interdepartmental

• Research and Training Center for Pathways to Positive Futures: Building Self-Determination and Community Living

and Participation • Temple University Rehabilitation Research and Training Center on Community Living and Participation of Individuals

with Psychiatric Disabilities • TEST – Translating Evidence to Support Transitions: Improving Outcomes of Youth in Transition with Psychiatric Disabilities by Use and Adoption of Best Practice Transition Planning • The Learning and Working During the Transition to Adulthood Rehabilitation Research and Training Center • Weight Management and Wellness for People with Psychiatric Disabilities • Workers with Psychiatric Disabilities and Self-Employment Through Microenterprise

• WorkingWell: Developing a Mobile Employment Support Tool for Individuals with Psychiatric Disabilities

– Behavioral Health Workforce Education and Training Program Training and Education Workforce Health Behavioral –

– Nurse Education, Practice, Quality and Retention: Behavioral Health Integration Program Integration Health Behavioral Retention: and Quality Practice, Education, Nurse –

Training/Workforce Programs Training/Workforce •

Title V Maternal and Child Health Block Grant Block Health Child and Maternal V Title • Ryan White HIV/AIDS Program HIV/AIDS White Ryan

– Home Visiting Program Visiting Home – – Healthy Start Program Start Healthy –

Specialized Health Care Service Grants Service Care Health Specialized

•

Health Center Program Center Health •

Administration Services and Resources Health

sharing the same active moiety active same the sharing relationship based on efficacy findings of immediate-release and long acting injectable antipsychotic formulations formulations antipsychotic injectable acting long and immediate-release of findings efficacy on based relationship Interdepartmental

Critical Path Initiative: Optimizing schizophrenia trial design elements and establishment of exposure-response exposure-response of establishment and elements design trial schizophrenia Optimizing Initiative: Path Critical •

Serious Mental Illness Administration Illness Drug and Food Mental Serious

Center for Medicare and Medicaid Innovation Demonstration Projects Demonstration Innovation Medicaid and Medicare for Center

Interdepartmental Interdepartmental Interdepartmental • Children’s Health Insurance Program (CHIP) Program Insurance Health Children’s •

Coordinating Committee Services Community-Based and Committee Home- – Coordinating

Serious Mental Illness Illness Mental Serious Serious MentalDiseases Mental for IllnessInstitutions in Treatment of Coverage Care Managed Medicaid of Study – – Medicaid and CHIP Quality Measurement and Improvement Program Improvement and Measurement Quality CHIP and Medicaid –

Coordinating Committee Committee Coordinating Coordinating Committee Tool That Analytic Data SMI – System a Program for Accelerator Action Innovation Medicaid Federal – Forward: Way The

– Health Homes Health –

Works for All People Living With SMI and SED and Their Their and SED and Innovation for SMI With Opportunities on Living Guidance – People All for Works

– Certified Community Behavioral Health Clinics Health Behavioral Community Certified – Caregivers and Families

Selected Programs Focused on SMI on Focused Programs Selected

The Way Forward: Federal Action for a System That That System a for Action Federal Forward: Way The The Way Forward: Federal Action for a System That •

Medicaid

Works for All People Living With SMI and SED and Their Their and SED and SMI With Living People All for Works Works for All People Living With SMI and SED and Their •

Care Management and Coordination Services Coordination and Management Care •

Medicare Families and Caregivers Caregivers and Families Families and Caregivers •

Centers for Medicare & Medicaid Services Medicaid & Medicare for Centers •

Preventive Health and Health Services Block Grant Block Services Health and Health Preventive •

National Violent Death Reporting System Reporting Death Violent National •

Senior Connection Research Study Study Research Connection Senior •

LET’S CONNECT CONNECT LET’S •

Centers for Disease Control and Prevention and Control Disease for Centers

recovery practices recovery

Ensuring that the needs of people with SMI are integrated into broader public health preparedness, response, and and response, preparedness, health public broader into integrated are SMI with people of needs the that Ensuring •

Assistant Secretary for Preparedness and Response and Preparedness for Secretary Assistant

Academy for Integrating Behavioral Health and Primary Care Primary and Health Behavioral Integrating for Academy •

Agency for Healthcare Research and Quality and Research Healthcare for Agency 2017 , 13 December

Department of Health and Human Services (continued) Services Human and Health of Department

That Can Support People With SMI and SED (continued) SED and SMI With People Support Can That

Programs SED and SMI to Related Programs Federal , 2017 , 13 December December 13, 2017 3.1. Table

, 2017 Table 3.1.December Federal Programs13 Related to SMI and SED Programs That Can Support People With SMI and SED (continued)

Department of Health and Human Services (continued)

, 2017 , – Teaching Health Center Graduate Medical Education Program 13 December – National Health Service Corps Indian Health Service • Behavioral Health Integration Initiative (BH2I) • Mental Health Direct Care Services • Zero Suicide Initiative National Institute of Mental Health • Addressing Suicide Research Gaps: Aggregating and Mining Existing Data Sets for Secondary Analyses (R01) • Addressing Suicide Research Gaps: Understanding Mortality Outcomes (R01) • ALACRITY – Advanced Laboratories for Accelerating the Reach and Impact of Treatments for Youth and Adults with

Mental Illness (Research Centers (P50) • AppliedFamilies Research Towards and Zero Caregivers Suicide Healthcare Systems (R01)

• Bipolar-Schizophrenia Network for Intermediate Phenotypes

• DetectingWorks and Preventing for AllSuicide People Behavior, Ideation Living and Self-Harm With in YouthSMI in Contact and with SED the Juvenile and Justice Their

SystemThe (R01) Way Forward: Federal Action for a System That • Effectiveness Trials for Post-Acute Interventions and Services to Optimize Longer-term Outcomes (R01 and R34) Caregivers and Families

• Exploratory Clinical trials of Novel Interventions for Mental Disorders (R61/R33)

• Improving Health Outcomes and Reducing Premature Their Mortality and in SeriousSED Mental Illnessand SMI With Living People All for Works

Coordinating Committee • North American Prodrome Longitudinal Study That System a for Action Federal Forward: Way The • Pilot Studies to Detect and Prevent Suicide Behavior, Ideation, and Self-Harm in Youth in Contact with the Juvenile

Justice System (R34)

• ProductsSerious to Support Applied Research Mental Towards Zero Suicide Illness Healthcare Systems (R43/R44)

• Psychiatric Genomics Consortium Committee Coordinating

• RAISEInterdepartmental Recovery after an Initial Schizophrenia Episode • Reducing the Duration of Untreated Psychosis in the United States (R01 and R34) Illness Mental Serious

• Temporal Dynamics of Neurophysiological Patterns as Potential Targets for Treating Cognitive Deficits in Brain

Disorders (R01)

• Using the NIMH Research Domain Criteria (RDoC) Approach to Understand Psychosis (R21/R01) Interdepartmental Office of Civil Rights

• 21st Century Cures Act: HIPAA Compassionate Communications • Disability nondiscrimination under Section 504 of the Rehabilitation Act, Title II of the Americans with Disabilities Act

and Section 1557 of the Affordable Care Act. Substance Abuse and Mental Health Services Administration • Assisted Outpatient Treatment • Children’s Mental Health Initiative • Circles of Care • Cooperative Agreements to Implement the National Strategy for Suicide Prevention

• Community Mental Health Services Block Grant

HUD – VA Supportive Housing Supportive VA – HUD •

Office of Public and Indian Housing Indian and Public of Office

Section 811 Supportive Housing for Persons with Disabilities with Persons for Housing Supportive 811 Section •

Office of Housing of Office

Housing Opportunities for Persons with AIDS with Persons for Opportunities Housing

•

Emergency Solutions Grant Solutions Emergency •

Continuum of Care of Continuum

•

Office of Community Planning and Development and Planning Community of Office

Development Urban and Housing of Department

Zero Suicide Grants Suicide Zero Interdepartmental • Interdepartmental

Transforming Lives Through Supported Employment Grant Program Grant Employment Supported Through Lives Transforming •

The National Consumer and Consumer Supporter Technical Assistance Centers (CCSTAC) Centers Assistance Technical Supporter Consumer and Consumer National The

Serious Mental Illness Illness • Mental Serious Suicide Prevention Resource Center Resource Prevention Suicide •

Statewide Family Networks Family Statewide Interdepartmental Interdepartmental Interdepartmental •

Statewide Consumer Networks Consumer Statewide

Coordinating Committee Committee • Coordinating

Service Members, Veterans, and their Families – Technical Assistance Center Assistance Technical – Families their and Veterans, Members, Service

Serious Mental Illness Illness Mental Serious Serious Mental Illness •

SAMHSA Social Inclusion and Public Education Program (VOICE) Program Education Public and Inclusion Social SAMHSA •

SAMHSA’s Behavioral Health and Justice Transformation Center Transformation Justice and Health Behavioral SAMHSA’s

Coordinating Committee Committee Coordinating Coordinating Committee That System a for Action Federal • Forward: Way The Recovery to Practice Task 4 Workgroup: Clinical Decision Making with People who have SMI have who People with Making Decision Clinical Workgroup: 4 Task Practice to Recovery •

Protection and Advocacy for Individuals with Mental Illness Mental with Individuals for Advocacy and Protection

Works for All People Living With SMI and SED and Their Their and SED and SMI With Living • People All for Works

Projects for Assistance in Transition from Homelessness from Transition in Assistance for Projects

Families and Caregivers • Caregivers and Families

Programs to Achieve Wellness Achieve to Programs

The Way Forward: Federal Action for a System That That System a for Action Federal Forward: Way The The Way Forward: Federal Action for a System That •

Primary and Behavioral Health Care Integration/ Promoting Integration of Primary and Behavioral Health Care Health Behavioral and Primary of Integration Promoting Integration/ Care Health Behavioral and Primary

Works for All People Living With SMI and SED and Their Their and SED and SMI With Living People All for Works Works for All People Living With SMI and SED and Their • Native Connections Native •

National Technical Assistance Center for Trauma-Informed Practice and Alternatives to Restraint and Seclusion and Restraint to Alternatives and Practice Trauma-Informed for Center Assistance Technical National

Families and Caregivers Caregivers and Families Families and Caregivers •

National Suicide Prevention Lifeline Crisis Center Follow-Up Grants Follow-Up Center Crisis Lifeline Prevention Suicide National •

National Suicide Prevention Lifeline Prevention Suicide National •

National Consumer and Consumer Supporter Technical Assistance Centers Assistance Technical Supporter Consumer and Consumer National •

National Child Traumatic Stress Initiative Stress Traumatic Child National •

Minority AIDS Initiative AIDS Minority •

Jail Diversion Jail •

Homeless and Housing Resource Network Resource Housing and Homeless •

Healthy Transitions Healthy •

Garrett Lee Smith State and Tribal Youth Suicide Prevention Program Prevention Suicide Youth Tribal and State Smith Lee Garrett •

Garrett Lee Smith Campus Suicide Prevention Program Prevention Suicide Campus Smith Lee Garrett •

Cooperative Agreements to Benefit Homeless Individuals Homeless Benefit to Agreements Cooperative • 2017 , 13 December

Department of Health and Human Services (continued) Services Human and Health of Department

That Can Support People With SMI and SED (continued) SED and SMI With People Support Can That

3.1. Table Federal Programs Related to SMI and SED Programs Programs SED and SMI to Related Programs Federal , 2017 , 13 December December 13, 2017

, 2017 Table 3.1.December Federal 13 Programs Related to SMI and SED Programs That Can Support People With SMI and SED (continued)

Department of Justice

, 2017 , Bureau of Justice Assistance 13 December • Justice and Mental Health Collaboration • Second Chance Act Reentry • Stepping Up Initiative Bureau of Prisons • Dual Diagnosis Residential Drug Abuse Program • Mental Health Step Down Unit • Resolve • Skills Program • Steps Toward Awareness, Growth, and Emotional Strength

• Office of Juvenile Justice and Delinquency Prevention • JuvenileFamilies Drug Treatment and Court ProgramCaregivers

• Formula Grants

• JuvenileWorks Accountability for Block All Grant People Living With SMI and SED and Their

• SecondThe Chance Way Act Reentry Forward: Federal Action for a System That

Department of Labor Caregivers and Families

Office of Disability Employment Policy Their and SED and SMI With Living People All for Works

• Campaign for Disability Employment Coordinating Committee • Job Accommodation Network That System a for Action Federal Forward: Way The

• State Leadership Mentoring Programs

• WorkforceSerious Recruitment Program Mental Illness

Employment and Training Administration Committee Coordinating • AmericanInterdepartmental Job Center Network

• Employer Technical Assistance Center • Reentry Employment Opportunities Illness Mental Serious

• State Leadership Mentoring Program

• Workforce Innovation and Opportunity Act Programs Interdepartmental • YouthBuild

Veterans’ Employment and Training Service • Homeless Veterans Reintegration Program

• Jobs for Veterans State Grants Program Department of Veterans Affairs Veterans Health Administration • General Outpatient Mental Health Services

• Inpatient Mental Health

programs in support of this goal and the committee’s vision. committee’s the and goal this of support in programs

ISMICC will strive to do everything possible to improve the direction and coordination of federal federal of coordination and direction the improve to possible everything do to strive will ISMICC

based services they need to live in recovery and experience an improved quality of life. The The life. of quality improved an experience and recovery in live to need they services based

concrete improvements in the proportion of people with SMI and SED who receive the evidence- the receive who SED and SMI with people of proportion the in improvements concrete

the work of the next several years. The committee looks forward to the opportunity to document document to opportunity the to forward looks committee The years. several next the of work the each of the federal departments, in collaboration with the membership of the ISMICC. This is is This ISMICC. the of membership the with collaboration in departments, federal the of each

by effort extensive an require will charter ISMICC the in outlined responsibilities the Fulfilling Interdepartmental Programs Federal Evaluate to ISMICC the of Work Future

Serious Mental Illness Illness Mental Serious

Work Incentives Planning and Assistance and Planning Incentives Work Interdepartmental Interdepartmental Interdepartmental •

Supported Employment Demonstration Employment Supported

Coordinating Committee Committee • Coordinating

Supplemental Security Income Security Supplemental

Serious Mental Illness Illness Mental Serious Serious Mental Illness •

Social Security Disability Insurance Disability Security Social •

SOAR – SSI/SSDI Outreach Access and Recovery and Access Outreach SSI/SSDI – SOAR

Coordinating Committee Committee Coordinating Coordinating Committee That System a for Action Federal • Forward: Way The Protection and Advocacy and Protection •

PROMISE – Promoting Readiness of Minors in SSI in Minors of Readiness Promoting – PROMISE

Works for All People Living With SMI and SED and Their Their and SED and SMI With Living • People All for Works

Military Casualties/Wounded Warriors Casualties/Wounded Military

Families and Caregivers • Caregivers and Families

Homeless with Schizophrenia Presumptive Disability* Presumptive Schizophrenia with Homeless The Way Forward: Federal Action for a System That That System a for Action Federal Forward: Way The The Way Forward: Federal Action for a System That •

Works for All People Living With SMI and SED and Their Their and SED and SMI With Living People All for Works Works for All People Living With SMI and SED andAdministration TheirSecurity Social Therapeutic and Supported Employment Services Employment Supported and Therapeutic •

Substance Use Disorder Treatment Disorder Use Substance

Families and Caregivers Caregivers and Families Families and Caregivers •

Specialized Homeless Services Homeless Specialized •

Re-Engaging Veterans with Serious Mental Illness Mental Serious with Veterans Re-Engaging •

REACH VET – Recovery Engagement And Coordination for Health --Veterans Enhanced Treatment Enhanced --Veterans Health for Coordination And Engagement Recovery – VET REACH •

Psychosocial Rehabilitation and Recovery Center Recovery and Rehabilitation Psychosocial •

Primary Care – Mental Health Integration Health Mental – Care Primary •

National Psychosis Registry Psychosis National •

•

Mental Health Residential Rehabilitation Treatment Rehabilitation Residential Health Mental •

Mental Health Enhancement Initiative Enhancement Health Mental •

Intensive Community Mental Health Recovery Services Recovery Health Mental Community Intensive •

Department of Veterans Affairs (continued) Affairs Veterans of Department 2017 , 13 December

That Can Support People With SMI and SED (continued) SED and SMI With People Support Can That

Programs SED and SMI to Related Programs Federal , 2017 , 13 December December 13, 2017 3.1. Table

, 2017 ChapterDecember 4: Recommendations 13 From Non-Federal ISMICC

Members

, 2017 , December 13 December

This chapter was developed solely by the non-federal members of the ISMICC. We, the non- federal members, have created a list of recommendations that reflects our hope that federal departments will better align and coordinate their efforts to support people with serious mental illnesses (SMI) and serious emotional disturbances (SED). Our goal is to advance the development of a comprehensive continuum of treatments and supports that have been demonstrated to improve outcomes for people of all ages with SMI and SED. We envision the establishment of standards of care for mental health treatment and supports across the full continuum, in communities nationwide. We intend to prom0te evidence-based practices and

strong community-based systems of care, and to end travesties such as unnecessary incarceration

and “boarding”Families of people and with Caregivers acute psychiatric conditions in emergency departments for hours orWorks days. We forhope All that People coordinated Living federal efforts With willSMI enable and our partnersSED inand states Their and

communities to strengthen their efforts in support of these goals.

The Way Forward: Federal Action for a System That

On the following pages we present these Caregivers and Families

Source of Recommendations recommendations. The recommendations callTheir and SED and SMI With Living People All for Works

for specificCoordinating actions that we see as important Committee and The Way Forward: Federal Action for a System That That These recommendationsSystem a for reflectAction the views of theFederal Forward: Way The achievable. The recommendations are grouped into non-federal ISMICC members. Federal members

five areas of focus. For each recommendation, we were consulted regarding factual concerns and

indicateSerious whether we believe Mental it could be achieved Illness in 1 federal processes, but the final list of recom-

mendations are the product of the non-federal year or less (short term), 2-3 years (medium term), or members. These recommendations do notCommittee repre - Coordinating 4-6 yearsInterdepartmental (longer term). sent federal policy, and the federal departments

represented on the ISMICC have not reviewed

All of the recommendations call for actions to be the recommendations to determine whatIllness role they Mental Serious

could play in the future activities of the depart- taken by federal departments represented on the ments. The recommendations should not be Interdepartmental

ISMICC. Realization of the broader vision will also interpreted as recommendations from the federal require changes at the state, tribal, and local levels, government.

with assistance from federal policies and programs, and through support and legislative action from

Congress.

While drafting this report, we received hundreds of recommendations from diverse sources, many of which had merit and are worthy of attention in due time. The carefully selected set of recommendations included in this first report, however, were chosen to provide critical points of deliberation within the ISMICC. They will help shape the activities of the ISMICC in the years to

come, and we anticipate that they will be refined and amended as the ISMICC moves forward.

needed to operationalize the ISMICC processes over full term of the committee. the of term full over processes ISMICC the operationalize to needed

Budget adequate resources for the level of federal staffing support and committee effort effort committee and support staffing federal of level the for resources adequate Budget

this report. report. this

describes how federal agencies have progressed in addressing the recommendations in in recommendations the addressing in progressed have agencies federal how describes

Draft an annual report due by July 1 following each calendar year of the ISMICC that that ISMICC the of year calendar each following 1 July by due report annual an Draft

participate in workgroup meetings. workgroup in participate Interdepartmental

address specific recommendations from this report. Outside experts may be invited to to invited be may experts Outside report. this from recommendations specific address

Content-specific subgroups with federal and non-federal ISMICC members will will members ISMICC non-federal and federal with subgroups Content-specific

Serious Mental Illness Illness d. Mental Serious

Interdepartmental Interdepartmental Interdepartmental charter.

are working sessions, and include the two public sessions as required under the ISMICC ISMICC the under required as sessions public two the include and sessions, working are Committee Coordinating

Serious Mental Illness Illness Mental Serious Seriousmeetings These areas. Mentalfocus within progress Illnesson group the update will members Federal

Conduct quarterly ISMICC meetings of federal and non-federal ISMICC members. members. ISMICC non-federal and federal of meetings ISMICC quarterly Conduct c.

The Way Forward: Federal Action for a System That That System a for Action Federal Forward: Way The Coordinating Committee Committee Coordinating Coordinating Committeeneeded. as Services Rehabilitative and

Invite sub-agencies such as the Bureau of Prisons and the Office of Special Education Education Special of Office the and Their Prisons of and Bureau SED the as and such SMI sub-agencies With Invite Living People All for Works

Conduct regularly occurring interdepartmental meetings of federal ISMICC members. members. ISMICC federal of meetings interdepartmental occurring regularly Conduct Families and Caregivers b. Caregivers and Families

The Way Forward: Federal Action for a System That That System a for Action Federal Forward: Way The The Way Forward: Federal Action for a System That

actively participate. actively

Works for All People Living With SMI and SED and Their Their and SED and SMI With Living People All for Works Worksto forempowered be All Peopleshould Livingrepresentatives With Department SMI andmeetings. SED and Theirinterdepartmental

Obtain commitment by all ISMICC federal departments to participate in in participate to departments federal ISMICC all by commitment Obtain

Families and Caregivers Caregivers and Families Families and Caregivers a.

people with SMI and SED, and will include the following. following. the include will and SED, and SMI with people [Short-term recommendation] [Short-term

SED populations. Activities, planning, and policies must focus on improving outcomes for for outcomes improving on focus must policies and planning, Activities, populations. SED

guidelines for ongoing coordination between federal departments to focus on SMI and and SMI on focus to departments federal between coordination ongoing for guidelines

Assistant Secretary for Mental Health and Substance Use. Substance and Health Mental for Secretary Assistant Develop procedures and and procedures Develop

Improve ongoing interdepartmental coordination under the guidance of the the of guidance the under coordination interdepartmental ongoing Improve 1.1.

Focus 1: Strengthen Federal Coordination to Improve Care Improve to Coordination Federal Strengthen 1: Focus

Full Recommendations Recommendations Full 2017 , 13 December

report also will include further recommendations to guide federal coordination in future years. years. future in coordination federal guide to recommendations further include will also report , 2017 , 13 December final DecemberThe 13, accomplished. 2017 been has what on data include will Congress to Report ISMICC final The

, 2017 1.2. DevelopDecember and implement 13 an interdepartmental strategic plan to improve the lives of people with SMI and SED and their families. Building on the foundation of this report, ISMICC federal departments will develop a joint federal strategic plan for improving services

and outcomes for people with SMI and SED. The plan should be consistent with the “strategic

, 2017 , planning” language in the 21st Century Cures Act, extend to all the federal ISMICC partners, 13 December and be complete by September 30, 2018, in conjunction with the strategic plan required under the 21st Century Cures Act. The plan must include measurable activities and outcomes for each participating department, as well as for all departments operating collectively. Though the development and implementation of the strategic plan, the Assistant Secretary for Mental and Substance Use shall review and propose modifications to federal programs that serve people with SMI and SED. [Short-term recommendation] 1.3. Create a comprehensive inventory of federal activities that affect the provision of services for people with SMI and SED. The list of federal programs will include federal

leadership efforts, regulations, policies, contracts, grants and other programs that focus

Familieson people with and SMI andCaregivers SED or play a significant role in the service system for people with

WorksSMI and SED. for [Short-term All People recommendation] Living With SMI and SED and Their

1.4. TheHarmonize Way and Forward: improve policies Federal to support Action federal for coordination. a System The That federal

departments participating in the ISMICC will address specific issues that impede Caregivers and Families

coordination and effectiveness. ActivitiesTheir includeand butSED are notand limitedSMI to theWith following.Living People All for Works

Coordinating[Short-term recommendation] Committee The Way Forward: Federal Action for a System That That System a for Action Federal Forward: Way The

a. Establish uniform definitions of SMI and SED and a shared lexicon across federal

Seriousdepartments to promoteMental understanding, Illness coordination, and integration of services

and supports for people with SMI and SED. Include definitions that support inclusionCommittee Coordinating

Interdepartmentalof individuals who have SMI or SED with co-occurring substance use disorders, developmental disabilities, and traumatic brain injury. Illness Mental Serious

b. Identify federal policies or other barriers across federal departments that preclude or

impede access to services, treatments, or continuity of care. Assess whether federal Interdepartmental program designs align with what is known from implementation research about

effective ways to promote lasting practice change and improve systems.

c. Identify age-based barriers to services in the federal policies of the ISMICC federal departments that impede access to needed treatments and services that support the transition to adulthood for 16- to 25-year-olds with or at risk of SED or SMI.

d. Align eligibility and benefits systems across federal departments to facilitate system

navigation and continuity of care for people with SMI and SED.

SED populations within the justice system. justice the within populations SED [Longer-term recommendation] [Longer-term

discharge. Standardize similar data gathering across all state and local systems for SMI and and SMI for systems local and state all across gathering data similar Standardize discharge.

rates after suicide attempts, emergency department presentation, and inpatient hospital hospital inpatient and presentation, department emergency attempts, suicide after rates

to mortality data, including tracking cause/manner of death, and analysis of survival survival of analysis and death, of cause/manner tracking including data, mortality to

by public and private health care systems of routine linking of SMI and SED populations populations SED and SMI of linking routine of systems care health private and public by

Improve national linkage of data to improve services. improve to data of linkage national Improve 1.8.

Promote national adoption adoption national Promote widely exist. exist. widely

recommendation] [Medium-term populations, such as younger children, for whom mental health quality measures do not not do measures quality health mental whom for children, younger as such populations,

members in measure development. Through this work, improve the use of measures for for measures of use the improve work, this Through development. measure in members Interdepartmental

behavioral health data is not excluded, and encourage the inclusion of peers and family family and peers of inclusion the encourage and excluded, not is data health behavioral

such as those that track rehospitalization and emergency department use, to ensure that that ensure to use, department emergency and rehospitalization track that those as Illness such Mental Serious Interdepartmental Interdepartmental Interdepartmentalmeasures, quality existing Examine departments. other and divisions HHS across measures

to harmonize and coordinate development and adoption of behavioral health quality quality health behavioral of adoption and development coordinate and harmonize Committee to Coordinating bodies, such as the National Quality Forum and/or the HHS Measurement Policy Council, Council, Policy Measurement HHS the and/or Forum Quality National the as such bodies,

Ensure that quality measurement efforts include mental health. mental include efforts measurement quality that Ensure 1.7. Serious Mental Illness Illness Mental Serious Serious existing Use Mental Illness

experiencing SMI. SMI. experiencing Coordinating Committee Committee Coordinating Coordinating Committee That recommendation] System a for [Medium-term Action Federal Forward: Way The

for all federal health programs for children and youth experiencing SED and for adults adults for and SED experiencing youth Their and and children SED for and programs SMI health With federal all for Living People All for Works quality measurement programs, and dashboard results should be regularly published published regularly be should results dashboard and programs, measurement quality

The measures included in this dashboard should be included in all federal health care care health federal all in included be should dashboard this in included measures The Caregivers and Families

The Way Forward: Federal Action for a System That That System a for Action Federal Forward: Way The The Waytransparently. Forward:progress measure Federalcan counties Actionand tribes, forstates, a Systemagencies, federal That which by Works for All People Living With SMI and SED and Their Their and SED and SMI With Living People All for Works Worksmeasures for recovery Allcore Peopleof set this Livingincluding With SMIdashboard andnational a SEDEstablish and Theirintegration.

Families and Caregivers Caregivers and Families Familiescommunity andand Caregiversillness, mental of decriminalization education, employment, access, issues for the ISMICC, including reduction in health disparities, and improvements in in improvements and disparities, health in reduction including ISMICC, the for issues

national benchmarks for making progress on core recovery measures which address key key address which measures recovery core on progress making for benchmarks national

Use the findings from data sets to reduce across-department variation and to establish establish to and variation across-department reduce to sets data from findings the Use

focused on health, education, criminal justice, labor, military personnel, and veterans. veterans. and personnel, military labor, justice, criminal education, health, on focused

of SMI/SED information and outcomes. Include all relevant federal data such as those those as such data federal relevant all Include outcomes. and information SMI/SED of

national data sets relevant to the lives of people with SMI and SED to incorporate tracking tracking incorporate to SED and SMI with people of lives the to relevant sets data national

Use data to improve quality of care and outcomes. and care of quality improve to data Use 1.6. Review and improve federal and and federal improve and Review

departments. [Short-term recommendation] [Short-term

within the larger support system. Identify and reduce non-coordinated duplication across across duplication non-coordinated reduce and Identify system. support larger the within

evaluation and accountability for individual federal programs. See how federal programs fit fit programs federal how See programs. federal individual for accountability and evaluation 2017 , 13 December

the federal government is failing to meet the needs of people with SMI and SED. Support Support SED. and SMI with people of needs the meet to failing is government federal the

measure, evaluate, and improve the federal government’s efforts. Identify areas where where areas Identify efforts. government’s federal the improve and evaluate, measure,

services, and supports for people with SMI and SED, and assess effectiveness. Routinely Routinely effectiveness. assess and SED, and SMI with people for supports and services,

Evaluate the federal approach to serving people with SMI and SED. and SMI with people serving to approach federal the Evaluate 1.5. , 2017 , 13 December Decembersystems, Evaluate 13, 2017

, 2017 Focus December2: Access and 13 Engagement: Make It Easier to Get Good Care

2.1. Define and implement a national standard for crisis care. Through federal departmental coordination, establish standards consistent with those defined in the

7 , 2017 , SAMHSA publication, Crisis Services: Cost Effectiveness and Funding Strategies. Develop 13 December standards that are person-centered, youth-guided, family-driven, and responsive to the circumstances and developmental needs of children, youth, and adults. Include a minimum standard for stabilization under the Emergency Medical Treatment and Labor Act (EMTALA). Once established, ensure that federal programs support the standards, and enable and incentivize states and communities to support and sustain adequate crisis care systems. [Longer-term recommendation]

2.2. Develop a continuum of care that includes adequate psychiatric bed capacity and community-based alternatives to hospitalization. Through partnerships at the

federal, state, and local levels, build the capacity of the mental health system to provide

Familiesa continuum ofand services Caregivers that includes inpatient psychiatric care, when needed, with Workscommunity-based for All resources People also Livingavailable. WithEnsure thatSMI people and with SED SMI and and SED Their receive

care in the least-restrictive safe setting available that meets their mental health service The Way Forward: Federal Action for a System That

needs. [Longer-term recommendation] Caregivers and Families

2.3. Educate providers, service agencies, Their peopleand with SED SMI andand SEDSMI and theirWith families,Living People All for Works

Coordinatingand caregivers about the Health Committee Insurance Portability and Accountability Act of 1996 (HIPAA) and other privacy laws, includingThat 42System CFRa Partfor 2, in theAction context Federal Forward: Way The

of psychiatric care. There is a need for clarification and guidance regarding the value

Seriousand need for communication Mental with family Illness members and caregivers. For example, there

are permitted disclosures of protected health information in the context of psychiatricCommittee Coordinating

Interdepartmentalcrises. There is justification for engaging families and caregivers in responding to the needs of their loved ones. Technical assistance and training is needed on how toIllness involve Mental Serious

family members and loved ones when a person with SMI or SED is in crisis and unable

to make their own decisions. This work should include strategies for involving families

while empowering people with SMI to direct their own care, such as psychiatric advance Interdepartmental

directives. [Short-term recommendation] 2.4. Reassess civil commitment standards and processes. Through federal coordination,

reexamine current standards and develop model standards that both protect individual rights and enable greater flexibility for families, caregivers, and mental health providers to provide care, when necessary. Consider standards for inpatient civil commitment, assisted outpatient treatment, short-term “holds,” and longer-term civil commitment. Help states adopt standards. [Medium-term recommendation]

7 Substance Abuse and Mental Health Services Administration. Crisis Services: Effectiveness, Cost-Effectiveness, and Funding Strategies. HHS Publication No. (SMA)-14-4848. Rockville, MD: Substance Abuse and Mental Health Services Administration,

2014.

programs. programs.

a. Include coverage of peer and family support specialists in federal health benefit benefit health federal in specialists support family and peer of coverage Include

recommendation]

workforce to meet the needs of people with SMI and SED and their families. families. their and SED and SMI with people of needs the meet to workforce [Longer-term [Longer-term

interdepartmental planning, find ways to increase the capacity of the behavioral health health behavioral the of capacity the increase to ways find planning, interdepartmental

2.8. Maximize the capacity of the behavioral health workforce. health behavioral the of capacity the Maximize Through federal federal Through

information regarding the use of these technologies. technologies. these of use the regarding information [Medium-term recommendation] [Medium-term and supports so that people with SMI and SED and their families have access to accurate accurate to access have families their and SED and SMI with people that so supports and

services health behavioral technology-based new of dissemination and testing, research, build workforce capacity and make better use of scarce professional resources. Support Support resources. professional scarce of use better make and capacity workforce build

care model and Project ECHO (Extension for Community Healthcare Outcomes) to to Outcomes) Healthcare Community for (Extension ECHO Project and model care Interdepartmental

meetings for payment). Apply telehealth to models of care such as the collaborative collaborative the as such care of models to telehealth Apply payment). for meetings

state licensure issues, requiring presence in a “clinic” setting, and requiring face-to-face face-to-face requiring and setting, “clinic” a in presence requiring issues, licensure Illness state Mental Serious Interdepartmental Interdepartmental Interdepartmentalcross- (e.g., telemedicine by services health mental of provision inhibit that regulations

with SMI and SED and increase access to care, specifically for rural populations. Change Change populations. rural for specifically care, to access increase and SED and SMI Committee with Coordinating for the use of telehealth to provide mental health and other support services for people people for services support other and health mental provide to telehealth of use the for

2.7. Use telehealth and other technologies to increase access to care. care. to access increase to technologies other and telehealth Use

Serious Mental Illness Illness Mental Serious Seriousstandards Establish Mental Illness

Coordinating Committee Committee Coordinating Coordinating Committee That System a for Action recommendation] Federal Forward: Way The accordance with the Workforce Innovation and Opportunity Act and IDEA. IDEA. and Act Opportunity and Innovation Workforce the with accordance

[Longer-term [Longer-term Their and SED and SMI With Living People All for Works adulthood. Coordinate transition planning with state vocational rehabilitation agencies, in in agencies, rehabilitation vocational state with planning transition Coordinate adulthood.

to ensure that they have access to treatment, services, and supports as they move into into move they as supports and services, treatment, to access have they that ensure to Caregivers and Families

The Way Forward: Federal Action for a System That That System a for Action Federal Forward: Way The The psychosis, Way Forward:first-episode or FederalSED/SMI with Action16-25 ages forstudents aall Systemfor planning That transition Works for All People Living With SMI and SED and Their Their and SED and SMI With Living People All for Works WorksProvide SED). forand AllSMI Peoplewith students Livingfor Withmeetings [IEP] SMI andprogram SEDeducation and Theirindividualized

Families and Caregivers Caregivers and Families Familiesin specialists andsupport Caregiversfamily and professionals health mental by participation as (such clinics to have appropriate systems (such as standardized assessments) and expertise expertise and assessments) standardized as (such systems appropriate have to clinics

to learning. Develop policies that provide for educational staff and school-based school-based and staff educational for provide that policies Develop learning. to

Act (IDEA) so that children and youth with SED are identified regardless of the impact impact the of regardless identified are SED with youth and children that so (IDEA) Act

illnesses, especially early psychosis. Enhance the Individuals with Disabilities Education Education Disabilities with Individuals the Enhance psychosis. early especially illnesses,

adults. Develop standards that help educational institutions identify signs of mental mental of signs identify institutions educational help that standards Develop

2.6. Prioritize early identification and intervention for children, youth, and young young and youth, children, for intervention and identification early Prioritize

treatment. treatment. [Medium-term recommendation] [Medium-term

of system capacity, as well as systematic monitoring of patient progress and response to to response and progress patient of monitoring systematic as well as capacity, system of

services. The use of validated instruments will allow for consistent metrics for adequacy adequacy for metrics consistent for allow will instruments validated of use The services.

across the nation to assess the need for level of care for people with SMI and SED receiving receiving SED and SMI with people for care of level for need the assess to nation the across 2017 , 13 December

Adolescent Level of Care Utilization System (CALOCUS) to create a common methodology methodology common a create to (CALOCUS) System Utilization Care of Level Adolescent

assessment tools such as the Level of Care Utilization System (LOCUS) and the Child and and Child the and (LOCUS) System Utilization Care of Level the as such tools assessment

progress. Through partnership with states and localities, support the use of standardized standardized of use the support localities, and states with partnership Through

2.5. , 2017 , 13 December Decemberconsumer of 13, 2017monitoring and care of level for assessments standardized Establish

, 2017 Decemberb. Incentivize 13 providers to obtain education and continuing education on evidence-based treatments and team-based care models.

c. Provide tuition reimbursement to encourage mental health professionals in roles where

, 2017 , there are severe shortages, such as child psychiatry and in addressing underserved 13 December populations.

d. Remove exclusions that disallow payment to certain qualified mental health professionals, such as marriage and family therapists and licensed professional counselors, within Medicare and other federal health benefit programs.

e. Remove reimbursement and administrative burdens associated with psychiatric care within Medicare, Medicaid, and other federal health benefit programs.

f. Explore how to fully implement integrated team models that are the most effective in

Familiesaddressing and the needs Caregivers of people with SMI and SED.

Worksg. Enable forhealth All care People providers toLiving practice Withto the full SMI extent and of their SED education and and Their

Thetraining. Way For Forward: example, remove Federal barriers thatAction prevent for advanced a System practice registeredThat nurses

from prescribing medication. Caregivers and Families

h. Develop a workforce that is representativeTheir and of the populationsSED and servedSMI (includingWith racialLiving People All for Works

Coordinating Committee and ethnic minorities, people in rural areas,That and populationsSystem a for facing healthAction disparitiesFederal Forward: Way The

such as lesbian, gay, bisexual, or transgender individuals) and able to provide services

Seriousin a culturally competent Mental manner. Illness

i. Develop standards for network adequacy in health plans, and identify and implementCommittee Coordinating

Interdepartmentalprocesses to monitor access to services and adherence to established standards.

2.9. Support family members and caregivers. Develop and disseminate programsIllness for non- Mental Serious

professional caregivers of children with SED and adults with SMI. Programming should be Interdepartmental

similar to those that exist for caregivers of people with intellectual disabilities, people with

developmental disabilities, and older adults. Include caregiver respite, family consultation, system navigation, caregiver training, and family psychoeducation. Provide technical

assistance and financial support for education programs by and for families and other

caregivers. [Medium-term recommendation]

linguistically responsive services; and services; responsive linguistically

Systems of care that provide family-driven, youth-guided, and culturally and and culturally and youth-guided, family-driven, provide that care of Systems i.

h. Trauma-informed systems of care; care; of systems Trauma-informed

departments;

and psychiatric hospitals, and eliminating “psychiatric boarding” in hospital emergency emergency hospital in boarding” “psychiatric eliminating and hospitals, psychiatric and

Psychiatric crisis response using least-restrictive appropriate settings in communities communities in settings appropriate least-restrictive using response crisis Psychiatric

disorders; use substance and SMI/SED co-occurring with people for services Integrated Interdepartmental e.

services; care primary and health mental integrated Bidirectional

outpatient civil commitment and assisted outpatient treatment; outpatient assisted and commitment civil Illness outpatient Mental Serious

Recovery-oriented models of team-based care to be used in conjunction with with conjunction in used be to care team-based of models Recovery-oriented

Interdepartmental Interdepartmental Interdepartmental d.

family support specialists as a matter of routine practice; routine of matter a as specialists support family Committee Coordinating

Team-based models of care delivery that are interdisciplinary and incorporate peer and and peer incorporate and interdisciplinary are that delivery care of models Team-based Serious Mental Illness Illness Mental Serious Serious Mental Illness c.

Supportive services, such as supportive housing, employment, and education; and employment, housing, supportive as such services, Supportive

Coordinating Committee Committee Coordinating Coordinating Committee That System a for Action b. Federal Forward: Way The

Works for All People Living With SMI and SED and Their Their and SED medications; and SMI antipsychotic With injectable Living People All for Works

immediate action to promote the appropriate use of clozapine and long-acting long-acting and clozapine of use appropriate the promote to action immediate Caregivers and Families

Guidance on effective use of psychopharmacological medications, including taking taking including medications, psychopharmacological of use effective on Guidance The Way Forward: Federal Action for a System That That System a for Action Federal Forward: Way The The Way Forward: Federal Action for a System That a.

Works for All People Living With SMI and SED and Their Their and SED and SMI With Living People All for Works Works for All People Living With SMI and SED and Their following. following. [Medium-term recommendation] [Medium-term

Families and Caregivers Caregivers and Families the Familiesleast at include andmust Caregiversstandards These systems. adult into transition youth and children

of development and aging. Give attention to service disconnections that can occur as as occur can that disconnections service to attention Give aging. and development of

to be effective and to improve outcomes. Standards should be appropriate to phases phases to appropriate be should Standards outcomes. improve to and effective be to

standards that include a full spectrum of integrated, complementary services known known services complementary integrated, of spectrum full a include that standards

3.1. Provide a comprehensive continuum of care for people with SMI and SED. SED. and SMI with people for care of continuum comprehensive a Provide Develop Develop

Focus 3: Treatment and Recovery: Close the Gap Between What Works and What Is Offered Is What and Works What Between Gap the Close Recovery: and Treatment 3: Focus

to accept new referrals. referrals. new accept to [Longer-term recommendation] [Longer-term

communities. This will ensure that those listed as providing services are actually available available actually are services providing as listed those that ensure will This communities.

then proactively monitor behavioral health provider network adequacy for all payers in all all in payers all for adequacy network provider health behavioral monitor proactively then 2017 , 13 December

behavioral health consultation occurs in primary care, using collaborative care models, and and models, care collaborative using care, primary in occurs consultation health behavioral

identification and engagement in primary care settings. Develop routine expectations that that expectations routine Develop settings. care primary in engagement and identification

access and facilitate early initiation of treatment for people with SMI and SED through through SED and SMI with people for treatment of initiation early facilitate and access

2.10. Expect SMI and SED screening to occur in all primary care settings. care primary all in occur to screening SED and SMI Expect , 2017 , 13 December December Expand 13, 2017

, 2017 j. DecemberComprehensive 13 and integrated systems of care for people who need varying levels of intensive services and supports on an ongoing basis, including community-delivered

services.

, 2017 , 3.2. Make screening and early intervention among children, youth, transition- 13 December age youth, and young adults a national expectation. Develop and implement interdepartmental guidelines for detecting and treating early signs of SED in children and youth, and of SMI in transition-age youth and young adults, in a wide range of settings, including primary care, day care, school- and college-based health clinics, public health clinics, juvenile justice facilities, jails, and emergency departments. In this work, pay special attention to vulnerable populations facing health disparities. [Medium-term recommendation]

3.3. Make coordinated specialty care for first-episode psychosis available nationwide.

Incentivize universal access to coordinated specialty care services in all federal health

Familiesbenefit programs, and including Caregivers Medicaid, Medicare, Department of Defense, the Veterans WorksAdministration, for All and PeopleTRICARE. Continue Living the With SAMHSA SMI block and grant SED set-aside and requirements, Their

and provide guidance to facilitate payment by all public and private insurance programs. The Way Forward: Federal Action for a System That

[Medium-term recommendation] Caregivers and Families

3.4. Make trauma-informed, whole-person Their healthand careSED the expectationand SMI inWith all our Living People All for Works

Coordinating Committee systems of care for people with SMI and SED.That AdverseSystem childhooda for experiencesAction and Federal Forward: Way The trauma play a tremendously important role in the development of SMI and SED, and

trauma-informed treatment is increasingly recognized as essential to enable recovery.

SeriousPeople with SMI and Mental SED commonly experience Illness problems with health, substance use

disorders, and the need for supportive housing, employment, and education. To addressCommittee Coordinating

Interdepartmentalthe mortality gap, we must provide access to integrated health and behavioral health care that identifies and addresses all health and social determinants in every treatmentIllness setting. Mental Serious

[Longer-term recommendation]

3.5. Implement effective systems of care for children, youth, and transition-age youth Interdepartmental

throughout the nation. This must include the following. [Longer-term recommendation]

a. Support national implementation of the SAMHSA System of Care model. b. Provide strong supports for students with or at risk of SED/SMI through special education and Section 504 of the Rehabilitation Act services and supports, including the requirement of a school-based mental health professional and family support specialist at all IEP and 504 planning meetings that include a student with SED/SMI or its early forms, and identification or development of payment mechanisms through

Medicaid or other health care coverage for health care services in IEP and 504 plans.

disease-modifying interventions for the treatment of people with SMI and SED. and SMI with people of treatment the for interventions disease-modifying

Establish a public-private partnership for discovering biomarkers and breakthrough breakthrough and biomarkers discovering for partnership public-private a Establish b.

the burden of disease they impose. impose. they disease of burden the

with prevalence rates of SED/SMI, the direct and indirect costs of these conditions, and and conditions, these of costs indirect and direct the SED/SMI, of rates prevalence with

Increase funding for research at the National Institute of Mental Health, commensurate commensurate Health, Mental of Institute National the at research for funding Increase

and recovery services. recovery and

[Medium-term recommendation] [Medium-term 3.8. Develop a priority research agenda for SED/SMI prevention, diagnosis, treatment, treatment, diagnosis, prevention, SED/SMI for agenda research priority a Develop

these strategies in the public health system. system. health public the in strategies these [Medium-term recommendation] [Medium-term

transparent targets for progress. Consider ways to widely disseminate and universally apply apply universally and disseminate widely to ways Consider progress. for targets transparent Interdepartmental

reduction, and agree to develop and implement strategic plans with achievable and and achievable with plans strategic implement and develop to agree and reduction,

departments, including VA and DoD, should adopt Zero Suicide as a model for suicide suicide for model a as Suicide Zero adopt should DoD, and VA including Illness departments, Mental Serious

3.7. Advance the national adoption of effective suicide prevention strategies. prevention suicide effective of adoption national the Advance Interdepartmental Interdepartmental Interdepartmentalfederal All

Coordinating Committee Committee Coordinating facilities, nursing homes, or board and care homes. homes. care and board or homes, nursing facilities, [Medium-term recommendation] [Medium-term

Serious Mental Illness Illness Mental Serious Seriouscorrectional as such Mentalsettings from Illnesstransitioning or homelessness chronic experiencing

requirements. Target resources such as Housing Choice Vouchers for individuals with SMI SMI with individuals for Vouchers Choice Housing as such resources Target requirements.

Coordinating Committee Committee Coordinating Coordinating housing fair federal with Committee consistent That SMI, with System people a for non-elderly for Action preferences Federal Forward: Way The

issue guidance for state and local housing authorities on establishing tenant selection selection tenant establishing on Their authorities and housing SED local and and state SMI for With guidance issue Living People All for Works

aging out of foster care. Have the Department of Housing and Urban Development Development Urban and Housing of Department the Have care. foster of out aging have been estranged from their families, those who experience homelessness, and those those and homelessness, experience who those families, their from estranged been have Caregivers and Families

The Way Forward: Federal Action for a System That That System a for Action Federal Forward: Way The The Way Forward: Federal Action for a System That housing, including supported housing, to those exiting jails and prisons, youth who who youth prisons, and jails exiting those to housing, supported including housing,

Works for All People Living With SMI and SED and Their Their and SED and SMI With Living People All for Works Worksproviding foron All Peopleemphasis special Livingwith SED, Withand SMI SMIwith andpeople for SED andtreatment Theiroriented

Families and Caregivers Caregivers and Families Familiesrecovery- of part and Caregiversstandard a as housing adequate require and support to policies federal

essential prerequisite for effective treatment and a life in recovery. Develop consistent consistent Develop recovery. in life a and treatment effective for prerequisite essential

3.6. Make housing more readily available for people with SMI and SED. SED. and SMI with people for available readily more housing Make Housing is an an is Housing

employment options. employment

successful assumption of adult roles, including state vocational rehabilitation and other other and rehabilitation vocational state including roles, adult of assumption successful

identifies treatment, services, and supports to achieve their best mental health and and health mental best their achieve to supports and services, treatment, identifies

special education programs, to ensure that they have a student-centered plan that that plan student-centered a have they that ensure to programs, education special

16-22 with SED/SMI or first-episode psychosis, including those not covered within within covered not those including psychosis, first-episode or SED/SMI with 16-22

Expand policies and guidelines that require transition planning for all students ages ages students all for planning transition require that guidelines and policies Expand

Improve postsecondary transition outcomes of all students with or at risk of SED/SMI. SED/SMI. of risk at or with students all of outcomes transition postsecondary Improve d.

, 2017 , 13 December

treatment capacity integrated with physical health services in all public schools. public all in services health physical with integrated capacity treatment

establish school-based clinics with Medicaid-billable behavioral health assessment and and assessment health behavioral Medicaid-billable with clinics school-based establish

the Health Resources and Services Administration, and the Department of Education, Education, of Department the and Administration, Services and Resources Health the

Through collaboration between SAMHSA, Centers for Medicare & Medicaid Services, Services, Medicaid & Medicare for Centers SAMHSA, between collaboration Through , 2017 , 13 December December 13, 2017 c.

and substance use disorders and the disproportionate share of opioid prescriptions that

, 2017 , go to people with mental illnesses, people with SMI and SED often do not have access 13 December to necessary MAT and other substance use disorder treatment services. Co-occurring treatment for mental illnesses and substance use disorders must be available in all treatment settings. In guidance accompanying federal funds to address the opioid crisis, clarify that those services and resources are to be made fully available on an ongoing basis to people with SMI and SED, with attention to housing, as well as mental and primary health needs. [Medium-term recommendation]

3.10. Develop national and state capacity to disseminate and support implementation of the national standards for a comprehensive continuum of effective care for

people with SMI and SED. The challenges of implementation are well known, but rarely

Familiesadequately addressed. and Caregivers As a consequence, we find a huge gap between what is known

Worksto be effective for andAll whatPeople is available Living in communities With SMI throughout and theSED nation. and Several Their

Thestates (includingWay Forward: New York, Ohio, Federal and Vermont) Action have forused a block System grant funds That to develop technical assistance centers to support widespread implementation of effective practices. Caregivers and Families

Implement these models more widely with national support, to bring implementation of

evidence-based and effective practicesTheir to scale.and [Medium-term SED and recommendation]SMI With Living People All for Works Coordinating Committee The Way Forward: Federal Action for a System That That System a for Action Federal Forward: Way The

Focus 4: Increase Opportunities for Diversion and Improve Care for People With SMI and SED

InvolvedSerious in the Criminal and Mental Juvenile Justice IllnessSystems

Support interventions to correspond to all stages of justice involvement. ConsiderCommittee Coordinating 4.1. Interdepartmental

all points included in the sequential intercept model. Pay particular attention to the “zero intercept”—the avoidance of initial arrest. Provide funding opportunitiesIllness for Mental Serious

communities to map their systems, develop programs and services, and promote diversion

of people with SMI and SED along the continuum of the sequential intercept model.8 Interdepartmental [Medium-term recommendation]

8 Substance Abuse and Mental Health Services Administration. (2016). Turning Point: Criminal Justice to Behavioral Health.

SAMHSA News, July 18, 2016. Retrieved from https://newsletter.samhsa.gov/2016/07/18/criminal-diversion-programs-resources.

therapeutic justice dockets, and probationary units with specialized capacity to work with with work to capacity specialized with units probationary and dockets, justice therapeutic

system. This includes support of therapeutic court models at local and federal levels, levels, federal and local at models court therapeutic of support includes This

local courts for any person with SMI or SED who becomes involved in the justice justice the in involved becomes who SED or SMI with person any for courts local

4.5. Develop and sustain therapeutic justice dockets in federal civilian, state, and and state, civilian, federal in dockets justice therapeutic sustain and Develop

post-arrest, and post-competency phases. post-competency and post-arrest, [Longer-term recommendation] [Longer-term

holding people in jails to await competency evaluations. Give consideration to pre-arrest, pre-arrest, to consideration Give evaluations. competency await to jails in people holding

charged with nonviolent crimes, use jail diversion options whenever possible instead of of instead possible whenever options diversion jail use crimes, nonviolent with charged

evidence-based strategies for reducing forensic bed waitlists. For people with SMI and SED SED and SMI with people For waitlists. bed forensic reducing for strategies evidence-based competency services. Support the use of mathematically based planning tools to develop develop to tools planning based mathematically of use the Support services. competency

of initiation for average, on days, 5 than more no wait SMI with people that ensure to states community-based evaluation and services. and evaluation community-based Develop federal guidelines and work with with work and guidelines federal Develop

4.4.

Establish and incentivize best practices for competency restoration that use use that restoration competency for practices best incentivize and Establish Interdepartmental

diversion programs. programs. diversion

[Longer-term recommendation] [Longer-term Illness Mental Serious

Interdepartmental Interdepartmental Interdepartmentaljustice local within people engage to able be and officers, patrol fellow and community abuse issues. Officers who receive this specialized training will then be a resource for the the for resource a be then will training specialized this receive who Officers issues. abuse

behavioral health resources, and in-depth training on mental health and substance substance and health mental on training in-depth and resources, health Committee behavioral Coordinating

Serious Mental Illness Illness Mental Serious Seriouscommunity with Mentalworking in training Illnessspecialized receive must community every within

health crisis situations. A select cadre of law enforcement officers in a patrol capacity capacity patrol a in officers enforcement law of cadre select A situations. crisis health Coordinating Committee Committee Coordinating Coordinatingmental de-escalate to training have and Committee SED and That SMI with System a people of for needs and Action symptoms Federal Forward: Way The

effectively to people with SMI and SED. All law enforcement staff should be aware of the the of aware be should staff enforcement Their law All and SED. and SED SMI and with SMI people to With effectively Living People All for Works law enforcement and other first responders should be prepared to respond safely and and safely respond to prepared be should responders first other and enforcement law

law enforcement. When the crisis system fails, or the level of dangerousness warrants, warrants, dangerousness of level the or fails, system crisis the When enforcement. law Caregivers and Families

SED. The Way Forward: Federal Action for a System That That System a for Action Federal Forward: Way The Theinvolving Waywithout Forward:resolved be Federalshould SED and ActionSMI with forpeople a Systemamong crises ThatIdeally,

4.3.

Works for All People Living With SMI and SED and Their Their and SED and SMI With Living People All for Works Worksand SMI with for Allpeople Peoplewith work Livingto how on With SMIresponders andfirst all SEDtrain andand TheirPrepare

Families and Caregivers Caregivers and Families Families and Caregivers recommendation] term

Services, the Veterans Health Administration, and other federal departments. departments. federal other and Administration, Health Veterans the Services, [Longer-

an interdepartmental group, including SAMHSA, the Centers for Medicare & Medicaid Medicaid & Medicare for Centers the SAMHSA, including group, interdepartmental an

personnel. Sustaining an adequate crisis response system must be addressed through through addressed be must system response crisis adequate an Sustaining personnel.

be plans for information sharing between crisis service providers and law enforcement enforcement law and providers service crisis between sharing information for plans be

without contact with law enforcement. However, until that goal is achieved, there must must there achieved, is goal that until However, enforcement. law with contact without

SED who is in crisis should be able to get adequate mental health care in the community community the in care health mental adequate get to able be should crisis in is who SED

law enforcement when needed; and dedicated crisis triage centers. A person with SMI or or SMI with person A centers. triage crisis dedicated and needed; when enforcement law

able to respond independently to nonviolent crisis situations, and to co-respond with with co-respond to and situations, crisis nonviolent to independently respond to able

law enforcement crisis response teams of clinicians and other behavioral health providers providers health behavioral other and clinicians of teams response crisis enforcement law

staffed by certified peer specialists, including family and youth support specialists; non- specialists; support youth and family including specialists, peer certified by staffed 2017 , 13 December

include services such as 24/7 access to crisis line services staffed by clinicians; warm lines lines warm clinicians; by staffed services line crisis to access 24/7 as such services include

to address the crisis needs of people with SMI and SED. A crisis response system should should system response crisis A SED. and SMI with people of needs crisis the address to

from the justice system. justice the from Community-based mental health services must be in place place in be must services health mental Community-based

4.2. , 2017 , 13 December DecemberSED and SMI 13,with 2017 people divert to system response crisis integrated an Develop

, 2017 Decemberpeople with mental 13 illness. Examples include mental health courts, accountability courts, veterans courts, and juvenile courts. Through coordination between federal departments and state and local agencies, community-based services for people with SMI and SED

should support diversion programs. Federal financing should incentivize states to adopt

, 2017 , and expand wraparound services such as case management; forensic assertive community 13 December treatment; cognitive skills training; and peer, family, and youth mentoring programs so courts and probation systems can connect people with SMI and SED to effective services. [Longer-term recommendation]

4.6. Require universal screening for mental illnesses, substance use disorders, and other behavioral health needs of every person booked into jail. Use evidence- based screening tools to screen for SMI, SED, co-occurring substance use disorders, cognitive disabilities, and suicide risk when the person is booked, and later if indicated. When people screen “positive” for mental illnesses or substance use disorders, conduct

a comprehensive assessment of mental and substance use disorder treatment needs, in

Familiesaccordance with and procedures Caregivers developed in the Stepping Up Initiative.9 Establish procedures

Worksfor serving forpeople All identified People through Living the screeningWith SMI process, and including SED immediate and Their crisis

Theresponse Way for those Forward: with a high Federal risk of suicide, Action diversion for services a System to behavioral That health

services for lower severity offenses, and adequate jail-based behavioral health services for Caregivers and Families

those who remain incarcerated. [Longer-term recommendation] Works for All People Living With SMI and SED and Their Their and SED and SMI With Living People All for Works

Coordinating Committee

4.7. Strictly limit or eliminate the use of solitaryThat confinement,System a for seclusion, Action restraint, Federal Forward: Way The

or other forms of restrictive housing for people with SMI and SED. Develop and Seriousimplement a plan to Mental reduce and eventually Illness eliminate the use of solitary confinement and

other forms of segregation, seclusion, restraint, and isolation of people with SMI within

Federal Bureau of Prison facilities. This plan must include implementation of mentalCommittee and Coordinating

Interdepartmentalsubstance use disorder treatment services to alleviate symptoms and, when appropriate, to help prepare people to reenter communities. Build on this policy to support similarIllness Mental Serious

measures for people with SMI and SED in state and local jurisdictions, while ensuring

that effective mental health services are available within juvenile and adult correctional Interdepartmental facilities. [Longer-term recommendation]

9 Stepping Up Initiative. (n.d.). Stepping Up: A National Initiative to Reduce the Number of People with Mental Illnesses in Jails.

Website home page. Retrieved from https://stepuptogether.org.

recommendation]

plans, and with state and local governments, to promote similar approaches. approaches. similar promote to governments, local and state with and plans, [Longer-term [Longer-term

managed care organizations. Federal departments should partner with private health health private with partner should departments Federal organizations. care managed

directly or through models such as health homes, accountable care organizations, and and organizations, care accountable homes, health as such models through or directly

models should make it easy to reimburse providers for services. Fund such services services such Fund services. for providers reimburse to easy it make should models

peer support services, and other services needed by people with SMI and SED. Payment Payment SED. and SMI with people by needed services other and services, support peer

care coordination, consultation, supported housing and employment services, family and and family services, employment and housing supported consultation, coordination, care

cover outreach services, bidirectional integration of physical and behavioral health care, care, health behavioral and physical of integration bidirectional services, outreach cover

Federal health benefit programs (including Medicaid, Medicare, VA, and TRICARE) should should TRICARE) and VA, Medicare, Medicaid, (including programs benefit health Federal

5.2. Adequately fund the full range of services needed by people with SMI and SED. SED. and SMI with people by needed services of range full the fund Adequately

quality measures at the individual and population levels. levels. population and individual the at measures quality [Longer-term recommendation] [Longer-term

and outcome employ should departments federal care, of quality and effectiveness measure

intellectual and developmental disabilities, and chronic physical health conditions. To To conditions. health physical chronic and disabilities, developmental and intellectual Interdepartmental

disorders, use substance co-occurring experience often SED and SMI with People SED.

range of complexity and co-occurring conditions experienced by people with SMI and and SMI with people by experienced conditions co-occurring and complexity of range

Such models provide support for integrated population health care that addresses the the addresses that care health population integrated for support provide models Illness Such Mental Serious

5.1. Interdepartmental Interdepartmental Interdepartmentalprograms. benefit health federal in models payment health population Implement Coordinating Committee Committee Coordinating

Serious Mental Illness Illness Mental Serious SeriousCare of MentalAffordability and IllnessAvailability Increase to Strategies Finance Develop 5: Focus

maximize resources and provide services. provide and resources maximize Coordinating Committee Committee Coordinating Coordinatingrecommendation] Committee [Short-term That System a for Action Federal Forward: Way The

juveniles and adults to identify opportunities to coordinate at the state and local level to to level local and state the at coordinate Their to and opportunities SED and identify to SMI adults and With juveniles Living People All for Works as the Byrne Justice Assistance Grant program and other relevant federal programs for for programs federal relevant other and program Grant Assistance Justice Byrne the as

opportunities to maximize resources and provide services. Review federal programs such such programs federal Review services. provide and resources maximize to opportunities Caregivers and Families

Offender Treatment and Crime Reduction Act and the 21 the and Act Reduction Crime and Treatment Offender The Way Forward: Federal Action for a System That That System a for Action Federal Forward: Way The Theidentify to Way Act Forward:Cures Century Federal Action for a System That

Works for All People Living With SMI and SED and Their Their and SED and SMI With Living People All for Works Works Ill forMentally Allthe of Peoplelanguage the Living review Withstrategy, SMI and SEDinterdepartmental andfederal a of Theirpart of people with mental illness and co-occurring substance use disorders. use substance co-occurring and illness mental with people of

Families and Caregivers Caregivers and Families Families As and Caregivers Century Cures Act, and other federal programs to reduce incarceration incarceration reduce to programs federal other and Act, Cures Century 21 the Act,

4.9. Build on efforts under the Mentally Ill Offender Treatment and Crime Reduction Reduction Crime and Treatment Offender Ill Mentally the under efforts on Build

and actions related to symptoms of SMI and SED. SED. and SMI of symptoms to related actions and [Longer-term recommendation] [Longer-term

probation or parole. Likewise, support forgiveness of criminal charges, including felonies, felonies, including charges, criminal of forgiveness support Likewise, parole. or probation

the Medicaid status of a person who has been arrested, confined but not convicted, or on on or convicted, not but confined arrested, been has who person a of status Medicaid the

are incarcerated less than 18 months. Help states discontinue the practice of changing changing of practice the discontinue states Help months. 18 than less incarcerated are

rather than terminate, Medicaid coverage and access to disability benefits for people who who people for benefits disability to access and coverage Medicaid terminate, than rather

facilities, including services such as supported employment. Encourage states to suspend, suspend, to states Encourage employment. supported as such services including facilities,

Security Income, and Social Security Disability Income) upon release from correctional correctional from release upon Income) Disability Security Social and Income, Security

policies that enable immediate access to benefits (such as Medicaid, Supplemental Supplemental Medicaid, as (such benefits to access immediate enable that policies 2017 , 13 December

employment, and community living. Work at the federal level and help states to adopt adopt to states help and level federal the at Work living. community and employment,

symptoms of SMI and SED should not impede a person’s ability to get housing, education, education, housing, get to ability person’s a impede not should SED and SMI of symptoms

upon release from correctional facilities. correctional from release upon Criminal charges that are related to to related are that charges Criminal

4.8. , 2017 , 13 December Decemberservices 13recovery , 2017and treatment to access immediate impede that barriers Reduce

, 2017 5.3. DecemberFully enforce 13 parity to ensure that people with SMI and SED receive the mental health and substance abuse services they are entitled to, and that benefits are offered on terms comparable to those for physical illnesses. Fully implement

the October 2016 recommendations from the White House Parity Task Force and the

, 2017 , recommendations made by the President’s Commission on Combating Drug Addiction 13 December and the Opioid Crisis for improving the implementation and enforcement of the Mental Health Parity and Addiction Equity Act (MHPAEA).10 These recommendations include enacting legislation to provide the Department of Labor the authority to impose civil monetary penalties for findings of noncompliance, authority to enforce MHPAEA directly against health plan insurance issuers, and additional funding to increase parity enforcement efforts. Review and implement the recommendations from the Coalition for Whole Health on parity implementation and enforcement, as documented in an August 10, 2017, letter to the Office of the Assistant Secretary for Planning and Evaluation.11 Ensure that the services needed by people with SMI and SED are covered by health insurance

and available at the same level as for other health conditions, with attention to parity in Familiespayment rate settingand Caregiversprocesses. [Medium-term recommendation]

5.4. WorksEliminate forfinancing All People practices Livingand policies With that SMI discriminate and SED against and behavioral Their The Way Forward: Federal Action for a System That health care. Identify and eliminate programs, practices, and policies that make it hard to Caregivers and Families

deliver good mental health care. This includes ending the exclusion for reimbursement

of services to adults under age 65 in InstitutionsTheir and for MentalSED Diseasesand SMI (IMD exclusion)With Living People All for Works

Coordinating Committee

and ending the 190-day lifetime limit on MedicareThat psychiatricSystem a inpatientfor hospitalization.Action Federal Forward: Way The

In addition, provide incentives for behavioral health providers to adopt electronic health

Seriousrecords similar to incentives Mental that other Illnesshealth care providers have received. [Medium-term

recommendation] Coordinating Committee Committee Coordinating

5.5. InterdepartmentalPay for psychiatric and other behavioral health services at rates equivalent to other health care services. In many states, reimbursement by public programsIllness for Mental Serious

mental health services is lower (as a percentage of cost) than reimbursement for other

health services. This forces providers to offer critical services (including psychiatric care

and hospitalization) at a loss. As a result, many mental health service providers do not Interdepartmental participate in public programs, leading to widespread mental health workforce shortages. Medicare, Medicaid, and other benefit programs should provide adequate reimbursement

for the full range of services needed by people with SMI and SED, at rates equivalent to rates for other types of health care services. [Longer-term recommendation]

10 Executive Office of the President of the United States. (2016). The Mental Health & Substance Use Disorder Parity Task Force: Final Report, October 2016. Retrieved from https://www.hhs.gov/sites/default/files/mental-health-substance-use-disorder-parity-task-force-final-report.pdf. 11 Coalition for Whole Health. (2017). Letter to Office of the Assistant Secretary for Planning and Evaluation, August 10, 2017.

Retrieved from https://www.aahd.us/wp-content/uploads/2017/09/CWHparitylisteningsessioncomments.pdf.

Interdepartmental

Serious Mental Illness Illness Mental Serious

Interdepartmental Interdepartmental Interdepartmental

Coordinating Committee Committee recommendation] Coordinating models of care delivery, even states not funded by the CCBHC program. program. CCBHC the by funded not states even delivery, care of models

Serious Mental Illness Illness Mental Serious Serious[Medium-term Mental Illness reach and quality of services and outcomes. Help interested states to move toward similar similar toward move to states interested Help outcomes. and services of quality and reach

effectiveness of the CCBHC model and, if needed, modify the model to improve the the improve to model the modify needed, if and, model CCBHC the of effectiveness

Coordinating Committee Committee Coordinating the Coordinating Evaluate model. payment Committee sustainable a That offers and System a framework for health Action population a in Federal Forward: Way The

nationwide. nationwide.

The CCBHC program provides a framework to support effective services services effective support to framework Their a and provides SED program and CCBHC SMI The With Living People All for Works

5.8.

Expand the Certified Community Behavioral Health Clinic (CCBHC) program program (CCBHC) Clinic Health Behavioral Community Certified the Expand Caregivers and Families

The Way Forward: Federal Action for a System That That System a for Action Federal Forward: Way The The Way Forward: Federal Action for a System That language. language. [Medium-term recommendation] [Medium-term

Works for All People Living With SMI and SED and Their Their and SED and SMI With Living People All for Works Workscontract care for Allmanaged Peoplemodel as Livingsuch Withavailable, SMImaterials and and SEDassistance andtechnical Theirmake

Families and Caregivers Caregivers and Families and Familiesstates across andpractices Caregiversbest highlight work, this in states support To SED. and SMI with state plan amendment processes so states can easily make changes to better serve people people serve better to changes make easily can states so processes amendment plan state

to expand the availability of evidence-based services. Streamline the waiver approval and and approval waiver the Streamline services. evidence-based of availability the expand to

meet the needs of people with SMI and SED. Medicaid waivers and options can be used used be can options and waivers Medicaid SED. and SMI with people of needs the meet

SED and adults with SMI. with adults and SED Through federal departmental coordination, help states states help coordination, departmental federal Through

5.7. Fund adequate home- and community-based services for children and youth with with youth and children for services community-based and home- adequate Fund

designed to support population health. health. population support to designed [Longer-term recommendation] [Longer-term

need. Outreach and engagement should be supported through financing models that are are that models financing through supported be should engagement and Outreach need.

homes. These activities help ensure that people with SMI and SED get the care they they care the get SED and SMI with people that ensure help activities These homes.

meet with people with SMI and SED and their families in the community and in their their in and community the in families their and SED and SMI with people with meet

in the past year. Outreach and engagement services allow mental health providers to to providers health mental allow services engagement and Outreach year. past the in 2017 , 13 December

one-third of adults with SMI and most children and youth with SED received no treatment treatment no received SED with youth and children most and SMI with adults of one-third

that are an essential part of so many effective mental health treatment models. More than than More models. treatment health mental effective many so of part essential an are that

health care. care. health The public health care system must cover outreach and engagement services services engagement and outreach cover must system care health public The

5.6. , 2017 , 13 December Decembermental to 13related , 2017 services engagement and outreach for reimbursement Provide

, 2017 AppendixDecember A 13 U.S. Department of Health & Human Services

Interdepartmental Serious Mental Illness Coordinating Committee , 2017 ,

Members 13 December

Families and Caregivers

Works for All People Living With SMI and SED and Their

The Way Forward: Federal Action for a System That

Families and Caregivers Caregivers and Families

Works for All People Living With SMI and SED and Their Their and SED and SMI With Living People All for Works

Coordinating Committee The Way Forward: Federal Action for a System That That System a for Action Federal Forward: Way The

Serious Mental Illness

Coordinating Committee Committee Coordinating

Interdepartmental

Serious Mental Illness Illness Mental Serious

Interdepartmental Interdepartmental

Deputy Associate Commissioner, Office of Disability Policy, Social Security Administration Security Social Policy, Disability of Office Commissioner, Associate Deputy

Melissa Spencer Melissa

Deputy Assistant Secretary, Office of Disability Employment Policy, Department of Labor of Department Policy, Employment Disability of Office Secretary, Assistant Deputy Jennifer Sheehy, M.B.A. Sheehy, Jennifer

Rehabilitative Services, Department of Education of Department Services, Rehabilitative and Education Special for Secretary Assistant Acting and Secretary Assistant Deputy

Kimberly M. Richey, J.D. Richey, M. Kimberly Interdepartmental

Associate Deputy Director, Bureau of Justice Assistance, Department of Justice of Department Assistance, Justice of Bureau Director, Deputy Associate

Serious Mental Illness M.P.A. Illness Qazilbash, Ruby Mental Serious

Interdepartmental Interdepartmental Interdepartmental Affairs Veterans Director, Serious Mental Illness Treatment Resource and Evaluation Center, Department of of Department Center, Evaluation and Resource Treatment Illness Mental Serious Committee Director, Coordinating

Serious Mental Illness Illness Mental Serious Serious Mental Illness M.P.H. Ph.D., McCarthy, John

Deputy Assistant Secretary of Defense for Health Affairs, Department of Defense of Department Affairs, Health for Defense of Secretary Assistant Deputy

Coordinating Committee Committee Coordinating Coordinating Committee That System a for M.P.P. Action McCaffery, Federal Thomas Forward: Way The

Lead Medical Officer, Office of Health Services Policy and Oversight, Department of Defense of Department Oversight, and Their Policy and Services SED Health of and Office SMI With Officer, Living Medical Lead People All for Works Captain Robert DeMartino, M.D. DeMartino, Robert Captain

Caregivers and Families

The Way Forward: Federal Action for a System That That System a for Action Federal Forward: Way The The Way Forward: Federal Action for a System That Deputy Associate Attorney General, Department of Justice of Department General, Attorney Associate Deputy

Works for All People Living With SMI and SED and Their Their and SED and SMI With Living People All for Works Works for All People Living With SMI and SED andJ.D. TheirCox, Stephen

Families and Caregivers Caregivers and Families FamiliesServices andMedicaid Caregivers& Medicare for Centers Operations, for Administrator Deputy Principal

Kimberly Brandt, J.D. Brandt, Kimberly

Assistant Secretary of Defense for Health Affairs, Department of Defense of Department Affairs, Health for Defense of Secretary Assistant

Deputy Assistant Secretary of Defense for Health Services Policy and Oversight, Office of the the of Office Oversight, and Policy Services Health for Defense of Secretary Assistant Deputy

Terry Adirim, M.D., M.P.H., F.A.A.P. M.P.H., M.D., Adirim, Terry

Secretary of the Department of Housing and Urban Development Urban and Housing of Department the of Secretary

Benjamin Carson, Sr., M.D. M.D. Sr., Carson, Benjamin

Acting Secretary of the Department of Health and Human Services Human and Health of Department the of Secretary Acting Eric D. Hargan, Esq. Hargan, D. Eric

, 2017 , 13 December

Assistant Secretary for Mental Health and Substance Use Substance and Health Mental for Secretary Assistant

Elinore F. McCance-Katz, M.D., Ph.D. M.D., McCance-Katz, F. Elinore , 2017 , 13 December December 13, 2017 Members Federal

, 2017 Non-FederalDecember Members 13

Linda Beeber, Ph.D., P.M.H.C.N.S.-B.C., F.A.A.N. , 2017 ,

Linda Beeber, Ph.D., P.M.H.C.N.S.-B.C., F.A.A.N., is a doctorally prepared 13 December advanced practice psychiatric mental health nurse with over 40 years of experience in practice and over 20 years of research experience in mental health. Funded through federal grants and private foundations, Dr. Beeber and her colleagues have conducted community-based research focused on reducing maternal depressive symptoms and enhancing parenting in populations of high-risk mothers of infants and toddlers. Her work has shown that reduction of barriers and provision of culturally and contextually tailored, evidence-based interventions can effectively reduce maternal depressive symptoms and improve parenting. Dr. Beeber has experience as an educator, academic

administrator, and psychiatric nursing leader. Through her work with the American Psychiatric

NursesFamilies Association (APNA) and Caregiversas the Chair of the Research Council, and more recently as President- Elect, andWorks as the pastfor Co-Chair All People of the Psychiatric Living MentalWith Health SMI and and Substance SED Abuse and Expert Their

Panel of the American Academy of Nursing, she advocates to reduce the risk factors that threaten The Way Forward: Federal Action for a System That mental health, and to improve the lives of people living with symptoms of mental illness through Caregivers and Families

models of recovery, culturally congruent symptom management, social support mobilization, and

healthy lifestyle patterning. Dr. Beeber has disseminatedTheir and herSED work throughand SMI peer-reviewedWith papers,Living People All for Works

Coordinating Committee national and international presentations, and serviceThat on nationalSystem policymakinga for panels.Action Federal Forward: Way The

Ron L. SeriousBruno Mental Illness

Ron L. Bruno is a Utah law enforcement officer with over 22 years of experience.Committee Mr. Coordinating

InterdepartmentalBruno has dedicated much of his career working with adult and child populations dealing with serious mental illness and emotional disturbances. Mr. BrunoIllness is a Mental Serious

founding board director of CIT International and currently is the corporation’s second

vice president; a founding board director of CIT Utah, Inc. and the corporation’s Interdepartmental Executive Director; and the Director of CTS Services, LLC, an organization that

provides de-escalation training for law enforcement officers and other disciplines throughout the country. Mr. Bruno has worked with national organizations such as the National Alliance

on Mental Illness in developing its CIT for Youth Implementation Manual; the International Association of Chiefs of Police in developing and conducting Law Enforcement Leadership Institutes on Juvenile Justice; and the Council of State Governments with its Learning Sites Program and its report on Statewide Law Enforcement/Mental Health Efforts. Within Utah, Mr. Bruno was instrumental in developing the fully integrated Salt Lake County crisis response system, and he continues to work with councils and committees for enhanced criminal justice

and behavioral health services integration.

National Council for Behavioral Health Boards of Directors. of Boards Health Behavioral for Council National

served on numerous committees and task forces on clinical care and crisis services, including the the including services, crisis and care clinical on forces task and committees numerous on served

the Chair of the National Suicide Prevention Lifeline SAMHSA Steering Committee. He has has He Committee. Steering SAMHSA Lifeline Prevention Suicide National the of Chair the the National Action Alliance for Suicide Prevention Executive Committee since 2010. He is also also is He 2010. since Committee Executive Prevention Suicide for Alliance Action National the

Mr. Covington is President-Elect of the American Association of Suicidology and has served on on served has and Suicidology of Association American the of President-Elect is Covington Mr.

magazine. magazine. in featured subsequently was program the and Line, Access and Crisis Business Week Business

competed as a finalist in Harvard’s Innovations in American Government in 2009 for the Georgia Georgia the for 2009 in Government American in Innovations Harvard’s in finalist a as competed

is a two-time national winner of the Council of State Governments Innovations Award. He also also He Award. Innovations Governments State of Council the of winner national two-time a is

Covington Mr. blogger, and speaker global innovations care health recognized A Healthcare. APS

Health, CEO of Behavioral Health Link, and Director of Public Sector Quality Management at at Management Quality Sector Public of Director and Link, Health Behavioral of CEO Health, Interdepartmental Magellan at President Vice as served previously He Memphis. of University

Mr. Covington received an M.B.A. from Kennesaw State and an M.S. from the the from M.S. an and State Kennesaw from M.B.A. an received Covington Mr. Illness Mental Serious “Zero Suicide,” “Crisis Now,” and “Peer 2.0.” A licensed professional counselor, counselor, professional licensed A 2.0.” “Peer and Now,” “Crisis Suicide,” “Zero

Interdepartmental Interdepartmental Interdepartmentalinitiatives international the leads and 360, CrisisTech of co-founder Link, Health

RI International (formerly Recovery Innovations). He is a partner in Behavioral Behavioral in partner a is He Innovations). Recovery (formerly International RI Committee Coordinating

David Covington, L.P.C., M.B.A., L.P.C., Covington, David Serious Mental Illness Illness Mental Serious of SeriousPresident and MentalOfficer Executive Chief Illnessis

Coordinating Committee Committee Coordinating Coordinating Committee That System a for M.B.A. L.P.C., Action Covington, Federal David Forward: Way The

Works for All People Living With SMI and SED and Their Their and SED and SMI With Living People All for Works homelessness, and mental health policy. policy. health mental and homelessness,

care integration, health care system reform, cultural competency, veterans’ health, trauma, trauma, health, veterans’ competency, cultural reform, system care health integration, care Caregivers and Families

The Way Forward: Federal Action for a System That That System a for Action Federal Forward: Way The Thehealth Wayof areas Forward:the in trainings Federal Actioninternational forconducted has a Systemalso He ThatAssociation. Psychiatric Works for All People Living With SMI and SED and Their Their and SED and SMI With Living People All for Works WorksAmerican the forfrom AllAward PeopleM.D., LivingWilliams, WithWarren the SMIreceived andand SEDHealth andBehavioral Theirfor Council

Families and Caregivers Caregivers and Families FamiliesNational the by andLeader CaregiversVisionary 2012 the named was Chau Dr. Disparities. Health Reducing for and was the Director of the Center of Excellence in Education, Training, Research and Advocacy Advocacy and Research Training, Education, in Excellence of Center the of Director the was and

Previously, he worked for the Orange County Health Care Agency Behavioral Health Services Services Health Behavioral Agency Care Health County Orange the for worked he Previously,

Public Health and an associate clinical professor of psychiatry at UC Irvine School of Medicine. Medicine. of School Irvine UC at psychiatry of professor clinical associate an and Health Public

grant in transforming clinical practice. Dr. Chau also is a lecturer for the UCLA School of of School UCLA the for lecturer a is also Chau Dr. practice. clinical transforming in grant

Investigator for a multi-year Center for Medicare & Medicaid Services’ health care innovation innovation care health Services’ Medicaid & Medicare for Center multi-year a for Investigator

Medical Director for Health Services at L.A. Care Health Plan, where he was Co-Principal Co-Principal was he where Plan, Health Care L.A. at Services Health for Director Medical

psychoneuroimmunology focusing on substance use and HIV. Previously, he served as Senior Senior as served he Previously, HIV. and use substance on focusing psychoneuroimmunology

Valley, followed by a fellowship with the National Institute of Mental Health in in Health Mental of Institute National the with fellowship a by followed Valley,

psychiatry residency at the University of California, Los Angeles, San Fernando Fernando San Angeles, Los California, of University the at residency psychiatry

and Ph.D. in clinical psychology from Chelsea University. Dr. Chau completed his his completed Chau Dr. University. Chelsea from psychology clinical in Ph.D. and

Orange County, California. He obtained his M.D. from the University of Minnesota Minnesota of University the from M.D. his obtained He California. County, Orange 2017 , 13 December

Health Network, St. Joseph Hoag Health/Providence St. Joseph Health System in in System Health Joseph St. Health/Providence Hoag Joseph St. Network, Health

Clayton Chau, M.D., M.D., Chau, Clayton is the Regional Executive Medical Director for the Mental Mental the for Director Medical Executive Regional the is , 2017 , 13 December December 13, 2017 M.D. Chau, Clayton

, 2017 MaryannDecember Davis, Ph.D. 13

Maryann Davis, Ph.D., is Research Associate Professor of Psychiatry

(Psychology) and Director of the Systems and Psychosocial Advances Research

, 2017 , Center and the Transitions Research and Training Center (RTC) at the 13 December Department of Psychiatry and the University of Massachusetts Medical School. A clinically trained research psychologist, she has spent her career studying transition-age youth and young adults with serious mental health conditions. Dr. Davis is a grant recipient of the National Institute of Mental Health; the National Institute on Disability, Independent Living, and Rehabilitation Research; the National Institute on Drug Abuse; and SAMHSA. She has collaborated with the Massachusetts Department of Mental Health in addressing the needs of transition-age youth for over 20 years. As Director of the Transitions RTC, she has extensive experience in sharing research-based knowledge with key stakeholders, including people with lived experience of serious mental health conditions and their families,

administrators, policymakers, and service providers. Dr. Davis has provided expert testimony

on transition-ageFamilies youth and with Caregivers serious mental health conditions before Congress, and served on

multipleWorks committees for of All the NationalPeople Academy Living of Sciences,With SMI Engineering, and SEDand Medicine. and Their

The Way Forward: Federal Action for a System That

Pete Earley Caregivers and Families

Pete Earley is a New York TimesTheir bestsellingand authorSED andand formerSMI reporterWith for TheLiving People All for Works Coordinating Committee Washington Post. A 1973 graduate of PhillipsThat UniversitySystem a in for Oklahoma, Action he previouslyFederal Forward: Way The

worked for the Emporia Gazette in Kansas and the Tulsa Tribune in Oklahoma.

SeriousFrom 1980 until Mental 1986, Mr. Earley Illnessworked as a reporter at The Washington Post before

writing books full-time. He is the author of six novels and 11 non-fiction books,Committee Coordinating Interdepartmentalincluding Crazy: A Father’s Search Through America’s Mental Health Madness,

which was a finalist for the 2007 Pulitzer Prize. Mr. Earley is a member of the National Alliance on

Mental Illness, serves on the board of the Corporation for Supportive Housing, and wasIllness appointed Mental Serious

to a Virginia Supreme Court task force that recommended changes to that state’s involuntary

commitment laws and is currently serving on a committee investigating ways to improve Virginia Interdepartmental jails. An advocate for mental health, Mr. Earley has testified five times before Congress, lectured

in five foreign countries, spoken in every state except Hawaii, and toured a combined total of

more than a hundred jails, prisons, treatment programs, and housing facilities.

Paul Emrich, Ph.D.

Paul Emrich, Ph.D., is Undersecretary of Family and Mental Health Services for the Chickasaw Nation, with responsibility for leading the integration of human services, addiction recovery, mental health, and medical care. Dr. Emrich received his training at Oklahoma State University and Oklahoma Baptist University, where he completed a postgraduate certificate in Medical Family Therapy, a Ph.D. in Human

Development and Family Science, an M.S. in Marriage and Family Therapy, and a

library.

decision-making, trauma-informed care, wellness recovery action planning, and the recovery recovery the and planning, action recovery wellness care, trauma-informed decision-making,

hospitalization-based model of mental health care, helping to spread awareness of shared shared of awareness spread to helping care, health mental of model hospitalization-based

service, Ms. Kravitz works to assist people pursuing recoveries move beyond a medication- and and medication- a beyond move recoveries pursuing people assist to works Kravitz Ms. service,

member of a peer-staffed crisis respite house and as a peer worker in a psychiatric emergency emergency psychiatric a in worker peer a as and house respite crisis peer-staffed a of member

and mental health together, promoting the police crisis intervention team. As a former staff staff former a As team. intervention crisis police the promoting together, health mental and

directives, taking a leadership role in her own county on initiatives to bring law enforcement enforcement law bring to initiatives on county own her in role leadership a taking directives,

for people pursuing recoveries. She is one of New Jersey’s leading trainers on psychiatric advance advance psychiatric on trainers leading Jersey’s New of one is She recoveries. pursuing people for

her county’s Freeholder-appointed Mental Health Board, Ms. Kravitz supports legal protections protections legal supports Kravitz Ms. Board, Health Mental Freeholder-appointed county’s her

Voice and NAMI Connection programs. A board member of Disability Rights–New Jersey and and Jersey Rights–New Disability of member board A programs. Connection NAMI and Voice

Own Our In the in trainer a as NAMI assists and Jersey New (NAMI) Illness Mental on Alliance

served as coordinator and lead presenter of the Hearts and Minds for the National National the for Minds and Hearts the of presenter lead and coordinator as served

New Jersey, a nationally recognized peer-led mental health organization. She also also She organization. health mental peer-led recognized nationally a Jersey, New Interdepartmental

manages a peer support wellness center for the Collaborative Support Programs of of Programs Support Collaborative the for center wellness support peer a manages

active volunteer and provider who brings a lived experience of recovery. Ms. Kravitz Kravitz Ms. recovery. of experience lived a brings who provider and volunteer active Illness Mental Serious

Interdepartmental Interdepartmental an Interdepartmentaland Practitioner Rehabilitation Psychiatric Certified a is she NJ, Bridge, Old of Elena M. Kravitz M. Elena

is a community mental health provider and advocate. A resident resident A advocate. and provider health mental community a is Committee Coordinating Serious Mental Illness Illness Mental Serious Serious Mental Illness Kravitz M. Elena

The Way Forward: Federal Action for a System That That System a for Action Federal Forward: Way The Coordinating Committee Committee Coordinating Coordinating Committee NAMI. at issues state

Prior to that, Ms. Giliberti served as the Director of Public Policy and Advocacy for federal and and federal for Advocacy and Policy Their Public of and Director SED the as and served SMI Giliberti With Ms. that, Living to Prior People All for Works

as a section chief in the Office for Civil Rights at the Department of Health and Human Services. Services. Human and Health of Department the at Rights Civil for Office the in chief section a as Caregivers and Families The Way Forward: Federal Action for a System That That System a for Action Federal Forward: Way The Theworked Wayshe Forward:NAMI, of CEO Federalbecoming Before ActionLaw. Health for aMental Systemfor Center ThatBazelon

Works for All People Living With SMI and SED and Their Their and SED and SMI With Living People All for Works the Worksat attorney for Allsenior a as People and LivingPensions and WithLabor, SMIEducation, and Health, SED on and Committee Their mental health field, Ms. Giliberti has served as disability counsel for the Senate Senate the for counsel disability as served has Giliberti Ms. field, health mental

Families and Caregivers Caregivers and Families Familiesthe in years 20 and over Caregiversof tenure her During School. Law Yale at J.D. her and College

Illness (NAMI). A native of North Bellmore, NY, she earned her B.A. at Harvard Harvard at B.A. her earned she NY, Bellmore, North of native A (NAMI). Illness

Mary Giliberti, J.D., Giliberti, Mary is the Chief Executive Officer of the National Alliance on Mental Mental on Alliance National the of Officer Executive Chief the is

Mary Giliberti, J.D. Giliberti, Mary

helping children, adults, and families experiencing serious emotional illnesses. emotional serious experiencing families and adults, children, helping

advocate, and educator, Dr. Emrich has over 20 years of experience in the mental health field field health mental the in experience of years 20 over has Emrich Dr. educator, and advocate,

Medicare & Medicaid Services. Having worked as a clinician, supervisor, administrator, researcher, researcher, administrator, supervisor, clinician, a as worked Having Services. Medicaid & Medicare

for LMFT and on the Tribal Technical Advisory Group on Behavioral Health for the Centers for for Centers the for Health Behavioral on Group Advisory Technical Tribal the on and LMFT for

of the American Society for Addiction Medicine. He has served on Oklahoma’s licensing board board licensing Oklahoma’s on served has He Medicine. Addiction for Society American the of 2017 , 13 December

a clinical fellow with the American Association for Marriage and Family Therapy and a member member a and Therapy Family and Marriage for Association American the with fellow clinical a

Behavioral Health Licensure to provide clinical supervision for license candidates. Dr. Emrich is is Emrich Dr. candidates. license for supervision clinical provide to Licensure Health Behavioral

(LMFT) and licensed professional counselor. He is also approved by the Oklahoma State Board of of Board State Oklahoma the by approved also is He counselor. professional licensed and (LMFT) , 2017 , 13 December Decembertherapist family 13and , 2017marital licensed a as licensed dually is Emrich Dr. Psychology. Family in B.A.

, 2017 KennethDecember Minkoff, M.D. 13

Kenneth Minkoff, M.D., is a Senior System Consultant for ZiaPartners, Inc.,

a part-time Assistant Professor of Psychiatry for Harvard Medical School, and

, 2017 , Director of Systems Integration for the Meadows MH Policy Institute in Dallas, 13 December TX. A recognized expert on integrated services and systems for individuals with co-occurring serious mental illnesses and substance use disorders, he is a Board- Certified Addiction Psychiatrist. In the 1990s, he chaired a SAMHSA Managed Care Initiative Panel on Co-occurring Disorders and developed a national model for integrated system design for individuals with co-occurring mental health and substance use disorders. For the past 17 years, Dr. Minkoff has worked with his consulting partner Christie A. Cline, M.D., M.B.A., to improve behavioral health systems all over the world. Dr. Minkoff also is active in policy and practice on a national and state level, serving as an emeritus board member of the American Association of Community Psychiatrists and currently as Chair of the Products and

Services Plank. An active participant in designing SAMHSA’s Recovery to Practice Curriculum for

psychiatrists,Families he is co-chair and ofCaregivers the Committee on Psychiatry and the Community for the Group for

the AdvancementWorks forof Psychiatry, All People and is an Living incoming With board SMImember and for the SED College and for Behavioral Their

Health TheLeadership. Way Forward: Federal Action for a System That

Families and Caregivers Caregivers and Families

Elyn R. Saks, J.D., Ph.D. Their and SED and SMI With Living People All for Works

Coordinating Committee Elyn R. Saks, J.D., Ph.D., isThat Orrin B. EvansSystem a Professor for of Law,Action Psychology,Federal Forward: Way The

and Psychiatry and the Behavioral Sciences at the University of Southern

SeriousCalifornia Mental Gould School Illness of Law. Dr. Saks is also Director of the Saks

Institute for Mental Health Law, Policy, and Ethics. She is an adjunctCommittee Coordinating Interdepartmentalprofessor of psychiatry at the University of California, San Diego, School

of Medicine, and faculty at the New Center for Psychoanalysis. Dr. Saks

received her J.D. from Yale Law School, and a Ph.D. in Psychoanalytic Science from theIllness New Mental Serious

Center for Psychoanalysis. She writes extensively on law and mental health, having published five

books and more than fifty articles and book chapters. Her memoir,The Center Cannot Hold: My Interdepartmental Journey Through Madness, describes her struggles with schizophrenia and her managing to craft a

good life for herself in the face of a dire prognosis. Dr. Saks has won numerous honors, including a 2009 John D. and Catherine T. MacArthur Fellowship and an honorary Doctor of Laws from

Pepperdine University.

100

Baptist Church Trustee Ministry. Ministry. Trustee Church Baptist

Association of Black Women Attorneys, Delta Sigma Theta Sorority, Inc., and the Providence Providence the and Inc., Sorority, Theta Sigma Delta Attorneys, Women Black of Association

Georgia Foundation, Education and Community Association’s Lawyers DeKalb Georgia, of

of Health Planning, respectively. Her civic and professional affiliations include the State Bar Bar State the include affiliations professional and civic Her respectively. Planning, Health of Interdepartmental Division its and Health Community of Department the for Director Executive and Counsel

and partner with Mitchell Graham & Stroud, P.C., in Decatur, GA, and worked as Deputy General General Deputy as worked and GA, Decatur, in P.C., Stroud, & Graham Mitchell with Illness partner and Mental Serious Trial Techniques Program. Before serving on the bench, Judge Stroud was a practicing attorney attorney practicing a was Stroud Judge bench, the on serving Before Program. Techniques Trial

Interdepartmental Interdepartmental InterdepartmentalKessler-Eidson Law of School University’s Emory for and Course Online Diversion Jail 20-Hour

Judge Stroud has served as faculty for the Institute of Continuing Judicial Education eLearning eLearning Education Judicial Continuing of Institute the for faculty as served has Committee Stroud Judge Coordinating

Serious Mental Illness Illness Mental Serious Seriousyears. 7 for court Mentalhealth mental the over Illnesspresided has She designation.

over Temporary Protective Order calendars as a superior court judge by by judge court superior a as calendars Order Protective Temporary over

presides over the DeKalb County DeKalb the over presides

Coordinating Committee Committee Coordinating and CoordinatingCourt Health Mental CommitteeMisdemeanor That System a for Action Federal Forward: Way The Georgia State University College of Law. As a magistrate, Judge Stroud Stroud Judge magistrate, a As Law. of College University State Georgia

native of Atlanta, GA, she graduated from the University of Georgia and and Georgia of University the from Their graduated and she GA, SED Atlanta, and of SMI native With Living People All for Works

and as Chief Judge for the City of Decatur, GA, Municipal Court. A A Court. Municipal GA, Decatur, of City the for Judge Chief as and Caregivers and Families

Judge Rhathelia Stroud, J.D., Stroud, Rhathelia Judge The Way Forward: Federal Action for a System That That System a for Action Federal Forward: Way The The WayMagistrate Forward:Georgia County, FederalDeKalb a is Action for a System That Works for All People Living With SMI and SED and Their Their and SED and SMI With Living People All for Works Works for All People Living With SMI and SED and Their

Families and Caregivers Caregivers and Families Families and Caregivers J.D. Stroud, Rhathelia Judge

represents a homecoming in his work on these important issues. important these on work his in homecoming a represents

Supreme Court on mental health issues and then at TAC. His return to TAC as Executive Director Director Executive as TAC to return His TAC. at then and issues health mental on Court Supreme

mental illness. Mr. Snook championed mental illness reform, working first with the West Virginia Virginia West the with first working reform, illness mental championed Snook Mr. illness. mental

reform. His focus on the issue began early, as he saw a loved one struggle with untreated serious serious untreated with struggle one loved a saw he as early, began issue the on focus His reform.

nationwide force for affordable housing policy. Mr. Snook’s passion has always been mental health health mental been always has passion Snook’s Mr. policy. housing affordable for force nationwide

for Humanity International, where he grew its state and local advocacy network into a driving driving a into network advocacy local and state its grew he where International, Humanity for

worked on housing policy at the Mortgage Bankers Association and at Habitat Habitat at and Association Bankers Mortgage the at policy housing on worked

advocacy experience at both the federal and state levels. Prior to joining TAC, he he TAC, joining to Prior levels. state and federal the both at experience advocacy

College in Pennsylvania. Mr. Snook brings to TAC nearly 20 years of policy and and policy of years 20 nearly TAC to brings Snook Mr. Pennsylvania. in College

George Mason School of Law in Virginia and his B.A. from Washington & Jefferson Jefferson & Washington from B.A. his and Virginia in Law of School Mason George 2017 , 13 December

an influential mental health advocacy organization. He received his J.D. from the the from J.D. his received He organization. advocacy health mental influential an

John Snook, J.D., Snook, John is Executive Director of the Treatment Advocacy Center (TAC), (TAC), Center Advocacy Treatment the of Director Executive is , 2017 , 13 December December 13, 2017 J.D. Snook, John

, 2017 Conni WellsDecember 13

Conni Wells is a mental health consultant and advocate with over 30 years

of lived experience. The parent and grandparent of children and young adults

, 2017 , with health and mental health challenges, she served as a consultant and 13 December then Project Director of a National Technical Assistance Center, expanding the capacity of family- and consumer-run organizations serving children and youth with mental, emotional, and behavioral disorders. She was as a member of the Systems of Care Site Visit Team for three states, for which she also provided consulting on developing organizational capacity for family-run organizations. For 12 years, Ms. Wells directed the Florida Statewide Family Network, assisting the state in developing its system of care approach for vulnerable populations with mental health challenges. She also developed Florida’s statewide family provider program for its Title V/CYSHCN Program, and served as a Senior Consultant at the Georgetown University National Center on Cultural Competence and as

a Transformation Facilitator for the Georgetown University National Technical Assistance Center

for SystemsFamilies of Care. Theand former Caregivers Chair for the National Certification for Parent Family Peers

Commission,Works Ms. forWells All currently People works Livingas a consultant With on SMIprojects and focusing SED on multiple and Their systems

of care Thevalues Wayand has Forward:multiple publications, Federal including Action Straight for Talk: a SystemFamilies Speak That to Families

about Child and Youth Mental Health. Caregivers and Families

Works for All People Living With SMI and SED and Their Their and SED and SMI With Living People All for Works

Coordinating Committee The Way Forward: Federal Action for a System That That System a for Action Federal Forward: Way The

Serious Mental Illness

Coordinating Committee Committee Coordinating

Interdepartmental

Serious Mental Illness Illness Mental Serious

Interdepartmental Interdepartmental

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102

Interdepartmental

, 2017 , 13 December

, 2017 , 13 December December 13, 2017

, 2017 AppendixDecember B 13 U.S. Department of Health and Human Services

Interdepartmental Serious Mental Illness Coordinating Committee , 2017 ,

Glossary of Terms Used in Report 13 December

The terms within this glossary appear within the report. Many of the definitions have been taken

verbatim or adapted from federal websites and reports.

Families and Caregivers

Works for All People Living With SMI and SED and Their

The Way Forward: Federal Action for a System That

Families and Caregivers Caregivers and Families

Works for All People Living With SMI and SED and Their Their and SED and SMI With Living People All for Works

Coordinating Committee The Way Forward: Federal Action for a System That That System a for Action Federal Forward: Way The

Serious Mental Illness

Coordinating Committee Committee Coordinating

Interdepartmental

Serious Mental Illness Illness Mental Serious

Interdepartmental Interdepartmental

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n.d.). (SAMHSA, comorbidity as to referred sometimes is condition This (DSM-5). Edition

or more of those identified in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Fifth Disorders, Mental of Manual Statistical and Diagnostic the in identified those of more or

example, alcohol dependence and depression). The combination of disorders can include any two two any include can disorders of combination The depression). and dependence alcohol example,

Co-existence of a substance use disorder and a mental health disorder at the same time (for (for time same the at disorder health mental a and disorder use substance a of Co-existence

Co-occurring mental health and substance use disorder (a.k.a., co-occurring disorders): disorders): co-occurring (a.k.a., disorder use substance and health mental Co-occurring

“aftercare” (CSAT, 2005). 2005). (CSAT, “aftercare” as

a process of post-treatment monitoring and a form of treatment itself. Sometimes referred to to referred Sometimes itself. treatment of form a and monitoring post-treatment of process a

can respond to a return to substance use or a return of symptoms of mental disorder. It is both both is It disorder. mental of symptoms of return a or use substance to return a to respond can Continuing care: care: Continuing

Care that supports a client’s progress, monitors his or her condition, and and condition, her or his monitors progress, client’s a supports that Care

n.d.). (NIMH, mental or physical Comorbidity: Comorbidity:

The existence of two or more illnesses in the same person. These illnesses can be be can illnesses These person. same the in illnesses more or two of existence The Interdepartmental

coping by thinking differently and coping by acting differently (CSAT, 2005). 2005). (CSAT, differently acting by coping and differently thinking by coping

defeating thoughts and behavior. CBT is aimed at both thought and behavior change—that is, is, change—that behavior and thought both at aimed is CBT behavior. and Illness thoughts defeating Mental Serious Cognitive behavioral therapy: therapy: behavioral Cognitive

Interdepartmental Interdepartmental Interdepartmentalself- or negative modify to seeks that approach therapeutic A

providers while addressing a person’s health and wellness (CIHS, n.d.). (CIHS, wellness and health person’s a addressing while Committee providers Coordinating

Coordinated care: care: Coordinated Serious Mental Illness Illness Mental Serious Seriousservice social and Mentalhealth, behavioral Illnessmedical, of efforts the Integrating

Health Services Block Grant (MHBG) (SAMHSA, 2017b). 2017b). That (SAMHSA, System a (MHBG) for Grant Block Action Services Federal Health Forward: Way The Coordinating Committee Committee Coordinating CoordinatingMental Community the and (SABG) CommitteeGrant Block Treatment and Prevention Abuse Substance

receive the formula-based funding. SAMHSA is responsible for two block grant programs: the the programs: grant block two for Their responsible and is SED SAMHSA and funding. SMI With formula-based the Living receive People All for Works

submit an annual application to demonstrate statutory and regulatory compliance in order to to order in compliance regulatory and statutory demonstrate to application annual an submit Caregivers and Families

Block grant: grant: Block

The Way Forward: Federal Action for a System That That System a for Action Federal Forward: Way The Themust Wayentities Forward:Eligible FederalCongress. by Actionmandated grant for formula a System Thatnoncompetitive, A

Works for All People Living With SMI and SED and Their Their and SED and SMI With Living People All for Works Works for All People Living With SMIn.d.-a). and SED(MedlinePlus, andirritable or Theircross being

Families and Caregivers Caregivers and Families or Familiesactive, and happy and very Caregiversbeing of periods with alternate may depressed and sad feeling of Periods

Bipolar disorder: disorder: Bipolar A mental condition in which a person has wide or extreme swings in mood. mood. in swings extreme or wide has person a which in condition mental A

n.d.).

(but are not limited to) serious psychological distress, suicide, and mental illness (SAMHSA, (SAMHSA, illness mental and suicide, distress, psychological serious to) limited not are (but

wellness. Substance use and misuse are one set of behavioral health problems. Others include include Others problems. health behavioral of set one are misuse and use Substance wellness.

Behavioral health: health: Behavioral A state of mental/emotional being and/or choices and actions that affect affect that actions and choices and/or being mental/emotional of state A

rooms for those who are severely intoxicated or dangerously ill (CSAT, 2005). (CSAT, ill dangerously or intoxicated severely are who those for rooms

Acute care: S care: Acute hort-term care provided in intensive care units, brief hospital stays, and emergency emergency and stays, hospital brief units, care intensive in provided care hort-term

a relationship based on mutual communication and trust (AHRQ, 2011). (AHRQ, trust and communication mutual on based relationship a 2017 , 13 December

finding providers who meet the needs of individual patients and with whom patients can develop develop can patients whom with and patients individual of needs the meet who providers finding

health care system, getting access to sites of care where patients can receive needed services, and and services, needed receive can patients where care of sites to access getting system, care health

outcomes. Attaining good access to care requires three discrete steps: gaining entry into the the into entry gaining steps: discrete three requires care to access good Attaining outcomes.

Access to care: to Access , 2017 , 13 December December health best 13the , 2017achieve to services health personal of use timely the Having

, 2017 CoordinatedDecember care: Integrating13 the efforts of medical, behavioral health, and social service providers while addressing a person’s health and wellness (CIHS, n.d.).

Coordinated specialty care: A type of treatment for first-episode psychosis that uses a team

, 2017 , of specialists who work with the client to create a personal treatment plan. The specialists 13 December offer psychotherapy, medication management, CSC case management, family education/support, and supported employment/education, depending on the person’s needs and preferences. The client and the team work together to make treatment decisions, involving family members as much as possible (NIMH, n.d.).

Crisis services (also known as crisis care or crisis continuum): A continuum of services that are provided to people experiencing a psychiatric emergency. The primary goal of these services is to stabilize and improve psychological symptoms of distress and to engage people in an appropriate treatment service to address the problem that led to the crisis. Core crisis services

include 24-hour crisis stabilization/observation beds, short-term crisis residential services and

crisis stabilization,Families mobile and crisisCaregivers services, 24/7 crisis hotlines, warm lines, psychiatric advance

directiveWorks statements, for and All peer People crisis services Living (SAMHSA, With 2014). SMI and SED and Their

CulturalThe appropriateness: Way Forward: In the context Federal of public Action health, sensitivityfor a System to the differences That among

ethnic, racial, and/or linguistic groups and awareness of how people’s cultural background, Caregivers and Families beliefs, traditions, socioeconomic status, history,Their andand other factorsSED and affect theirSMI needsWith and howLiving People All for Works

Coordinating Committee they respond to services. Generally used to describe That interventionsSystem ora practicesfor (SAMHSA,Action n.d.).Federal Forward: Way The

Culturally competent treatment: Cultural competence is the ability to interact effectively with

people Seriousof different cultures. Mental In practice, both Illnessindividuals and organizations can be culturally

competent. Culture is a term that goes beyond just race or ethnicity. It can also refer to suchCommittee Coordinating characteristicsInterdepartmental as age, gender, sexual orientation, disability, religion, income level, education, geographical location, or profession. Cultural competence means being respectful and Illness responsive Mental Serious

to the health beliefs and practices—and cultural and linguistic needs—of diverse population

groups. Developing cultural competence is an evolving, dynamic process that takes time and

occurs along a continuum (SAMHSA, 2016a). Interdepartmental

Engagement: A client’s commitment to and maintenance of treatment in all of its forms. A successful engagement program helps clients view the treatment facility as an important resource

(CSAT, 2005).

Evidence-based practice: A practice that is based on rigorous research that has demonstrated effectiveness in achieving the outcomes that it is designed to achieve (SAMHSA, n.d.).

Fidelity: Occurs when implementers of a research-based program or intervention (e.g., teachers, clinicians, counselors) closely follow or adhere to the protocols and techniques that are defined as

part of the intervention (SAMHSA, n.d.).

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operates according to the premise that youth are fundamentally different from adults, both in in both adults, from different fundamentally are youth that premise the to according operates

adjudications, dispositions, placement, probation, and reentry—the juvenile justice process process justice juvenile reentry—the and probation, placement, dispositions, adjudications,

criminal justice system in many ways—processes include arrest, detainment, petitions, hearings, hearings, petitions, detainment, arrest, include ways—processes many in system justice criminal

criminal act are typically processed through a juvenile justice system. While similar to the adult adult the to similar While system. justice juvenile a through processed typically are act criminal

Juvenile justice system: system: justice Juvenile Youth under age 18 who are accused of committing a delinquent or or delinquent a committing of accused are who 18 age under Youth

systems. Justice system: system: Justice

Term meant to be inclusive of both the criminal justice and juvenile justice justice juvenile and justice criminal the both of inclusive be to meant Term

the criminal justice system while also addressing issues of public safety (SAMHSA, 2015). 2015). (SAMHSA, safety public of issues addressing also while system justice criminal the

community-based diversion services designed to keep people with behavioral health issues out of of out issues health behavioral with people keep to designed services diversion community-based

of array an providing by system justice criminal the in, involvement of risk at or in, involved Justice diversion program: diversion Justice

A program that addresses the behavioral health needs of people people of needs health behavioral the addresses that program A Interdepartmental

existing condition (treatment intervention) (SAMHSA, n.d.). n.d.). (SAMHSA, intervention) (treatment condition existing

intervention), promote a desirable outcome (promotion intervention), or alter the course of an an of course the alter or intervention), (promotion outcome desirable a promote Illness intervention), Mental Serious

Intervention: Intervention: Interdepartmental Interdepartmental Interdepartmental(preventive outcome undesirable an prevent to intended approach or strategy A

Coordinating Committee Committee Coordinating health, and related needs of a client, and is the preferred model of treatment (CSAT, 2005). 2005). (CSAT, treatment of model preferred the is and client, a of needs related and health,

It recognizes the need for a unified treatment approach to meet the meet to approach treatment unified a for need the recognizes It substance abuse, mental mental abuse, substance Serious Mental Illness Illness Mental Serious Serious Mental Illness

are combined within the context of a primary treatment relationship or service setting. setting. service or relationship treatment primary a of context the within combined are disorders

Integrated treatment: treatment: Integrated Any mechanism by which treatment interventions for interventions treatment which by mechanism Any co-occurring co-occurring Coordinating Committee Committee Coordinating Coordinating Committee That System a for Action Federal Forward: Way The

Works for All People Living With SMI and SED and Their Their and SED and SMI With Living People All for Works facility, such as a hospital or skilled nursing facility (CMS, n.d.). n.d.). (CMS, facility nursing skilled or hospital a as such facility,

Inpatient care: care: Inpatient Health care that a person receives when admitted as an inpatient to a health care care health a to inpatient an as admitted when receives person a that care Health Caregivers and Families

The Way Forward: Federal Action for a System That That System a for Action Federal Forward: Way The The Way Forward: Federal Action for a System That

Works for All People Living With SMI and SED and Their Their and SED and SMI With Living People All for Works Works for All People Living With SMI n.d.). and SED(SAMHSA, andmodel its Their to fidelity

hours, and an optimal length of treatment) to ensure the intervention is implemented with with implemented is intervention the ensure to treatment) of length optimal an and hours,

Families and Caregivers Caregivers and Families service Families or treatment andof Caregiversnumber explicit an curriculum, defined a (e.g., components structured and

designed to achieve a specific purpose. An intervention should have specified goals, objectives, objectives, goals, specified have should intervention An purpose. specific a achieve to designed

Implementation: Implementation: A planned, coordinated group of activities, processes, and procedures procedures and processes, activities, of group coordinated planned, A

Doubled up: Doubled • Staying with friends or family temporarily (SAMHSA, 2017c) (SAMHSA, temporarily family or friends with Staying

Sheltered: • Staying in emergency shelters or transitional housing transitional or shelters emergency in Staying

buildings

Unsheltered: • Living on the streets, camping outdoors, or living in cars or abandoned abandoned or cars in living or outdoors, camping streets, the on Living

homelessness may find themselves in one of the following groups: following the of one in themselves find may homelessness 2017 , 13 December

Homelessness: Homelessness: Not being able to find a stable and safe place to stay. People experiencing experiencing People stay. to place safe and stable a find to able being Not

definition for psychosis) (NIMH, n.d.). n.d.). (NIMH, psychosis) for definition

First-episode psychosis: psychosis: First-episode , 2017 , 13 December December (see 13psychosis ,of 2017 episode an experiences person a time first The

, 2017 terms ofDecember level of responsibility 13 and potential for rehabilitation. The primary goals of the juvenile justice system, in addition to maintaining public safety, are skill development, habilitation, rehabilitation, addressing treatment needs, and successful reintegration of youth into the

community (youth.gov, n.d.).

, 2017 , December 13 December Major depression: A mood disorder. It occurs when feelings of sadness, loss, anger, or frustration get in the way of a person’s life over a long period of time. It also changes how a person’s body works (MedlinePlus, n.d.-b).

Outpatient: A structured service setting or program that provides ambulatory (not overnight) care delivered in a specialty mental health facility/hospital/center/clinic, specifically for the treatment of mental health clients. Care is generally provided for visits of 3 hours or less in duration and 1 or 2 days per week (SAMHSA, 2017a).

Outreach strategies (mental health): Approaches that actively seek out people in a community

who mayFamilies have substance and use Caregivers disorders and engage them in substance abuse treatment (CSAT,

2005). Works for All People Living With SMI and SED and Their

Peer: InThe the context Way of Forward: peer support, Federala peer is a person Action who has for lived a Systemexperience with That a

psychiatric, traumatic, and/or addiction challenge, and may benefit from peer support (CIHS, Caregivers and Families n.d.). Their and SED and SMI With Living People All for Works

Coordinating Committee Peer support: The process of giving and receiving That nonclinical assistanceSystem a for to achieveAction long-term Federal Forward: Way The

recovery from severe psychiatric, traumatic, or addiction challenges. This support is provided by

peer supporters—peopleSerious who Mental have “lived experience” Illness and have been trained to assist others in

initiating and maintaining long-term recovery and enhancing the quality of life for people Committee and Coordinating their families.Interdepartmental Peer support services are inherently designed, developed, delivered, evaluated, and supervised by peers in long-term recovery (CIHS, n.d.). Illness Mental Serious

Person-centered care (also known as patient-centered care): Means consumers have control

over their services, including the amount, duration, and scope of services, as well as choice of Interdepartmental providers. Person-centered care also is respectful and responsive to the cultural, linguistic, and

other social and environmental needs of the individual (SAMHSA, 2016b).

Poverty: The Census Bureau uses a set of income thresholds that vary by family size and composition to determine who is in poverty. If a family’s total income is less than the family’s threshold, then that family and every person in it is considered in poverty (United States Census Bureau, 2017).

Practice standards: Rules or guidelines used as the basis for informed decision-making about acceptable work performance and practices. They are established by an authoritative entity through a collaborative process with input from a wide range of people who perform the

work. Standards are based on values, ethics, principles, and competencies. Having a core set

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disorganized or abnormal motor behavior. Although these symptoms are chronic and severe, severe, and chronic are symptoms these Although behavior. motor abnormal or disorganized

experiences that can include: delusions, hallucinations, disorganized thinking, and grossly grossly and thinking, disorganized hallucinations, delusions, include: can that experiences

“thought disorder”), and is characterized by a range of cognitive, behavioral, and emotional emotional and behavioral, cognitive, of range a by characterized is and disorder”), “thought

Schizophrenia: Schizophrenia: A brain disorder that impacts the way a person thinks (often described as a a as described (often thinks person a way the impacts that disorder brain A

variation (DOJ, 2017). 2017). (DOJ, variation

the day, typically 22 hours or more. Even this definition, however, leaves substantial room for for room substantial leaves however, definition, this Even more. or hours 22 typically day, the

alone or with another inmate; and (3) inability to leave the room or cell for the vast majority of of majority vast the for cell or room the leave to inability (3) and inmate; another with or alone

population, whether voluntary or involuntary; (2) placement in a locked room or cell, whether whether cell, or room locked a in placement (2) involuntary; or voluntary whether population, Restrictive housing: housing: Restrictive

Any type of detention that involves (1) removal from the general inmate inmate general the from removal (1) involves that detention of type Any

n.d.). (SAMHSA, community and purpose, home, Initiative, SAMHSA has delineated four major dimensions that support a life in recovery: health, health, recovery: in life a support that dimensions major four delineated has SAMHSA Initiative,

self-directed life, and strive to reach their full potential. Through the Recovery Support Strategic Strategic Support Recovery the Through potential. full their reach to strive and life, self-directed Interdepartmental

Recovery: Recovery: A process of change through which people improve their health and wellness, live a a live wellness, and health their improve people which through change of process Illness A Mental Serious

Interdepartmental Interdepartmental Interdepartmental 2005). (CSAT, life everyday in function to ability person’s that with capacity, ability to recognize reality, and relationships to others to such a degree that it interferes interferes it that degree a such to others to relationships and reality, recognize to ability capacity,

Psychosis: Psychosis: A mental disorder that is characterized by distinct distortions of a person’s mental mental person’s a of distortions distinct by characterized is that disorder mental A Committee Coordinating

Serious Mental Illness Illness Mental Serious Serious Mental Illness behavioral, or social), organ system, or diagnosis (CIHS, n.d.). n.d.). (CIHS, diagnosis or system, organ social), or behavioral,

Coordinating Committee Committee Coordinating Coordinating(biological, origin problem by Committeelimited not That patient) System a for “undifferentiated” (the Action concern Federal health or Forward: Way The comprehensive first contact and continuing care for people with any undiagnosed sign, symptom, symptom, sign, undiagnosed any with people for care continuing and contact first comprehensive

Primary care: care: Primary The care provided by physicians specifically trained for and skilled in in skilled and for trained Their specifically and SED physicians by and provided SMI care With The Living People All for Works

Families and Caregivers Caregivers and Families The Way Forward: Federal Action for a System That That System a for Action Federal Forward: Way The The Way Forward: Federal Action for a System That n.d.).

Works for All People Living With SMI and SED and Their Their and SED and SMI With Living People All for Works Works(SAMHSA, for All problems) Peopleuse Livingsubstance with Withparents of SMI andchildren the SEDexample, and(for Theirfactors for mental health disorders or substance use disorders because of highly correlated risk risk correlated highly of because disorders use substance or disorders health mental for

Selective prevention strategies prevention Selective •

Families and Caregivers Caregivers and Families risk Families higher at andbeing as Caregiversviewed groups specific on focus

levels of a particular disorder. particular a of levels

problems in people who may be showing early signs but are not yet meeting diagnostic diagnostic meeting yet not are but signs early showing be may who people in problems

Indicated prevention strategies prevention Indicated • focus on preventing the onset or development of of development or onset the preventing on focus

development of behavioral health disorders. health behavioral of development

community, school, or neighborhood), with messages and programs to prevent or delay the the delay or prevent to programs and messages with neighborhood), or school, community,

Universal prevention strategies prevention Universal • address the entire population (such as national, local local national, as (such population entire the address

health disorders. The Institute of Medicine has defined three types of preventions strategies: preventions of types three defined has Medicine of Institute The disorders. health

Prevention strategies: strategies: Prevention

Approaches that seek to prevent the onset of physical and behavioral behavioral and physical of onset the prevent to seek that Approaches 2017 , 13 December

competencies, and 3) ethical guidelines or code of ethics (CIHS, n.d.). n.d.). (CIHS, ethics of code or guidelines ethical 3) and competencies,

have three basic components: 1) practice guidelines, 2) identification and description of core core of description and identification 2) guidelines, practice 1) components: basic three have , 2017 , 13 December Decembergenerally 13standards , 2017Practice practice. of field a legitimize to way important one is standards of

, 2017 significantlyDecember impairing 13 occupational and social functioning, recovery is possible (SAMHSA, n.d.).

Service utilization: A measure of whether the program is reaching the appropriate target

population (SAMHSA, n.d.). , 2017 ,

Serious emotional disturbance (SED): Refers to children and youth who have had a 13 December diagnosable mental, behavioral, or emotional disorder in the past year, which resulted in functional impairment that substantially interferes with or limits the child’s role in family, school, or community activities (SAMHSA, 2017d).12

Serious mental illness (SMI): Refers to people age 18 or older, who currently or at any time during the past year have had a diagnosable mental, behavioral, or emotional disorder of sufficient duration to meet diagnostic criteria specified in the diagnostic manual of the American Psychiatric Association that has resulted in functional impairment, which substantially interferes

with or limits one or more major life activities. Serious mental illnesses include major depression,

schizophrenia,Families and bipolar and disorder,Caregivers and other mental disorders that cause serious impairment

(SAMHSA,Works 2017d). for All People Living With SMI and SED and Their

SolitaryThe confinement: Way Forward:See “restrictive Federal housing” (DOJ,Action 2017). for a System That Families and Caregivers Caregivers and Families

Stigma: A negative association attached to anTheir activityand or condition.SED and A causeSMI of shameWith or Living People All for Works

embarrassment (CSAT, 2005). Coordinating Committee The Way Forward: Federal Action for a System That That System a for Action Federal Forward: Way The

Sustainability: The long-term survival and continued effectiveness of an intervention (SAMHSA,

n.d.). Serious Mental Illness

Symptomatology: The combined symptoms or signs of a disorder or disease (SAMHSA, n.d.).Committee Coordinating Interdepartmental Transition-age youth: People between ages 16 to 25. People in this age group are at highIllness risk for Mental Serious

substance use and mental health disorders, but they are also among those least likely to seek help

(Development Services Group, Inc., 2016). Interdepartmental Treatment guidelines: Descriptions of best practices for assessment or management of a health

condition (CIHS, n.d.).

12 This is different from the IDEA definition of emotional disturbance; for detail on the criteria for emotional disturbance under

IDEA, see http://idea.ed.gov/explore/view/p/,root,regs,300,A,300.8,.html.

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