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 ecember 13 TableD of Contents

Section Page

7 1 20 , 3 1 ber m e c e D

Introduction...... 1

Role of the ISMICC...... 2

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

ISMICC Vision Statement...... 5

Families and Caregivers

for All People Living With SMI and SED and Their

WorksRecommendations From the Non-Federal Members Summary (See Chapter 4 for Full

he Way Forward: Federal Action for a System That T Recommendations)...... 5

rs rs e iv g e ar C d n a s e i l Fami

ir e h T d n a D SE d n a SMI With ing v i L le p o Pe l Al or f

Focus 1: Strengthen Federal Coordination to Improve Care...... 5 Works

Coordinating Committee t t a h T em t s y S a for n ctio A eral d Fe : d ar w r o F y a W e h T

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

Serious Mental Illness

ee t Commit ating n i d

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

departmental

InterOffered...... 6

Illness Mental ious r Se

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

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

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 partmental e d Inter

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 ious r Se

partmental e d Inter 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 ee t Commit ating n i d Coor

Illness Mental ious r Se Serious Mental Illness

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

. t a h T em t s y S a for n ctio A eral d Fe : d ar w r o F y a W e h T Substance Abuse and Mental Health Services Administration: Support of Support Administration: Services Health Mental and Abuse Substance ee t Commit ating n i d Coor Coor dinating Committee

ir e h T d n a D SE d n a SMI With ing v i L le p o Pe l Al or f Works

Challenges of SMI and SED and SMI of Challenges 42 ...... rs e iv g e ar C d n a s e i l Fami

t t a h T em t s y S a for n ctio A eral d Fe : d ar w r o F y a W e h T 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

ir e h T d n a D SE d n a SMI With ing v i L le p o Pe l Al or f Works Works f or All People Living With SMI and SED and Their

...... Presentations Federal rs rs e iv g e ar C d n a s e i l Fami 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

7 1 20 , 3 1 ber m e c e D

Page Section 7 1 20 , 3 1 ber m e c e D December 13, 2017 (continued) Contents of Table

, 2017 ecember 13 D Areas to Be Explored by the ISMICC...... 57

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

7 1 20 , 3 1 ber m e c e D 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

for All People Living With SMI and SED and Their

ChapterWorks 4: Recommendations From Non-Federal ISMICC Members...... 77

The Way Forward: Federal Action for a System That

rs rs e iv g e ar C d n a s e i l

Full Recommendations...... 78 Fami ir e h T d n a D SE d n a SMI With ing v i L le p o Pe l Al or f Works

Coordinating Committee

t t a h T em t s y S a for n ctio A eral d Fe : d ar w r o F y a W e h

Focus 1: Strengthen Federal Coordination to Improve Care...... 78 T

Serious Mental Illness

ee t Commit ating n i d

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

Interdepartmental

Illness Mental ious r Focus 3: Treatment and Recovery: Close the Gap Between What Works and What Is Se

Offered...... 84

partmental e d Inter 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. partmental e d Inter

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 Illness 1. Mental ious r Se partmental e d Inter Interdepartmental

ee t Commit Figures ating n i d Coor

Illness Mental ious r Se 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.

ee t Commit ating n i d Coor Coor dinating Commit t a h T em t s y tS ee a for n ctio A eral d Fe : d ar w r o F y a W e h T

ir e h T d n a D SE d n a SMI With ing v i L le p o Pe l Al or f Works

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

. rs e iv g e ar C d n a s e i l Fami

t t a h T em t s y S a for n ctio A eral d Fe : d ar w r o F y a W e h T 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 ...... ir e h T d n a D SE d n a SMI With ing v i L le p o Pe l Al or f Works Works for Al. l People Living With SMI and SED and Their

rs rs e iv g e ar C d n a s e i l Fami 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

7 1 20 , 3 1 ber m e c e D

Page Appendices 7 1 20 , 3 1 ber m e c e D December 13, 2017 (continued) Contents of Table

, 2017 ecember 13 1.4. D Receipt of 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

7 1 20 , 3 1 ber m e c e

1.5. Past Year Major Depressive Episode Among Adolescents Ages 12 to 17 in the United D 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

for All People Living With SMI and SED and Their 3.1. WorksGovernment and Private Funding Sources for Mental Health (MH) and Substance

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

The Way Forward: Federal Action for a System That

rs rs e iv g e ar C d n a s e i l Fami

ir e h T d n a D SE d n a SMI With ing v i L le p o Pe l Al or f Works

Coordinating Committee t t a h T em t s y S a for n ctio A eral d Fe : d ar w r o F y a W e h T

Serious Mental Illness

ee t Commit ating n i d Coor

Interdepartmental

Illness Mental ious r Se

partmental e d Inter

Illness Mental ious r Se partmental e d Inter Interdepartmental ee t Commit ating n i d Coor Illness Mental ious r Se Serious Mental Illness ee t Commit ating n i d Coor Coordinating Commit t a h T em t s y tS ee a for n ctio A eral d Fe : d ar w r o F y a W e h T ir e h T d n a D SE d n a SMI With ing v i L le p o Pe l Al or f Works rs rs e iv g e ar C d n a s e i l Fami t t a h T em t s y S a for n ctio A eral d Fe : d ar w r o F y a W e h T The Way Forward: Federal Action for a System That ir e h T d n a D SE d n a SMI With ing v i L le p o Pe l Al or f Works Works for All People Living With SMI and SED and Their rs rs e iv g e ar C d n a s e i l Fami Families and Caregivers

7 1 20 , 3 1 ber m e c e D

7 1 20 , 3 1 ber m e c e D December 13, 2017

, 2017 ecember 13

IntroductionD

7 1 20 , 3 1 ber m e c e In 2003, the President’s New Freedom Commission on Mental Health concluded that America’s D 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

for All People Living With SMI and SED and Their

WorksThe Health Care System Has Failed to Address the Needs of Persons

he Way Forward: Federal Action for a System That

T With Serious Mental Illnesses (SMI) and Serious Emotional Disturbances (SED) rs rs e iv g e ar C d n a s e i l Fami

ir e h T d n a D SE d n a SMI With ing v i L le p o Pe l Al or f Works

Coordinating Committee t t a h T em t s y S a for n ctio A eral d Fe : d ar w r o F y a W e h T

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

rious Mental Illness Se had attempted suicide prior to receiving services2

ee t Commit ating n i d

4.2% Coor

Approximate number of departmental InterPercentage of the adult population, age 18

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

3 Illness Mental ious r

2 million annually to U.S. jails Se

Sources

1 CBHSQ, 2017a partmental e d Nearly one in four 2 CMHS/SAMHSA, 2016 Only about one in three Inter 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

• partmental e d Inter

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 ious r Se partmental e d Inter InterMental Serious departmentalInterdepartmental the authorizes 114-255) Law (Public Act Cures Century 21st The

ee t Commit ating n i d Coor Illness Mental ious r Se Serious Mental Illness ISMICC the of Role

ee t Commit ating n i d Coor Coordinating Commit t Act. a h T em Education t s y tS ee a Disabilities for with n ctio A Individuals eral the d and Fe : Act d ar w r o F y a W e h T 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 ir e h T supports d n a and D SE services d n a access don’t SMI they With ing v i L discrimination, le p and o Pe l Al or f 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 rs e iv g communities. e ar C d n a s e i l Fami

t t a h T em t s y S a for n ctio A eral d Fe : d ar w r o F y a W e h T T hetheir Win ay Fvalued orand ward: embraced Fe deralbeing from Actionconditions for ahealth Sysmental t em Tserious hawith t adults and ir e h T d n a D SE d n a SMI With ing v i L le p o Pe l Al or f Works Works youth, for Alchildren, l Peoplepreventing Lcare, i vinghealth Withand SMIwork, aschool, nd SEincluding D andsetting, Thevery eof ir part

rs rs e iv g e ar C d n a s e i l Fami 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 Marilyn (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 7 1 20 , 3 1 ber m e c e D

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 7 1 20 , 3 1 ber m e c e D December 13, 2017 comorbid unemployment, supports, social Poor

, 2017 ecember 13 The ISMICCD is chaired 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

7 1 20 , 3 1 ber m e c e Committee will work across HHS and the federal government so Americans with SMI and SED are D 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

lies and Caregivers will be Famiinformed and strengthened by the • Secretary of the Department of Defense

participation of non-federal members, • Secretary of the Department of Housing and Urban

for All People Living With SMI and SED and Their

includingWorks national experts on health Development

• Secretary of the Department of Education

he Way Forward: Federal Action for a System That

care research,T mental health providers, • Secretary of the Department of Labor

rs rs e iv g e ar C d n a s e i l advocates, and people with mental health • Administrator of the Centers for Medicare & Medicaid Fami

Services

ir e h T d n a D SE d n a SMI With ing v i L le p o Pe l Al or f conditions and their families and caregivers. Works

The ISMICC is currently authorized through • Commissioner of the Social Security Administration

Coordinating Committee t t a h T em t s y S a for n ctio A eral d Fe : d ar w r o F y a W e h

2022, at which time the Secretary of HHS T

will submit a recommendation to Congress

rious Mental Illness about whetherSe to extend the ISMICC.

ee t Commit ating n i d Coor

departmental The non-federalInter ISMICC members have firsthand experience with the mental health service

Illness Mental ious r system, and knowledge of what barriers exist for people who are seeking help. Moreover, the non- Se

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

and improve lives, in partnership with the federal members.

partmental e d Inter 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 partmental e d Inter

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 ious r Se

partmental e d Inter to Interpartnerships departmentalpromote will and coordination cross-sector for model a as serve will ISMICC The

ee t work. Commit Committee’s ating n i d Coor

Illness Mental ious r Se Se the rof iousprogress 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

ee t Commit ating n i d Coor Coordinating Commit t a h T em improving t s for y tS ee a for n opportunities ctio future A eral identify d will Fe : and d ar w r o F y a W e h T

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

availability and affordability of care of affordability and availability ir e h T d n a D SE d n a SMI With ing v i L le p o Pe l Al or f 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 rs e final iv g The e ar C d n a s e i l Fami

t t a h T em t s y S a for n ctio A eral d Fe : d ar w r o F y a W e h T The Way Forward: Fesystems deral 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

ir e h T d n a D SE d n a SMI With ing v i L le p o Pe l Al or f Works WorksSED and SMI forwith Alpeople l for Pe care opleimprove 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.

rs rs e iv g e ar C d n a s e i l Fami 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 7 1 20 , 3 1 ber m e c e D 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 7 1 20 , 3 1 ber m e c e D December 13, 2017 Congress to Report ISMICC 2017 The

, 2017 ecember 13 ISMICCD Vision Statement

Federal interdepartmental leadership, with genuine collaboration and shared accountability of

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

7 1 20 , 3 1 ber m e c e supports a mental health system that successfully addresses the needs of all individuals living D 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

lies and Caregivers

1.1. FamiImprove ongoing interdepartmental coordination under the guidance of the Assistant

for All People Living With SMI and SED and Their WorksSecretary for Mental Health and Substance Use.

he Way Forward: Federal Action for a System That

1.2. TDevelop and implement an interdepartmental strategic plan to improve the lives of people rs rs e iv g e ar C d n a s e i l

with SMI and SED and their families. Fami

ir e h T d n a D SE d n a SMI With ing v i L le p o Pe l Al or f Works

dinating Committee

1.3. CoorCreate a comprehensive inventory of federal activities that affect the provision of services t t a h T em t s y S a for n ctio A eral d Fe : d ar w r o F y a W e h

for people with SMI and SED. T

rious Mental Illness 1.4. SeHarmonize and improve policies to support federal coordination.

ee t Commit ating n i d

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

Illness Mental ious r

1.6. Use data to improve quality of care and outcomes. Se

partmental e d 1.7. Ensure that quality measurement efforts include mental health. Inter

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 partmental e d Inter

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 ious r Se partmental e d Inter Interdepartmental

expectation. ee t national a adults Commit young ating n i d Coor 3.2.

Illness Mental ious r Se and Se ryouth, ious Mentaltransition-age youth, children, Illnessamong intervention early and screening Make

3.1.

ee t Commit ating n i d Coor CoordSED. i nand atingSMI with Commitpeople t a for h T care of em t s y tS ee continuum a for n ctio comprehensive A a eral d Provide Fe : d ar w r o F y a W e h T

Focus 3: Treatment and Recovery: Close the Gap Between What Works and What Is Offered Is What and Works What ir e h T Between d n a Gap D the SE Close d n a Recovery: SMI and With ing Treatment v i 3: L le p Focus o Pe l Al or f Works

rs rs e iv g e ar C d n a s e i l Fami 2.10.

t t a h T em t s y S a for n ctio A eral d Fe : d ar w r o F y a W e h T The Way Forwarsettings. d: Fecare deralprimary all Ain ctiooccur nto for a Sscreening ystSED emand TSMI h at Expect

2.9. ir e h T d n a D SE d n a SMI With ing v i L le p o Pe l Al or f Works Works for All People Living With SMIcaregivers. aand nd SEmembers D afamily n d ThSupport eir

rs rs e iv g e ar C d n a s e i l Fami 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 7 1 20 , 3 1 ber m e c e D

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. 7 1 20 , 3 1 ber m e c e D De cemand ber 13capacity , 20bed 17 psychiatric adequate includes that care of continuum a Develop

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

disorders.

7 1 20 , 3 1 ber m e c e 3.10. Develop national and state capacity to disseminate and support implementation of the D 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

lies and Caregivers

Famijustice system.

for All People Living With SMI and SED and Their

4.3. WorksPrepare and train all first responders on how to work with people with SMI and SED.

The Way Forward: Federal Action for a System That

rs rs e iv g e ar C d n a s e i l

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

ir e h T d n a D SE d n a SMI With ing v i L le p o Pe l Al or f

based evaluation and services. Works

Coordinating Committee

t t a h T em t s y S a for n ctio A eral d Fe : d ar w r o F y a W e h

4.5. Develop and sustain therapeutic justice dockets in federal, state, and local courts for any T

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

Serious Mental Illness

ee t Commit ating n i d

4.6. Require universal screening for mental illnesses, substance use disorders, and other Coor

behavioral health needs of every person booked into jail. Interdepartmental

Illness Mental ious r

4.7. Strictly limit or eliminate the use of solitary confinement, seclusion, restraint, or other Se

forms of restrictive housing for people with SMI and SED.

partmental e d

4.8. Reduce barriers that impede immediate access to treatment and recovery services upon Inter 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.

partmental e d Inter

ir e h T d n a D SE d n a SMI With ing v i L le p o Pe l Al or f Works Works for All People Living With SMI and SED and Their

5.8. rs rs e iv g e ar C d n a s e i l Fami Faminationwide. lies program a nd Car(CCBHC) egClinic iv ersHealth 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 7 1 20 , 3 1 ber m e c e D

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. 7 1 20 , 3 1 ber m e c e D Dechealth e mbermental 13the , 2017receive SED and SMI with people that ensure to parity enforce Fully

, 2017 ecember 13 ReferencesD

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

7 1 20 , 3 1 ber m e c e Abuse and Mental Health Services Administration. D

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

for All People Living With SMI and SED and Their President’sWorks New Freedom Commission on Mental Health. (2003). Achieving the Promise:

Transforming Mental Health Care in America. Retrieved from http://govinfo.library.unt.edu/

The Way Forward: Federal Action for a System That

rs rs e iv g e ar C d n a s e i l mentalhealthcommission/reports/FinalReport/downloads/FinalReport.pdf. Fami

ir e h T d n a D SE d n a SMI With ing v i L le p o Pe l Al or f

Steadman, H. J., Osher, F. C., Robbins, P. C., Case, B., & Samuels, S. (2009). Prevalence of serious Works

Coordinating Committee t t a h T em t s y S a for n ctio A eral d Fe : d ar w r o F y a W e h mental illness among jail inmates. Psychiatric Services, 60(6), 761-765. T

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

rious Mental Illness

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

ee t Commit ating n i d

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

departmental

U.S. DepartmentInter of Health and Human Services (HHS) Office of the Surgeon General and Illness Mental ious r

National Action Alliance for Suicide Prevention. (2012). 2012 national strategy for suicide Se

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

partmental e d

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

partmental e d Inter

7 1 20 , 3 1 ber m e c e D

7 1 20 , 3 1 ber m e c e D December 13, 2017

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

Mental Illnesses and Serious Emotional Disturbances

7 1 20 , 3 1 ber m e c e D

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

lies and Caregivers

Fami Major life activities include basic daily living skills (e.g.

diagnoses of mental disorders combined eating, bathing, dressing); instrumental living skills (e.g.,

for All People Living With SMI and SED and Their with significantWorks impairment in functioning. maintaining a household, managing money, getting

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

he Way Forward: Federal Action for a System That

T and functioning in social, family, and vocational/educa- rs rs e iv g e ar C d n a s e i l depressive disorder are the diagnoses most Fami

tional contexts.

commonly associated with SMI, but people

ir e h T d n a D SE d n a SMI With ing v i L le p o Pe l Al or f

with one or more other disorders may also fit Works

Coordinating Committee t t a h T em t s y S a for n ctio A eral d Fe : d ar w r o F y a W e h the definition of SMI if those disorders result in T

functional impairment.

rious Mental Illness

About Se1 in 25 adults has an SMI in a given year. In 2016, 4.2 percent of U.S. adults age 18 ee t Commit ating n i d

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

departmental

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

(Medley et al., 2016). Across racial and ethnic groups, people of two or more races (7.5 percent)

partmental e d and Non-Hispanic Whites (4.8 percent) had higher percentages of SMI in the past year than the Inter

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 partmental e d Inter

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 ious r Se partmental e d Inter Interhealth general and d epartmentalsubstance-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 ee number t substantial a as well Commit as other, ating n i d Coor 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

Illness Mental ious r Se Seand rious“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

ee t Commit ating n i d Coor CoorAs dinating Commit t a h T em t s y tS ee a for n ctio A eral d Fe : d ar w r o F y a W e h T

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 ir e the h T from d n Results a D SE d n a SMI With ing v i L le p o Pe l Al or f Works rs rs e iv g e ar C d n a s e i l Fami t t a h T em t s y S a for n ctio A eral d Fe : d ar w r o F y a W e h T The Way Forward: Federal Action for a System That ir e h T d n a D SE d n a SMI With ing v i L le p o Pe l Al or f Works Works for All People Living With SMI and SED and Their rs rs e iv g e ar C d n a s e i l Fami Families and Caregivers

7 1 20 , 3 1 ber m e c e D

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

1.1. Figure 7 1 20 , 3 1 ber m e c e D the Din ecemOlder beror 18 1 3, 20Age 17 Adults Among (SMI) Illness Mental Serious Year Past

, 2017 ecember 13 estimatedD 2.6 million 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

7 1 20 , 3 1 ber m e c e with a single diagnosis, as well as higher rates of violence, suicide, and homelessness” (Bellack, D 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

rs rs e iv g e ar C d n a s e i l Fami

ir e h T d n a D SE d n a SMI With ing v i L le p o Pe l Al or f Works

Coordinating Committee t t a h T em t s y S a for n ctio A eral d Fe : d ar w r o F y a W e h T

Serious Mental Illness

ee t Commit ating n i d Coor

Interdepartmental

Illness Mental ious r Source: Adapted from Figure 69 of: Substance Abuse and Mental Health Services Administration. (2017). Key substance use and mental Se

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.

partmental e d

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

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

partmental e d Inter

Illness Mental ious r Se partmental e d Inter Interdepartmental ee t Commit ating n i d Coor

Illness Mental ious r Se Serious Mental Illness

ee t Commit ating n i d Coor Coor2016 dinatingPercentages, Commit t Disorders: a h T Use em t s y tSubstance S ee a and for n Illness ctio A Mental eral d Fe : d ar w r o F y a W e h T 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 ir e h T d n a D SE d n a SMI With ing v i 1.4. L le p Figure o Pe l Al or f Works rs rs e iv g e ar C d n a s e i l Fami t t a h T em t s y S a for n ctio A eral d Fe : d ar w r o F y a W e h T The Way Forward: Federal Action for a System That

ir e h T d n a D SE d n a SMI With ing v i L le p o Pe l Al or f 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 rs rs e iv g e ar C d n a s e i l Fami health: Famiand use drug l ieon s asurvey nd national C ar2016 egivers

7 1 20 , 3 1 ber m e c e D

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

1.3. Figure 7 1 20 , 3 1 ber m e c e D or 18 D ecAge e mberAdults 13, 201Among 7 Year Past the in Services Health Mental of Receipt

, 2017 ecember 13 EffectiveD treatment 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

7 1 20 , 3 1 ber m e c e those with mental health conditions, including SMI and SED, who are Medicaid eligible and D 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.

lies and Caregivers

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

for All People Living With SMI and SED and Their

WorksMental Health Systems in 20164

The Way Forward: Federal Action for a System That

rs rs e iv g e ar C d n a s e i l Fami Percent of State MH

Population Who Receive Practice in States ir e h T d n a D SE d n a SMI With ing v i L le p o Pe l Al or f

Evidence-Based Practice Target Population for Service that Report Data Works

Coordinating Committee t t a h T em t s y S a for n ctio A eral d Fe : d ar w r o F y a W e h Medication management Adults and youth with SMI/SED 32.0% T

Illness self-management Adults with SMI 19.0%

Dual diagnosis treatment Adults with SMI and SUD 10.5% rious Mental Illness

AssertiveSe community treatment Adults with SMI 2.1% ee t Commit ating n i d

Supported employment Adults and transition-age youth 2.1% Coor

departmental

Inter with SMI

Illness Mental ious r Supported housing Adults and transition-age youth 3.1% Se

with SMI

Therapeutic foster care Children and youth with SED 1.5% partmental e d

Multi-systemic therapy Children and youth with SED 3.6% Inter 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 partmental e d Inter

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 ious r Se

partmental e d Inter 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 ee notable t generated also have Commit services ating n i d Coor

Illness Mental ious r Se Sesupport riouspeer 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 ee t Commit ating n i d Coor Coorpromote to dindemonstrated ating been have Commit t services a h T support em t s Peer y tS ee 2016). a for n Vecchio, del ctio & A eral (Myrick d Fe : possible d ar w r o F y a W e h T

mental health system and should be included as a part of a full continuum of services, whenever whenever services, of continuum full ir a e h of T part d a n a as D SE included d be n a should SMI and With system ing v i health L le p mental o Pe l Al or f 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 rs e iv g professional e ar C d n a s e i l Fami

t t a h T em t s y S a for n ctio A eral d Fe : d ar w r o F y a W e h T The Waylicensed Forwarincluding d: Feproviders, d eralservice Actiohealth n formental of a Systemcategories are Ththere a t Also, 2009). ir e h T d n a D SE d n a SMI With ing v i L le p o Pe l Al or f Works WorksMorrissey, f& or AllHolzer, PeopKonrad, le LEllis, iving With(Thomas, SMItherapists anfamily d and SE D amarriage ndand Their counselors,

rs rs e iv g e ar C d n a s e i l Fami Familiesprofessional and licensed C aregworkers, iverssocial 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 7 1 20 , 3 1 ber m e c e D

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, 7 1 20 , 3 1 ber m e c e D Dcare e cembermanaged 13, 2017 Medicaid-contracted and programs Medicaid state from services psychiatric for

, 2017 ecember 13 AdultsD with SMI are 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

7 1 20 , 3 1 ber m e c e Osher, Robbins, Case, & Samuels, 2009). Among likely to find employment.” D 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

lies and Caregivers competencyFami restoration can lead to waits for pretrial jail detainees that may average weeks, or

for All People Living With SMI and SED and Their even a yearWorks or longer (Fuller, Sinclair, Lamb, Cayce, & Snook, 2017). Only about one in three people

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

he Way Forward: Federal Action for a System That

contribute,T in turn, to higher rates of recidivism. Specialty courts for people with mental or substance rs rs e iv g e ar C d n a s e i l

use disorders are promising, but their availability is extremely limited. Fami

ir e h T d n a D SE d n a SMI With ing v i L le p o Pe l Al or f Works

Coordinating Committee

t t a h T em t s y S a for n ctio A eral d Fe : d ar w r o F y a W e h

Many adults with SMI are unemployed. Only 36 percent (CBHSQ, 2017a) of people with SMI T

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

rious Mental Illness

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

ee t Commit ating n i d

disability applications in Federal Fiscal Year 2016 to the Social Security Administration were based Coor

departmental on mentalInter health, as were 64.56 percent of childhood disability applications (Social Security

Illness Mental ious r Administration, 2017). Se

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

partmental e d

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

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 partmental e d Inter

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 ious r Se

partmental e d Inter Interare costs dmedical epartmentalHigh 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 ee t services. or Commit medications health ating n i d Coor

Illness Mental ious r Se Serbehavioral iousfor 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 ee t Commit ating n i d Coor Coorthree to two by d inatingincreased are costs Commitcare t a h Health T em t s y tS ee a for n ctio A eral d Fe : d ar w r o F y a W e h T ir e h T d n a D SE d n a SMI With ing v i L le p o Pe l Al or f Works

for the general populations (Hor & Taylor, 2010). 2010). Taylor, & (Hor populations rs general e iv the g for e ar C d n a s e i l Fami

t t a h T em t s y S a for n ctio A eral d Fe : d ar w r o F y a W e h T Tthan he Whigher aytimes F20 o rwrate a ar d: Fesuicide, by d eraldies 20 Ain 1 ctio n for aschizophrenia, Sywith s tem Tdiagnosed h at adults Among

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

ir e h T d n a D SE d n a SMI With ing v i L le p o Pe l Al or f Works Works for All People Living 25 Withbe to SMI estimated a nis d SEdisorder D anbipolar d or Their depression

ISMICC)

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

— rs rs e iv g e ar C d n a s e i l Fami Famithe to licomments e s public andthrough Care(submitted gAnne ivers

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 7 1 20 , 3 1 ber m e c e D

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 7 1 20 , 3 1 ber m e c e D Dthan ecemore m beryear, 1the 3 , of 2017 period some For year. the during insurance private had percent) (51.5 half

, 2017 ecember 13 threat ofD harm to self 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

7 1 20 , 3 1 ber m e c e access care when decompensated until they have done he has endured this cruel disease. No, instead D 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.”

lies and Caregivers PlanningFami and Evaluation and the National Institute of

— Judy (submitted through public comments to the

Mental Health to evaluate the effect of various aspects ISMICC)

for All People Living With SMI and SED and Their

of AOTWorks implementation in 17 communities throughout

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

rs rs e iv g e ar C d n a s e i l

to address some of these issues, such as advance directives and other forms of consumer-directed Fami

ir e h T d n a D SE d n a SMI With ing v i L le p o Pe l Al or f care planning such as wellness recovery action plans. Works

Coordinating Committee t t a h T em t s y S a for n ctio A eral d Fe : d ar w r o F y a W e h

Caregivers of people with mental illness face complex situations and a high burden of T

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

rious Mental Illness

8.4 millionSe Americans provide care to an adult with an emotional or mental health issue, mainly

ee t Commit ating n i d related to SMI (NAC, 2016). It found that, for nearly one in five mental health caregivers, taking Coor

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

care forInter more than 10 years (NAC, 2016). Many people with SMI are financially dependent on Illness Mental ious r family and friends. Caregivers also bear a significant emotional burden, and often report feeling Se

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

partmental e d

problems, as nearly 4 in 10 caregivers report difficulty taking care of their own health, and about Inter 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,

Adapted 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 Adapted 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 partmental e d Inter

child. the of age the on depending varies

reflects the nature of childhood; role functioning in family, school, and community naturally naturally community and school, family, 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 ious r Se

partmental e d Inter Interdepartmental have to considered not are disorder developmental

intellectual/ ee an t or disorder use Commit substance a is ating n i d Coor - expe disorders as people young in address to

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

Illness Mental ious r Se Seimportant as riousjust 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

ee t Commit ating n i d Coor Coorhave often youth dand inchildren atingby experienced Commit t a h T em t s y tS ee a for n ctio A eral d Fe : d ar w r o F y a W e h T

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 ir not e h T d n a D SE d n a SMI With ing v i L le p o Pe l Al or f 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 rs e iv g e ar C d n a s e i l Fami

others that are less commonly seen in children than than children in seen commonly less are that others t t a h T em t s y S a for n ctio A eral d Fe : d ar w r o F y a W e h T Theconcerns Whave ay FISMICC othe r wof ard:members FeThe deral Action for a System That

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

ir e h T d n a D SE d n a SMI With ing v i L le p o Pe l Al or f 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

rs rs e iv g e ar C d n a s e i l Fami 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

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

Serious Emotional Disturbances Emotional Serious

of care conversations (NAC, 2016). (NAC, conversations care of 7 1 20 , 3 1 ber m e c e D

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 7 1 20 , 3 1 ber m e c e D Decembercaregivers 13many , 2017 management, disease day-to-day in involvement their Despite 2016). (NAC,

, 2017 ecember 13 The NationalD Comorbidity 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/

7 1 20 , 3 1 ber m e c e or distress was 22.2 percent. Lifetime prevalence of mood disorders (including major depressive D 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

lies and Caregivers

care refersFami to a coordinated network of community-based services and supports organized to meet

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

he Way Forward: Federal Action for a System That in 2015,T the five most common diagnoses were mood disorders (such as depression, 29.3 percent),

rs rs e iv g e ar C d n a s e i l attention deficit hyperactivity disorder (ADHD, 24.9 percent), oppositional defiant disorder (15.8 Fami

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

ir e h T d n a D SE d n a SMI With ing v i L le p o Pe l Al or f

stress disorder (12.6 percent) (CMHS/SAMHSA, 2016). Data from the 2016 National Survey of Works

Coordinating Committee t t a h T em t s y S a for n ctio A eral d Fe : d ar w r o F y a W e h

Children’s Health (NSCH), shown in Table 1.2, indicate reported diagnoses for younger children, T

ages birth to 11, as well as for older youth. It should be noted that the NSCH methodology involves

rious Mental Illness asking Sea parent about the statements made by a doctor or health provider, an approach that may

ee t Commit ating n i d be less precise and result in lower estimates than a diagnostic interview. Coor

departmental

On average,Inter 15 percent of young children (ages 2-8) in the United States have a parent-reported

Illness Mental ious r mental, behavioral, or developmental disorder (MBDD) diagnosis, which includes ADHD, Se

depression, anxiety problems, behavioral or conduct problems such as oppositional defiant

partmental e d disorder or conduct disorder, Tourette syndrome, autism spectrum disorder, learning disability, Inter

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

partmental e d Inter

the United States, by Race/Ethnicity: 2016 Race/Ethnicity: by States, United the Illness Mental ious r Se

Past Year Major Depressive Episode Among Adolescents Ages 12 to 17 in in 17 to 12 Ages Adolescents Among Episode Depressive Major Year Past partmental e d Inter Interdepartmental 1.5. Figure ee t Commit ating n i d Coor

Illness Mental ious r Se 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

ee t Commit ating n i d Coor Black CoorNon-Hispanic d iwith n atinggroups, ethnic Commit t across a h T episodes em t s y tS ee depressive a major for n of rate ctio A the in eral d Fe : differences d ar w r o F y a W e h T

estimated 3.1 million youth) experienced a major depressive episode (CBHSQ, 2017j). There were were There 2017j). (CBHSQ, episode ir e h T d depressive n a major D a SE d n a experienced SMI youth) With million 3.1 ing v i L le p estimated o Pe l Al or f 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 rs e iv g SAMHSA’s e ar C d n a s e i l Fami

t t a h T em t s y S a for n ctio A eral d Fe : d ar w r o F y a W e h T The Way Forward: Federal Action for a System That ir e h T d n a D SE d n a SMI With ing v i L le p o Pe l Al or f Works Works for All People Living With Whites. SMI and SENon-Hispanic to D andcompared Their adolescents

rs rs e iv g e ar C d n a s e i l Fami FamiHispanic lieamong s and disorders Carmood e gof iverates rs 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 7 1 20 , 3 1 ber m e c e D

Percentage by Age Category: Age by Percentage

1.2. Table 7 1 20 , 3 1 ber m e c e D December 1Health 3 , 2017 Children’s of Survey National 2016 From Data Weighted

, 2017 ecember 13 Youth Dwith SED often 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

7 1 20 , 3 1 ber m e c e adolescents ages 12 to 17 had both a substance use disorder and a major depressive episode in D 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

rs rs e iv g e ar C d n a s e i l Fami

ir e h T d n a D SE d n a SMI With ing v i L le p o Pe l Al or f Works

Coordinating Committee t t a h T em t s y S a for n ctio A eral d Fe : d ar w r o F y a W e h T

Serious Mental Illness

ee t Commit ating n i d

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

departmental health indicatorsInter 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. Illness Mental ious r Se

partmental e d Early intervention is crucial to address development of mental disorders. The vast majority Inter 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 partmental e d Inter

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 ious r Se

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

partmental e d Inter 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 ee t Commit ating n i d Coor

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

a challenging life circumstances circumstances life challenging

Illness Mental ious r Se 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

ee t Commit ating n i d Coor Coordinating Commit t a h T em t s y tS ee a for n ctio A eral d Fe : d ar w r o F y a W e h T critical time. critical

important step toward achieving a system of care that ensures screening for youth during this this during youth for screening ir e h ensures T d that n a care D of SE d system n a a SMI achieving With toward step ing v i L le p important o Pe l Al or f 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 rs e 18-26. iv g ages e ar C d n a s e i l Fami

t t a h T em t s y S a for n ctio A eral d Fe : d ar w r o F y a W e h T Tadults he young W afor y Forwarspecifically d: Fedmedications eral Actiopreventive nand for aservices, Systemcounseling That screenings, as such

ir e h T d n a D SE d n a SMI With ing v i L le p o Pe l Al or f Works Worksservices forpreventive Allclinical Pefor ople Livingrecommendations With SMI evidence-based a nd SEDstandardized aof ndset 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

rs rs e iv g e ar C d n a s e i l Fami FamilieEngineering, s andScience, Cof aregivAcademy ers 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 7 1 20 , 3 1 ber m e c e D

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 7 1 20 , 3 1 ber m e c e D Deceexpansion man ber by 13, 2017 accompanied be must efforts screening so follow-up, and treatment, diagnosis,

, 2017 ecember 13 EffectiveD treatments 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

7 1 20 , 3 1 ber m e c e psychosocial services such as cognitive behavioral therapy and social skills training are evidence- D 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-

lies and Caregivers driven,Fami youth-guided, and culturally and linguistically competent services are widely accepted.

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

for All People Living With SMI and SED and Their

coordinationWorks across child-serving systems are extensively used as the standards of care throughout

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

rs rs e iv g e ar C d n a s e i l Fami

ir e h T d n a D SE d n a SMI With ing v i L le p o Pe l Al or f

Most children and youth with SED do not receive Works “The last 10 months of our lives have been filled

treatment. Identifiable mental health problems are

dinating Committee Coor with a life-altering and horrific change as my be- t t a h T em t s y S a for n ctio A eral d Fe : d ar w r o F y a W e h common, but few children receive services for those loved youngest son had a psychotic break and T

problems. The lack of services received by these young, was diagnosed with schizophrenia. Like many

rious Mental Illness

multi-challengedSe children is a services systems and other families, we were naïve. We have been

screaming for help and information, waiting

ee t Commit ating n i d

social policy failure (McCue Horwitz et al., 2012). Coor on services, and watching my son slowly fade

About 4 in 10 (40.9 percent) of youth ages 12 to 17 with

departmental Inter 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 Illness Mental ious r treatment of any kind in 2016 (Figure 1.7) (CBHSQ, and not as a true and serious medical illness.” Se

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

ISMICC) partmental e d study, that 36.2 percent of adolescents with mental Inter

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).

partmental e d Inter

ir e h T d n a D SE d n a SMI With ing v i L le p o Pe l Al or f Works rs rs e iv g e ar C d n a s e i l Fami

t t a h T em t s y S a for n ctio A eral d Fe : d ar w r o F y a W e h T The Way Forward: Federal Action for a System That

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

ir e h T d n a D SE d n a SMI With ing v i L le p o Pe l Al or f 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

rs rs e iv g e ar C d n a s e i l Fami United Famithe in lieindicators s ahealth ndmental Cand aruse egivsubstance e rsKey

7 1 20 , 3 1 ber m e c e D

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

1.7. Figure 7 1 20 , 3 1 ber m e c e D With D17 e cto e m12 ber 1Ages 3, 2017 Adolescents Among Depression for Treatment Year Past

, 2017 ecember 13 Transition-ageD youth 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-

7 1 20 , 3 1 ber m e c e health system. Exact definitions of the transition period ly became aggressively psychotic. My husband D 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

lies and Caregivers

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

watched his brain disease deteriorate year after

for All People Living With SMI and SED and Their many ofWorks these youth drop out of services when they year from countless psychotic episodes.”

reach adulthood. The adult outcomes for most youth who

he Way Forward: Federal Action for a System That T — Regina (submitted through public comments to the

enter adulthood with SED or SMI are bleak; many don’t ISMICC) rs rs e iv g e ar C d n a s e i l

finish high school, college enrollment and completion Fami

ir e h T d n a D SE d n a SMI With ing v i L le p o Pe l Al or f

is low, unemployment is high, and they are at increased Works

Coordinating Committee t t a h T em t s y S a for n ctio A eral d Fe : d ar w r o F y a W e h risk of homelessness (Davis & Vander Stoep, 1997; Rinaldi et al., 2010; Wagner & Newman, 2012). As T 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).

rious Mental Illness

Evidence-basedSe practices such as supported employment and supported housing have been adapted

ee t Commit ating n i d and shown promising results for transition-age youth. The coordinated specialty care model also Coor

departmental

early adulthoodInter (Kane et al., 2016). A review of health care and services for young adults by the Illness Mental ious r

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 adolescence or Se

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

adults. Inter

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 partmental e d Inter

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 ious r Se

partmental e d Inter Interpercent) (60.1 d10 in e 6 partmentalwhile 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 ee t one-third than More Commit ating n i d Coor Illness Mental ious r Se Se rioushealth have Mentaldo episode Illnessdepressive major year past with youth and children Most

ee t Commit ating n i d Coor Coordinating Commit t a h T em t s y tS ee a for n ctio 2012). A Gates, eral & d Fe : (Durso d ar w r o F y a W e h T experiencing homelessness self-identify as LGBT LGBT as self-identify homelessness experiencing

ir e h T d n a youth D of SE d n percent a 40 as SMI many as With that ing v i found L le p survey o Pe l Al or f Works

ISMICC)

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

Jeanne (submitted through public comments to the the to comments public through (submitted Jeanne — rs e iv g e ar C d n a s e i l Fami

t t a h T em t s y S a for n ctio A eral d Fe : d ar w r o F y a W e h T The Way Forward: Federal Afor ctiorisk n forhigh at aare Sysyouth tem (LGBT) T hat 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.

ir e h T d n a D SE d n a SMI With ing v i L le p o Pe l Al or f Works is Worksillness mental of for All Pecriminalization the opyet le 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 rs rs e iv g e ar C d n a s e i l Fami 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

capacity to realize they need to be in a 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 7 1 20 , 3 1 ber m e c e D

(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 7 1 20 , 3 1 ber m e c e D Dpercent) e cem(20.2 berfive 1in 3 , 20one 17than More

, 2017 ecember 13 While Dthe highest rates 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

7 1 20 , 3 1 ber m e c e almost doubled since 1993. The research shows that from 1993 to 2012, a total of 657 U.S. children D 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

rs rs e iv g e ar C d n a s e i l Fami

ir e h T d n a D SE d n a SMI With ing v i L le p o Pe l Al or f Works

Coordinating Committee t t a h T em t s y S a for n ctio A eral d Fe : d ar w r o F y a W e h T

Serious Mental Illness

ee t Commit ating n i d Coor

Interdepartmental

Illness Mental ious r Se

partmental e d Inter

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 partmental e d Inter

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 ious r Se

partmental e d Inter 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 ee impairments t mobility with Commit adolescents ating n i d Coor

Illness Mental ious r Se Seamong riousfactors 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 ee t Commit ating n i d Coor Coor dpracticing iUS n of atingPopulation Commit t (2016). a S. h J. T Ross, em t & s y A., tS H. ee a for Pincus, n K., J. ctio A Seirup, F., eral T. d Fe : Bishop, d ar w r o F y a W e h T

ir e h T d n a D SE d n a SMI With ing v i L le p o Pe l Al or f 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 rs e iv Psychiatrists g e ar C d n a s e i l Fami

t t a h T em t s y S a for n ctio A eral d Fe : d ar w r o F y a W e h T Th e by Way FInsurance o rof ward: FeAcceptance deral(2014). AH.A. ctionPincus, for& S. a SyKeyhani, s , tJ. em M. ThPress, a t T.F., Bishop,

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

ir e h T d n a D SE d n a SMI With ing v i L le p o Pe l Al or f Works Works. for All People Living With SMI and SED and Their

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

rs rs e iv g e ar C d n a s e i l Fami FamiRetrieved Inc. l ies andStrategies, CCare ar egivHealth efor rs 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 . .

https://www.aacap.org/App_Themes/AACAP/docs/clinical_practice_center/ from Retrieved

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 . 7 1 20 , 3 1 ber m e c e D

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

Agency for Healthcare Review and Quality (AHRQ). (2012, September). Evidence-based practice practice Evidence-based September). (2012, (AHRQ). Quality and Review Healthcare for Agency 7 1 20 , 3 1 ber m e c e D December 13, 2017 References

, 2017 ecember 13 Cavazos-Rehg,D P. A., Breslau, N., Hatsukami, D., Krauss, M. J., Spitznagel, E. L., Grucza, R. A., … Bierut, L. J. (2014). Smoking cessation is associated with lower rates of mood/anxiety and alcohol use disorder. Psychological Medicine, 44(12), 2523–2535.

Center for Behavioral Health Statistics and Quality (CBHSQ). (2017a). 2016 national survey on

7 1 20 , 3 1 ber m e c e drug use and health: Detailed tables. (NSDUH 2016, Table 8.5A). Rockville, MD: Substance D Abuse and Mental Health Services Administration.

Center for Behavioral Health Statistics and Quality (CBHSQ). (2017b). 2016 national survey on drug use and health: Detailed tables. (NSDUH 2016, Tables 8.24A, B). Rockville, MD:

Substance Abuse and Mental Health Services Administration. Center for Behavioral Health Statistics and Quality (CBHSQ). (2017c). 2016 national survey on drug use and health: Detailed tables. (NSDUH 2016, Table 8.9B). Rockville, MD: Substance Abuse and Mental Health Services Administration.

Center for Behavioral Health Statistics and Quality (CBHSQ). (2017d). 2016 national survey on

drug use and health: Detailed tables. (NSDUH 2016, Table 8.20B). Rockville, MD: Substance

lies and Caregivers

AbuseFami and Mental Health Services Administration.

Works for All People Living With SMI and SED and Their

Center for Behavioral Health Statistics and Quality (CBHSQ). (2017e). 2016 national survey

The Way Forward: Federal Action for a System That

on drug use and health: Detailed tables. (NSDUH 2016, Tables 8.33A, B). Rockville, MD:

rs rs e iv g e ar C d n a s e i l Substance Abuse and Mental Health Services Administration. Fami

ir e h T d n a D SE d n a SMI With ing v i L le p o Pe l Al or f

Center for Behavioral Health Statistics and Quality (CBHSQ). (2017f). 2016 national survey Works

on drug use and health: Detailed tables. (NSDUH 2016, Tables 8.42A, B). Rockville, MD:

Coordinating Committee t t a h T em t s y S a for n ctio A eral d Fe : d ar w r o F y a W e h Substance Abuse and Mental Health Services Administration. T

Center for Behavioral Health Statistics and Quality (CBHSQ). (2017g). 2016 national survey on

rious Mental Illness

drugSe use and health: Detailed tables. (NSDUH 2016, Table 8.40B). Rockville, MD: Substance

ee t Commit ating n i d

Abuse and Mental Health Services Administration. Coor

departmental

Center Interfor Behavioral Health Statistics and Quality (CBHSQ). (2017h). 2016 national survey on Illness Mental ious r drug use and health: Detailed tables. (NSDUH 2016, Tables 8.31B and 8.32B). Rockville, MD: Se

Substance Abuse and Mental Health Services Administration.

partmental e d Center for Behavioral Health Statistics and Quality (CBHSQ). (2017i). 2016 national survey on Inter

drug use and health: Detailed tables. (NSDUH 2016, Table 8.6A). Rockville, MD: Substance

Abuse and Mental Health Services Administration. Center for Behavioral Health Statistics and Quality (CBHSQ). (2017j). 2016 national survey on

drug use and health: Detailed tables. (NSDUH 2016, Tables 9.6A, B). Rockville, MD: Substance Abuse and Mental Health Services Administration. Center for Behavioral Health Statistics and Quality (CBHSQ). (2017k). 2016 national survey on drug use and health: Detailed tables. (NSDUH 2016, Table 9.11A). Rockville, MD: Substance Abuse and Mental Health Services Administration. Center for Behavioral Health Statistics and Quality (CBHSQ). (2017l). 2016 national survey on drug use and health: Detailed tables. (NSDUH 2016, Tables 9.14A, B). Rockville, MD:

Substance Abuse and Mental Health Services Administration.

partmental e d Inter

Illness Mental ious r Se

partmental e d Inter Interdepartmental (2), 217-225. (2), , 82 disorders affective

adulthood. in disorders depressive of risk the and experiences childhood Adverse

Journal of of Journal ee t Commit ating n i d Coor

Illness Mental ious r Se Se(2004). rF. iousR. Anda, & MentalJ., V. Edwards, R., S. Illness Dube, J., V. Felitti, L., C. Whitfield, P., D. Chapman,

Services-Booklet-ICN903195.pdf .

ee t Commit ating n i d Coor Coordinating Commit t a h T em t s y tS ee a for n ctio A eral d and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/Mental-Health- Fe : d ar w r o F y a W e h T Centers for Medicare & Medicaid Services. Retrieved from from Retrieved Services. Medicaid & Medicare for Centers https://www.cms.gov/Outreach-

Centers for Medicare & Medicaid Services (CMS). (2015). Mental health services. Baltimore, MD: MD: Baltimore, services. health ir e Mental h T d (2015). n a D (CMS). SE d Services n a SMI Medicaid & With Medicare ing v for i L le p Centers o Pe l Al or f Works

https://www.cdc.gov/violenceprevention/nvdrs/index.html from Retrieved System. . rs e iv g e ar C d n a s e i l Fami t t a h T em t s y S a for n ctio A eral d Fe : d ar w r o F y a W e h T The WReporting ay FDeath orwarViolent d: FeNational deral(2017). Actio(CDC). n for Prevention a Sand ystemControl ThaDisease t for Centers

ir e h T d n a D SE d n a SMI With ing v i L le p o Pe l Al or f Works Works for All People Living With SMI and SED and Their https://www.cdc.gov/violenceprevention/pdf/suicide-datasheet-a.pdf from . .

rs rs e iv g e ar C d n a s e i l Fami FamiRetrieved lies aGlance. a n dat CarFacts egivSuicide: ers (2015). (CDC). Prevention and Control Disease for Centers

135.

among children—United States, 2005–2011. Morbidity and Mortality Weekly Report, 62(02), 62(02), Report, Weekly Mortality and Morbidity 2005–2011. States, children—United among

Centers for Disease Control and Prevention (CDC). (2013, May). Mental health surveillance surveillance health Mental May). (2013, (CDC). Prevention and Control Disease for Centers

sites/default/files/programs_campaigns/nitt-ta/2015-report-to-congress.pdf .

https://www.samhsa.gov/ from Retrieved PEP16-CMHI2015). No. Publication (SAMHSA 2015

health services for children with serious emotional disturbances program, report to Congress, Congress, to report program, disturbances emotional serious with children for services health

Administration (SAMHSA). (2016). The evaluation of the comprehensive community mental mental community comprehensive the of evaluation The (2016). (SAMHSA). Administration

Center for Mental Health Services (CMHS), Substance Abuse and Mental Health Services Services Health Mental and Abuse Substance (CMHS), Services Health Mental for Center

. FYPS_Literature_Review_FINAL.pdf

http://www.chcs.org/media/

CHIPRA Quality Improvement Collaborative. Retrieved from from Retrieved Collaborative. Improvement Quality CHIPRA 7 1 20 , 3 1 ber m e c e D Center for Health Care Strategies. (2013). Family and youth peer support literature review. review. literature support peer youth and Family (2013). Strategies. Care Health for Center

Abuse and Mental Health Services Administration. Services Health Mental and Abuse

drug use and health: Detailed tables. (NSDUH 2016, Table 9.8A). Rockville, MD: Substance Substance MD: Rockville, 9.8A). Table 2016, (NSDUH tables. Detailed health: and use drug 7 1 20 , 3 1 ber m e c e D on Decesurvey m ber 13national , 202016 17 (2017m). (CBHSQ). Quality and Statistics Health Behavioral for Center

, 2017 ecember 13 Daniels,D A., England, M. J., Page, A. K., & Corrigan, J. (2005). Crossing the quality chasm: Adaptation for mental health and addictive disorders. International Journal of Mental Health, 34(1), 5-9.

Davis, M. (2003). Addressing the needs of youth in transition to adulthood. Administration and

7 1 20 , 3 1 ber m e c e Policy in Mental Health, 30(6), 495-509. D Davis, M., Banks, S. M., Fisher, W. H., Gershenson, B., & Grudzinkas, A. J. (2007). Arrests of

adolescent clients of a public mental health system during adolescence and young adulthood. Psychiatric Services, 58(11), 1454-1460. Davis, M., & Koroloff, N. (2006). The great divide: how public mental health policy fails young adults. Community Based Mental Health Services for Children and Adolescents, Volume 14. Oxford, UK: Elsevier Services, 53-74. Davis, M. A., Lin, L. A., Liu, H., & Sites, B. D. (2017). Prescription opioid use among adults

with mental health disorders in the United States. Journal of the American Board of Family

Medicine, 30(4), 407-417. doi: 10.3122/jabfm.2017.04.170112. lies and Caregivers

Davis, M.,Fami & Vander Stoep, A. (1997). The transition to adulthood for youth who have serious Works for All People Living With SMI and SED and Their

emotional disturbance: developmental transition and young adult outcomes. Journal of

he Way Forward: Federal Action for a System That MentalT Health Administration, 24(4), 400-427.

rs rs e iv g e ar C d n a s e i l

Dube, S. R., Anda, R. F., Felitti, V. J., Chapman, D. P., Williamson, D. F., & Giles, W. H. (2001). Fami

ir e h T d n a D SE d n a SMI With ing v i L le p o Pe l Al or f

Childhood abuse, household dysfunction, and the risk of attempted suicide throughout the Works

life span: findings from the Adverse Childhood Experiences Study. Jama, 286(24), 3089-3096. Coordinating Committee t t a h T em t s y S a for n ctio A eral d Fe : d ar w r o F y a W e h

Durso, L. E., & Gates, G. J. (2012). Serving our youth: Findings from a national survey of service T

providers working with lesbian, gay, bisexual, and transgender youth who are homeless or at

rious Mental Illness

riskSe of becoming homeless. Los Angeles, CA: The Williams Institute with True Colors Fund

ee t Commit ating n i d

and The Palette Fund. Retrieved from https://williamsinstitute.law.ucla.edu/wp-content/ Coor

uploads/Durso-Gates-LGBT-Homeless-Youth-Survey-July-2012.pdf. Interdepartmental

Illness Mental ious r Essex, M. J., Kraemer, H. C., Slattery, M. J., Burk, L. R., Boyce, W. T., Woodward, H. R., & Se

Kupfer, D. J. (2009). Screening for childhood mental health problems: outcomes and early

identification. Journal of Child Psychology and Psychiatry, 50(5), 562-570.

partmental e d

Fuller, D. A., Sinclair, E., Lamb, H. R., Cayce, J. D., & Snook, J. (2017). Emptying the “new asylums”: Inter A beds capacity model to reduce mental illness behind bars. Arlington, VA: Treatment

Advocacy Center.

202. 202.

9-12 – United States and Selected Sites, 2015. MMWR Surveillance Summary, 65(No. SS-9):1- 65(No. Summary, Surveillance MMWR 2015. Sites, Selected and States United – 9-12

Identity, Sex of Sexual Contacts, and Health-Related Behaviors Among Students in Grades Grades in Students Among Behaviors Health-Related and Contacts, Sexual of Sex Identity,

Chyen, D., Whittle, L., Thornton, J., Lim, C., Yamakawa, Y., Brener, N., &Zaza, S. (2016). Sexual Sexual (2016). S. &Zaza, N., Brener, Y., Yamakawa, C., Lim, J., Thornton, L., Whittle, D., Chyen,

Kann, L., Olsen, E.O., McManus, T., Harris, W., Shaklin, S.L., Flint, K.H., Queen, B., Lowry, R., R., Lowry, B., Queen, K.H., Flint, S.L., Shaklin, W., Harris, T., McManus, E.O., Olsen, L., Kann,

Journal of Psychiatry, 173(4), 362-372. 173(4), Psychiatry, of Journal

psychosis: two-year outcomes from the NIMH RAISE early treatment program. The American American The program. treatment early RAISE NIMH the from outcomes two-year psychosis: episode first for care community usual versus Comprehensive (2016). K. R. Heinssen, & .

Kane, J. M., Robinson, D. G., Schooler, N. R., Mueser, K. T., Penn, D. L., Rosenheck, R. A., . . . . A., R. Rosenheck, L., D. Penn, T., K. Mueser, R., N. Schooler, G., D. Robinson, M., J. Kane, partmental e d Inter Press. Academies National The DC: Washington, adults. young of well-being and

Institute of Medicine (IOM), & National Research Council (NRC). (2014). Investing in the health health the in Investing (2014). (NRC). Council Research National & (IOM), Illness Medicine of Institute Mental ious r Se

partmental e d Inter Interdepartmental SMA11-PHYDE021111.pdf Baltimore, MD. Retrieved from from Retrieved MD. Baltimore, https://store.samhsa.gov/shin/content/SMA11-PHYDE021111/

at the Bureau of Justice Assistance, Justice and Mental Health Collaboration Program, Program, Collaboration Health Mental and Justice ee t Assistance, Justice of Bureau Commit the at ating n i d Coor

Illness Mental ious r Se Sepresented riousPowerpoint Mentalpopulations. involved Illnessjustice and health Behavioral (2011). S. Pamela Hyde,

factors. (4_suppl), 81-90. (4_suppl), , Journal of psychopharmacology of Journal 24

ee t Commit ating n i d Coor Coorrisk and drates iof natingreview systematic Commita t a h T em t schizophrenia: s y and t S ee a Suicide for n (2010). ctio M. A Taylor, eral & d K., Fe : Hor, d ar w r o F y a W e h T ir Directors. e h T d Program n a D Health SE d n Mental a State of SMI With Association ing v i L National le p o Pe l Al or f Works

Hepburn, S. (2017). Crisis services’ role in reducing avoidable hospitalization. Alexandria, VA: VA: Alexandria, hospitalization. avoidable reducing in role services’ Crisis (2017). S. rs e iv g Hepburn, e ar C d n a s e i l Fami

. t t a h T em t s y S a for n ctio A eral d Fe : d ar w r o F y a W e h T The Way Forward: Federal Action for a System That ahrq.gov

Rockville, MD: Agency for Healthcare Research and Quality. Retrieved from from Retrieved Quality. and Research Healthcare for Agency MD: Rockville, ir e h T d n a D SE d n a SMI With ing v i L le p o Pe l Al or f Works Works fhttps://hcupnet. or All People Living With SMI and SED and Their

rs rs e iv g e ar C d n a s e i l Fami Famistatistics. lies anational nd Carinpatient egiveHospital rs (2014b). (HCUP). Project Utilization and Cost Healthcare

. hcupnet.ahrq.gov

statistics. Rockville, MD: Agency for Healthcare Research and Quality. Retrieved from from Retrieved Quality. and Research Healthcare for Agency MD: Rockville, statistics. https://

Healthcare Cost and Utilization Project (HCUP). (2014a). Emergency department national national department Emergency (2014a). (HCUP). Project Utilization and Cost Healthcare

Academy of Pediatrics. of Academy

ed. Elk Grove Village, IL: American American IL: Village, Grove Elk ed. 4 Adolescents. and Children, Infants, of Supervision

Hagan, J. F., Shaw, J. S., & Duncan, P. M. (Eds.). (2017). Bright Futures: Guidelines for Health Health for Guidelines Futures: Bright (2017). (Eds.). M. P. Duncan, & S., J. Shaw, F., J. Hagan,

onset and early course. The British Journal of Psychiatry, 23, 29-38. 23, Psychiatry, of Journal British The course. early and onset

Gattaz, W. F. (1994). The epidemiology of early schizophrenia. Influence of age and gender on on gender and age of Influence schizophrenia. early of epidemiology The (1994). F. W. Gattaz,

Hafner, H., Maurer, K., Loffler, W., Fatkenheuer, B., an der Heiden, W., Riecher-Rossler, A., … & … A., Riecher-Rossler, W., Heiden, der an B., Fatkenheuer, W., Loffler, K., Maurer, H., Hafner,

Asthma, 51(6), 639-644. 639-644. 51(6), Asthma, 7 1 20 , 3 1 ber m e c e D C. (2014). Asthma and mental health among youth in high-risk service settings. Journal of of Journal settings. service high-risk in youth among health mental and Asthma (2014). C.

Goodwin, R. D., Hottinger, K., Pena, L., Chacko, A., Feldman, J., Wamboldt, M. Z., & Hoven, Hoven, & Z., M. Wamboldt, J., Feldman, A., Chacko, L., Pena, K., Hottinger, D., R. Goodwin,

65(6), 816-811. 65(6), Services, Psychiatric way. 7 1 20 , 3 1 ber m e c e D Decem berthird 1A 3 , 2017 reexamined: commitment Outpatient Commentary: (2014). H. H. Goldman,

, 2017 ecember 13

Kessler,D R. C., Berglund, P., Demler, O., Jin, R., Merikangas, K. R., & Walters, E. E. (2005). Lifetime

prevalence and age-of-onset distributions of DSM-IV disorders in the national comorbidity survey replication. Archives of General Psychiatry, 62(6), 593-602.

Kessler, R. C., Chiu, W. T., Demler, O., & Walters, E. E. (2005). Prevalence, severity, and

7 1 20 , 3 1 ber m e c e comorbidity of 12-month DSM-IV disorders in the national comorbidity survey replication. D Archives of General Psychiatry, 62(6), 617-627.

McCue Horwitz, S., Hurlburt, M. S., Heneghan, A., Zhang, J., Rolls-Reutz, J., Fisher, E., . . . Stein, R. E. (2012). Mental health problems in young children investigated by U.S. child welfare agencies. Journal of the American Academy of Child and Adolescent Psychiatry, 51(6), 572-581.

Medley, G., Lipari, R. N., Bose, J., Cribb, D. S., Kroutil, L. A., & McHenry, G. (2016). Sexual orientation and estimates of adult substance use and mental health: Results from the 2015 National Survey on Drug Use and Health. NSDUH Data Review. Retrieved from http://www. samhsa.gov/data.

Melek, S. P., Norris, D. T., & Paulus, J. (2014). Economic impact of integrated medical-behavioral

lies and Caregivers

healthcare.Fami Milliman Am Psychiatr Assoc Rep.

Works for All People Living With SMI and SED and Their

Merikangas, K. R., He, J. P., Burstein, M., Swanson, S. A., Avenevoli, S., Cui, L., . . . & Swendsen, J.

he Way Forward: Federal Action for a System That

(2010).T Lifetime prevalence of mental disorders in US adolescents: results from the National

rs rs e iv g e ar C d n a s e i l Journal of the American Fami Comorbidity Survey Replication–Adolescent Supplement (NCS-A).

Academy of Child & Adolescent Psychiatry, 49(10), 980-989.

ir e h T d n a D SE d n a SMI With ing v i L le p o Pe l Al or f

Merikangas, K. R., He, J. P., Burstein, M., Swendsen, J., Avenevoli, S., Case, B., & Olfson, M. (2011). Works

Coordinating Committee t t a h T em t s y S a for n ctio A eral d Fe : d ar w r o F y a W e h Service utilization for lifetime mental disorders in US adolescents: results of the National T

Comorbidity Survey–Adolescent Supplement (NCS-A). Journal of the American Academy of

Child & Adolescent Psychiatry, 50(1), 32-45.

Serious Mental Illness

ee t Commit ating n i d

McQuilken, M., Zahniser, J. H., Novak, J., Starks, R. D., Olmos, A., & Bond, G. R. (2003). The work Coor

project survey: Consumer perspectives on work. Journal of Vocational Rehabilitation, 18(1), departmental

59-68Inter.

Illness Mental ious r

Moore, B. J., Stocks, C., & Owens, P. L. (2017). Trends in emergency department visits, 2006-2014. Se

HCUP Statistical Brief #227. Rockville, MD: Agency for Healthcare Research and Quality.

partmental e d Inter

148-162. 22(2), Psychiatry, of Review International review. a employment: and psychosis

Rinaldi, M., Killackey, E., Smith, J., Shepherd, G., Singh, S. P., & Craig, T. (2010). First episode episode First (2010). T. Craig, & P., S. Singh, G., Shepherd, J., Smith, E., Killackey, M., Rinaldi, partmental e d Inter 392-411. 20(4), Health, Mental of Journal

Repper, J., & Carter, T. (2011). A review of the literature on peer support in mental health services. services. health mental in support peer on literature the of review A (2011). T. Carter, Illness & J., Repper, Mental ious r Se

partmental e d Inter Interdepartmental 351-358. 38(4), Health, Adolescent nationally representative sample of American adolescents involved with foster care. Journal of of Journal care. foster with involved adolescents American of sample representative nationally Pilowsky, D. J., & Wu, L. (2006). Psychiatric symptoms and substance use disorders in a a in disorders use substance and symptoms Psychiatric ee t (2006). L. Wu, & J., D. Commit Pilowsky, ating n i d Coor

Illness Mental ious r Se Serious Mental Illness effect of sex and Hispanic origin/race. Journal of Pediatric Obesity, 6(5-6), 462-466. 6(5-6), Obesity, Pediatric of Journal origin/race. Hispanic and sex of effect

ee t Commit ating n i d Coor Coorobesity: dadolescent i nand atingdifficulties Commit t a h T em t s y Emotional/behavioral t S ee a (2011). A. for C. n ctio A Reuben, & N., eral P. d Fe : Pastor, d ar w r o F y a W e h T preventive health care. Adolescent Medicine: State of the Art Reviews, 24(3), 507-525. 24(3), Reviews, Art the of State Medicine: Adolescent care. health preventive

Ozer, E. M., Scott, J. T., & Brindis, C. D. (2013). Seizing the opportunity: improving young adult adult young improving ir opportunity: e h the T d n Seizing a D (2013). SE D. d C. n a Brindis, SMI & T., J. With Scott, ing v M., i L E. le p Ozer, o Pe l Al or f Works

treatment-for-substance-use-disorders#preventinghomeless3 . . rs e iv g e ar C d n a s e i l Fami

document.] Retrieved from from Retrieved document.]

t t a h T em t s y S a for n ctio A eral d Fe : d ar w r o F y a W e h T The Way Forward: Federal Action for ahttps://obamawhitehouse.archives.gov/ondcp/chapter-integrate- System That ir e h T d n a D SE d n a SMI With ing v i L le p o Pe l Al or f Works Works fAdministration or AllObama People[Archived Livingrecovery. for With support SMI aexpand ndand SEcare D ahealth nd Theirmainstream

rs rs e iv g e ar C d n a s e i l Fami into Famidisorders luse ie s andsubstance Cfor ar egivetreatment rs Integrate (n.d.). Policy. Control Drug National of Office

solutions. Washington, DC: National Council for Behavioral Health. Behavioral for Council National DC: Washington, solutions.

National Council Medical Director Institute. (2017). The psychiatric shortage: causes and and causes shortage: psychiatric The (2017). Institute. Director Medical Council National

inpatient-capacity-united-states-and-each-state-1970-to-2014 .

https://www.nri-inc.org/our-work/nri-reports/trends-in-psychiatric- from Retrieved NRI.

psychiatric inpatient capacity, United States and each state, 1970 to 2014. Falls Church, VA: VA: Church, Falls 2014. to 1970 state, each and States United capacity, inpatient psychiatric

National Association of State Mental Health Program Directors (NASMHPD). (2017b). Trend in in Trend (2017b). (NASMHPD). Directors Program Health Mental State of Association National

. Hospitals_508C.pdf

https://www.nasmhpd.org/sites/default/files/TACPaper.10.Forensic-Patients-in-State- from

patients in state psychiatric hospitals: 1999-2016. Alexandria, Virginia: NASMHPD. Retrieved Retrieved NASMHPD. Virginia: Alexandria, 1999-2016. hospitals: psychiatric state in patients National Association of State Mental Health Program Directors (NASMHPD). (2017a). Forensic Forensic (2017a). (NASMHPD). Directors Program Health Mental State of Association National

7 1 20 , 3 1 ber m e c e D mental illness. Bethesda, MD: National Alliance for Caregiving. for Alliance National MD: Bethesda, illness. mental

National Alliance for Caregiving (NAC). (2016). On pins & needles: caregivers of adults with with adults of caregivers needles: & pins On (2016). (NAC). Caregiving for Alliance National

State of the field. Psychiatric Rehabilitation Journal, 39(3), 197-203. 39(3), Journal, Rehabilitation Psychiatric field. the of State 7 1 20 , 3 1 ber m e c e D Deceworkforce: mber 13healthcare , 2017 behavioral the in services support Peer (2016). P. Vecchio, del & K., Myrick,

, 2017 ecember 13

Robinson,D L. R., Holbrook, J. R., Bitsko, R. H., Hartwig, S. A., Kaminski, J. W., Ghandour, R. M., . . . Boyle, C. A. (2017). Differences in health care, family, and community factors associated with mental, behavioral, and developmental disorders among children aged 2-8 years in rural and

urban areas—United States, 2011-2012. Morbidity and Mortality Weekly Report, 66(8), 1-11.

7 1 20 , 3 1 ber m e c e Sheftall, A.H., Asti, L., Horowitz, L.M., Felts, A., Fontanella, C.A., Campo, J.V., & Bridge, J.A. D (2016). Suicide in Elementary School-Aged Children and Early Adolescents. Pediatrics, 138(4), e20160436; DOI: 10.1542/peds.2016-0436. Sheidow, A. J., McCart, M., Zajac, K., & Davis, M. (2012). Psychiatric Rehabilitation Journal, 35(3), 235-243.

Sherrill, E., & Gonzales, G. (2017). Recent changes in health insurance coverage and access to care by mental health status, 2012-2015. JAMA Psychiatry, 74(10), 1076-1079. Silverman, W. K., & Hinshaw, S. P. (2008). The second special issue on evidence-based

psychosocial treatments for children and adolescents: A ten-year update. Journal of Clinical

Child Adolescent Psychology, 37(1). lies and Caregivers

Social SecurityFami Administration. (2017). Internal Review of Data for all SSA Initial Applications for All People Living With SMI and SED and Their

AdjudicatedWorks in FY 2016. Washington, DC: Social Security Administration.

The Way Forward: Federal Action for a System That

rs rs e iv g e ar C d n a s e i l Fami Steadman, H. J., Osher, F. C., Robbins, P. C., Case, B., & Samuels, S. (2009). Prevalence of serious

mental illness among jail inmates. Psychiatric Services, 60(6), 761-765.

ir e h T d n a D SE d n a SMI With ing v i L le p o Pe l Al or f

Stroul, B. A., & Friedman, R. M. (2011). Issue brief: Strategies for expanding the system of care Works

Coordinating Committee t t a h T em t s y S a for n ctio A eral d Fe : d ar w r o F y a W e h

approach. Washington, DC: Technical Assistance Partnership for Child and Family Mental T

Health.

rious Mental Illness

SubstanceSe Abuse and Mental Health Services Administration (SAMHSA). (n.d.-a). Tobacco and

ee t Commit ating n i d

behavioral health: The issue and resources. Rockville, MD: Substance Abuse and Mental Coor

Health Services Administration. Retrieved from https://www.samhsa.gov/atod/tobacco. Interdepartmental

Illness Mental ious r Substance Abuse and Mental Health Services Administration (SAMHSA). (n.d.-b). Homelessness Se

and housing. Retrieved from https://www.samhsa.gov/homelessness-housing.

partmental e d Substance Abuse and Mental Health Services Administration (SAMHSA). (2002). Report Inter

to Congress on the prevention and treatment of co-occurring substance abuse disorders and mental disorders. Rockville, MD: Substance Abuse and Mental Health Services

Administration.

Substance Abuse and Mental Health Services Administration (SAMHSA). (2015). Screening and assessment of co-occurring disorders in the justice system (HHS Publication No. (SMA)-15-

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

disturbance. Psychiatric Rehabilitation Journal, 35(3), 199-208. 35(3), Journal, Rehabilitation Psychiatric disturbance. partmental e d Inter

emotional with youth of outcomes transition Longitudinal (2012). L. Newman, & M., Wagner,

Illness report_2003_08_complete.pdf Mental ious r Se

Department of Education. Retrieved from from Retrieved Education. of Department

partmental e d Inter Interdepartmentalhttps://nlts2.sri.com/reports/2003_08/nlts2_ report from the National Longitudinal Transition Study-2 (NLTS2). Washington, DC: U.S. U.S. DC: Washington, (NLTS2). Study-2 Transition Longitudinal National the from report

L. (2003). The individual and household characteristics of youth with disabilities. A A disabilities. with youth of characteristics household ee and t individual The Commit (2003). L. ating n i d Coor

Illness Mental ious r Se SeNewman, r& ious. . . J., MentalBlackorby, W., T. IllnessCadwallader, R., Cameto, P., Levine, C., Marder, M., Wagner,

www.uspreventiveservicestaskforce.org/BrowseRec/Index/browse-recommendations . .

U.S. Preventive Services Task Force. (n.d.). Published recommendations. Retrieved from Retrieved recommendations. Published (n.d.). Force. Task Services Preventive U.S. https://

ee t Commit ating n i d Coor Coor dinating Commit t a h T em t s y tS ee a for n ctio A eral d Fe : d ar w r o F y a W e h T

ir e h T d n a D SE d n a SMI With ing v i L NatlTerrDC_2016.pdf le p o Pe l Al or f Works

‌ https://www.hudexchange.info/resource/reportmanagement/ from published/CoC_PopSub_

of care homeless assistance programs homeless populations and subpopulations. Retrieved Retrieved subpopulations. and populations homeless programs assistance homeless rs e care iv of g e ar C d n a s e i l Fami t t a h T em t s y S a for n ctio A eral d Fe : d ar w r o F y a W e h T The Wcontinuum a y F2016 orwHUD ard:(2016). Federal(HUD). ActioDevelopment n forUrban a Sand ystemHousing of That Department U.S.

ir e h T d n a D SE d n a SMI With ing v i L le p o Pe l Al or f Works Works for All People Living With SMI and SED and Their https://www.ncbi.nlm.nih.gov/books/NBK109917 from Retrieved Services. .

rs rs e iv g e ar C d n a s e i l Fami Fami lHuman i e& s anHealth d of C aregiveDepartment rsU.S. DC: Washington, action. for objectives and Goals

Action Alliance for Suicide Prevention. (2012). 2012 national strategy for suicide prevention: prevention: suicide for strategy national 2012 (2012). Prevention. Suicide for Alliance Action

U.S. Department of Health & Human Services (HHS) Office of the Surgeon General and National National and General Surgeon the of Office (HHS) Services Human & Health of Department U.S.

National Institutes of Health, National Institute of Mental Health. Mental of Institute National Health, of Institutes National

Abuse and Mental Health Services Administration, Center for Mental Health Services, Services, Health Mental for Center Administration, Services Health Mental and Abuse

Substance Substance Services, Human and Health of Department US MD: Rockville, general. surgeon

U.S. Department of Health & Human Services (HHS). (1999). Mental health: A report of the the of report A health: Mental (1999). (HHS). Services Human & Health of Department U.S.

. poverty/poverty.html

https://www.census.gov/topics/income- from Retrieved Poverty. (n.d.). Bureau. Census U.S.

60(10), 1323-1328. 60(10), Services,

Psychiatric Psychiatric

level estimates of mental health professional shortage in the United States. United the in shortage professional health mental of estimates level 7 1 20 , 3 1 ber m e c e D Thomas, K. C., Ellis, A. R., Konrad, T. R., Holzer, C. E., & Morrissey, J. P. (2009). County- (2009). P. J. Morrissey, & E., C. Holzer, R., T. Konrad, R., A. Ellis, C., K. Thomas,

1031.

45(9), 1023- 45(9), Psychiatry, Adolescent & Child of Academy American the of Journal psychiatrists. 7 1 20 , 3 1 ber m e c e D Dec ember 13adolescent , 20and 17 child of shortage continuing The (2006). E. C. Holzer, & R., C. Thomas,

, 2017 ecember 13 Weitzman,D C., Wegner, L., Section on Developmental and Behavioral Pediatrics, Committee on Psychosocial Aspects of Child and Family Health, Council on Early Childhood, & Society for Developmental and Behavioral Pediatrics. (2015). Promoting optimal development: screening

for behavioral and emotional problems. Pediatrics, 135(2), 384-395.

7 1 20 , 3 1 ber m e c e Williams, N. J., Scott, L., & Aarons, G. A. (2017). Prevalence of serious emotional disturbance D among U.S. children: A meta-analysis. Psychiatric Services. Advance online publication. Retrieved from https://doi.org/10.1176/appi.ps.201700145. Wissow, L. S., Brown, J., Fothergill, K. E., Gadomski, A., Hacker, K., Salmon, P., & Zelkowitz, R. (2013). Universal mental health screening in pediatric primary care: a systematic review. Journal of the American Academy of Child and Adolescent Psychiatry, 52(11), 1134-1147. Wright, D., Livermore, G., Hoffman, D., Grau, E., & Bardos, M. (2012). 2010 National Beneficiary Survey: Methodology and Descriptive Statistics. Washington, DC: Mathematica Policy Research.

Zhu, J. M., Zhang, Y., & Polsky, D. (2017). Networks in ACA marketplaces are narrower for mental

lies and Caregivers

healthFami care than for primary care. Health Affairs, 36(9), 1624-1631.

Works for All People Living With SMI and SED and Their

The Way Forward: Federal Action for a System That

rs rs e iv g e ar C d n a s e i l Fami

ir e h T d n a D SE d n a SMI With ing v i L le p o Pe l Al or f Works

Coordinating Committee t t a h T em t s y S a for n ctio A eral d Fe : d ar w r o F y a W e h T

Serious Mental Illness

ee t Commit ating n i d Coor

Interdepartmental

Illness Mental ious r Se

partmental e d Inter

7 1 20 , 3 1 ber m e c e D

7 1 20 , 3 1 ber m e c e D December 13, 2017

, 2017 ecember 13 ChapterD 2: Improving Practice Related to Serious Mental

Illness and Serious Emotional Disturbances

7 1 20 , 3 1 ber m e c e D

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

for All People Living With SMI and SED and Their The firstWorks ISMICC meeting occurred on August 31, 2017, John McCarthy, Director, Serious Mental Illness

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

he Way Forward: Federal Action for a System That

headquartersT at the Hubert H. Humphrey Building in (SMITREC), Department of Veterans Affairs rs rs e iv g e ar C d n a s e i l

(VA) Fami

Washington D.C. Federal and non-federal experts were

ir e h T d n a D SE d n a SMI With ing v i L le p o Pe l Al or f

invited to present information on relevant advances Ruby Qazilbash, Associate Deputy Director, Works

dinating Committee Coor Bureau of Justice Assistance (BJA), Department t t a h T em t s y S a for n ctio A eral d Fe : d ar w r o F y a W e h for addressing the needs of people with SMI and SED. T

This chapter reflects the content of the presentations, of Justice

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

ISMICCSe members. Federal Advances in Addressing the Needs ee t Commit ating n i d

of People With SMI and SED Coor

departmental

The advancesInter included in this chapter come directly Lynda Gargan, Executive Director, National

Illness Mental ious r from the presentations of the federal leaders and Federation of Families for Children’s Mental Se

national experts. All of the advances are relevant Health

partmental e d to SMI and SED populations. Each advance has a Lisa Dixon, Professor of Psychiatry, Columbia Inter

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 partmental e d Inter

that help predict risk risk predict help that

biomarkers Illness identify (2) SMI, Mental ious r Se partmental e d Inter Interdepartmental of development the predict to

ee t ability our enhance Commit and risk ating n i d Coor priorities include: (1) identify identify (1) include: priorities

Illness Mental ious r Se Serious Mental Illness NIMH that noted Gordon Dr. ee t Commit ating n i d Coor Coordinating(NIMH) Health Commit Mental t a of h T em Institute t s y tS ee a National for n Director, ctio A Gordon, eral A. d Fe : Joshua d ar w r o F y a W e h T

ir e h T d n a D SE d n a SMI With ing v i L le p o Pe l Al or f 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 rs e iv g e ar C d n a s e i l Fami t t a h T em t s y S a for n ctio A eral d Fe : d ar w r o F y a W e h T The Way Forward: Federal Action for a System That

ir e h T d n a D SE d n a SMI With ing v i L le p o Pe l Al or f Works Works for All People Living With SMI and SED and Their

rs rs e iv g e ar C d n a s e i l Fami 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 7 1 20 , 3 1 ber m e c e D

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 7 1 20 , 3 1 ber m e c e D December 13, 2017 •

, 2017 ecember 13 Dr. GordonD remarked 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

7 1 20 , 3 1 ber m e c e this approach, researchers seek to group people with psychosis according to common anatomic D

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

rs rs e iv g e ar C d n a s e i l Fami

ir e h T d n a D SE d n a SMI With ing v i L le p o Pe l Al or f Works

Coordinating Committee t t a h T em t s y S a for n ctio A eral d Fe : d ar w r o F y a W e h T

Serious Mental Illness

ee t Commit ating n i d Coor

departmental

LongitudinalInter studies that use multiple modalities—including neuroimaging and

Illness Mental ious r neuropsychological measures—allow the development of predictive tools and methods for Se

charting illness progression. The Recovery After an Initial Schizophrenia Episode (RAISE)

partmental e d project was a research initiative of the NIMH. RAISE studied coordinated specialty care (CSC), Inter

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

psychoeducation. family partmental e d Inter

supported employment, and and employment, supported

treatment, Illness community Mental ious r Se

partmental e d Inter Interdepartmental assertive management, practices such as medication medication as such practices

ee t Commit evidence-based receive ating n i d Coor Illness Mental ious r Se Senot do r iousSED or SMI Mentalfor services health Illnessmental public receive who people most that show 2016

ee t Commit ating n i d Coor Coorfrom Data dintreatments. ating Commitevidence-based to t a h T access of em t issue s y tS ee a central the for on n ctio focused A eral Vecchio d del Fe : Mr. d ar w r o F y a W e h T 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), ir Services e h T Health d n a D Mental for SE d n a Center SMI Director, With Vecchio, ing v i del L le p Paolo o Pe l Al or f Works

rs rs e iv g e ar C d n a s e i l Fami

t t a h T em t s y S a for n ctio A eral d Fe : d ar w r o F y a W e h T The Way Forward:SED Feand d eralSMI of Action forChallenges a SyAddress sto tem ThAdvances a tof Support

Substance Abuse and Mental Health Services Administration: Administration: Services Health Mental and Abuse Substance ir e h T d n a D SE d n a SMI With ing v i L le p o Pe l Al or f Works Works for All Pe ople Living With SMI and SED and Their

rs rs e iv g e ar C d n a s e i l Fami 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 7 1 20 , 3 1 ber m e c e D

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 7 1 20 , 3 1 ber m e c e D December 13, 2017 predicting on focused also is NIMH

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

such as cognitive behavioral

7 1 20 , 3 1 ber m e c e therapy. Similarly, few are receiving D 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 lies and Caregivers

receiveFami evidence-based supported employment. Similarly, few have access to supportive housing,

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

he Way Forward: Federal Action for a System That justice Tsystems involvement, and increased employment. Jail diversion programs have also

rs rs e iv g e ar C d n a s e i l demonstrated effectiveness. Major advances have been made in recent decades to promote peer Fami

and family support, with 40 states including this as a billable Medicaid optional service. As a ir e h T d n a D SE d n a SMI With ing v i L le p o Pe l Al or f

part of recovery support services, and given the elevated rates of mortality, attention to self-care Works

Coordinating Committee t t a h T em t s y S a for n ctio A eral d Fe : d ar w r o F y a W e h and general health by people with SMI and SED is also important. Studies show the benefits of T

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

rious Mental Illness

CoordinatedSe care approaches are critical. Through a partnership across the Centers for Medicare ee t Commit ating n i d

& Medicaid Services (CMS), SAMHSA, and the Assistant Secretary for Planning and Evaluation Coor

departmental

(ASPE),Inter over 70 Certified Community Behavioral Health Clinics in eight states have enhanced Illness Mental ious r Medicaid federal match to provide comprehensive, coordinated care as a result of the Section 223 Se

Demonstration Program to Improve Community Mental Health Services. Equally promising is the

partmental e d collaboration involving SAMHSA, ASPE, and NIMH to look at the impact of assisted outpatient Inter 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 partmental e d Inter

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 ious r Se partmental e d Inter Interand 1999 dbetween e partmentalsteadily increased disorder bipolar for care receiving people of number The ee t Commit ating n i d Coor

Illness Mental ious r Se 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

ee t Commit ating n i d Coor CoorRe-Engage SMI dVA’s inThe atingpsychoses. Commitother t or a h T disorder, em t s y tbipolar S ee a for n schizophrenia, ctio A with eral d patients Fe : about d ar w r o F y a W e h T

In response, the VA established the National Psychosis Registry in 1999, which generates data data generates which 1999, in ir e h Registry T d n a Psychosis D SE National d n the a SMI established VA With the ing v i L response, le p In o Pe l Al or f Works they generate disproportionate expenditures and service utilization. service and expenditures disproportionate rs e generate iv g they e ar C d n a s e i l Fami

t t a h T em t s y S a for n ctio A eral d Fe : d ar w r o F y a W e h T 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

ir e h T d n a D SE d n a SMI With ing v i L le p o Pe l Al or f Works Works with users f or Al(VHA) l People LAdministration ivingHealth With Veterans SMI andconditions. SEhealth D anmental d Twith h eir veterans

rs rs e iv g e ar C d n a s e i l Fami Famiof needs l iesthe anmeet dto Carecapacity g ivits ers 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 7 1 20 , 3 1 ber m e c e D

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 7 1 20 , 3 1 ber m e c e D Deonset ce15; mberage 13before , 2017 happens illness mental of onset the people, of percent 50 estimated an For

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

Among those who received

7 1 20 , 3 1 ber m e c e VHA care since 1999, suicide D 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

lies and Caregivers bipolarFami disorder, despite VA efforts such as the Mental Health Enhancement Initiative and the

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

for All People Living With SMI and SED and Their

decreasedWorks somewhat for VHA users with schizophrenia, and overall among people with mental or

he Way Forward: Federal Action for a System That substanceT use disorders. Suicide risks are particularly high after inpatient discharges, especially

rs rs e iv g e ar C d n a s e i l among people with depressive disorder, followed by bipolar disorder and schizophrenia. Fami

ir e h T d n a D SE d n a SMI With ing v i L le p o Pe l Al or f

Suicide prevention for people with SMI is an important priority. REACH VET (Recovery Works

Coordinating Committee t t a h T em t s y S a for n ctio A eral d Fe : d ar w r o F y a W e h

Engagement And Coordination for Health—Veterans Enhanced Treatment) uses a suicide T

predictive model based on information in the VA’s electronic health record system to identify

rious Mental Illness and engageSe veterans at high risk for suicide, particularly among those with SMI. Strategic

ee t Commit ating n i d partnerships—such as the one between the Veterans Administration, CMS, SAMHSA, and the Coor

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

who dieInter of suicide and who are not recent users of VHA care or otherwise connected with the VA. Illness Mental ious r Se

partmental e d Department of Justice: Inter

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 partmental e d Inter 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 ious r Se

partmental e d Inter 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 ee issues t health mental Commit involving calls ating n i d Coor

Illness Mental ious r Se Seservice riousGenerally, 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

ee t Commit ating n i d Coor is Coorcalls 10 in 1 dthat inatingindicating report Commit t Florida a h one T with em t s y tS ee a increasing, be for to n ctio appears A SMI eral with d Fe : people d ar w r o F y a W e h T 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 ir e h first T d n become a D have SE d n a officers and SMI agencies With ing v i L enforcement le p Law o Pe l Al or f Works rs rs e iv g e ar C d n a s e i l Fami t t a h T em t s y S a for n ctio A eral d Fe : d ar w r o F y a W e h T The Way Forward: Federal Action for a System That ir e h T d n a D SE d n a SMI With ing v i L le p o Pe l Al or f Works Works for All People Living With SMI and SED and Their rs rs e iv g e ar C d n a s e i l Fami Families and Caregivers

7 1 20 , 3 1 ber m e c e D

community. 7 1 20 , 3 1 ber m e c e D the Decewithin m ber 1services 3 ,to 201jails 7of out and in cycling are who people connect to and jail, jurisdiction’s

, 2017 December 13

7 1 20 , 3 1 ber m e c e D

Families and Caregivers

for All People Living With SMI and SED and Their

In 2012,Works BJA and the Council of State Governments Justice Center released a shared framework

he Way Forward: Federal Action for a System That

for reducingT recidivism and promoting recovery for adults with behavioral health needs who are

rs rs e iv g e ar C d n a s e i l

under correctional supervision. The framework reflects a consensus with SAMHSA, the National Fami

ir e h T d n a D SE d n a SMI With ing v i L le p o Pe l Al or f

Institute of Corrections, and major associations representing state directors of corrections, Works

dinating Committee probationsCoor and parole, substance use services, and mental health services. The outcome was that t t a h T em t s y S a for n ctio A eral d Fe : d ar w r o F y a W e h there is a need for risk and needs assessments for people under correctional control who have T

behavioral health needs. People with low criminogenic risk need to be connected to community

rious Mental Illness

servicesSe and medical care. People with moderate to high criminogenic risk need intensive

ee t Commit ating n i d

supervision with a combination of supports. The shared framework is part of the Justice and Coor

departmental

MentalInter Health Collaboration Program funded by the Bureau of Justice Assistance, which is

Illness Mental ious r adding 55 new grantees in 2017 to help communities apply the framework and allocate resources Se

appropriately.

partmental e d Inter

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 partmental e d Inter

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 ious r Se partmental e d Inter 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 ee t recidivism the (4) and Commit release, ating n i d Coor 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

Illness Mental ious r Se Sepeople rfor ious 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

ee t Commit ating n i d Coor Coorquestions key dinanswer to atingcounties ask Commit t a h T Questions” “Six em t s y tS ee a initiative’s The for n ctio Initiative. A Up eral d Stepping Fe : the d ar w r o F y a W e h T

least 384 county boards (representing 115 million people) have passed resolutions committing to to committing resolutions passed ir have e h T d people) n a D million 115 SE d n a SMI (representing boards With ing county v i L 384 le p least o Pe l Al or f 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 rs e iv g Stepping e ar C d n a s e i l Fami t t a h T em t s y S a for n ctio A eral d Fe : d ar w r o F y a W e h T The Way Forward: Federal Action for a System That

ir e h T d n a D SE d n a SMI With ing v i L le p o Pe l Al or f Works Works jails. in forSMI Alwith l Peopeople pof le Livingprevalence Withthe SMIreducing on andfocuses SED aInitiative nUp d TheirStepping The rs rs e iv g e ar C d n a s e i l Fami Families and Caregivers

7 1 20 , 3 1 ber m e c e D

7 1 20 , 3 1 ber m e c e D December 13, 2017

, 2017 ecember 13

D Non-Federal Stakeholder Presentations

7 1 20 , 3 1 ber m e c e Challenges and Opportunities in Improving Children’s Mental Health Care D

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,

lies and Caregivers identifyFami children’s behavioral

for All People Living With SMI and SED and Their health Worksas a public health

crisis, and support a system

he Way Forward: Federal Action for a System That

that willT help our teachers

rs rs e iv g e ar C d n a s e i l

teach. Children are not little Fami

ir e h T d n a D SE d n a SMI With ing v i L le p o Pe l Al or f adults, so data cannot be Works

Coordinating Committee t t a h T em t s y S a for n ctio A eral d Fe : d ar w r o F y a W e h extrapolated from what works T

for adults, and then applied

to children. She noted the

rious Mental Illness

exampleSe of medications ee t Commit ating n i d

that are dispensed without Coor

departmental longitudinalInter data or Food

Illness Mental ious r and Drug Administration Se

indications for children.

Prescriptions should not be the first line of response. Culturally responsive supports are needed. partmental e d Inter 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 partmental e d Inter

Illness intervention. based Mental ious r Se

partmental e d Inter Interdepartmental evidence- this of development additional support to further the the further to support additional

ee t provide government local Commit and state ating n i d Coor

Illness Mental ious r Se Serious Mental Illness states, many In program. Grant

administered Mental Health Block Block Health Mental administered ee t Commit ating n i d Coor Coordinating Commit t a h T em t s y tS ee a for n SAMHSA- ctio the A eral through d Fe : services d ar w r o F y a W e h T

ir e h T d n a D SE d n a CSC SMI provide With to ing funds v i L aside le p set o Pe l Al or f Works Congress has asked states to to states asked has Congress

outcomes associated with CSC, CSC, with associated rs e iv g outcomes e ar C d n a s e i l Fami

t t a h T em t s y S a for n ctio A eral d Fe : d ar w r o F y a W e h T The Way Forward: Federal Action for a Syspositive temthe on ThaBased t psychosis. ir e h T d n a D SE d n a SMI With ing v i L le p o Pe l Al or f Works Works for All People Living With SMI anearly d SEwith D youth a nd Theirtransition-age on

rs rs e iv g e ar C d n a s e i l Fami 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.

7 1 20 , 3 1 ber m e c e D 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 7 1 20 , 3 1 ber m e c e D December 13, 2017 SED and SMI With People of Care Clinical the in Advances Key

, 2017 ecember 13 Upon entryD into the New 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

7 1 20 , 3 1 ber m e c e competitive employment, has consistently been demonstrated as more effective than traditional D

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

rs rs e iv g e ar C d n a s e i l Fami

ir e h T d n a D SE d n a SMI With ing v i L le p o Pe l Al or f Works

Coordinating Committee t t a h T em t s y S a for n ctio A eral d Fe : d ar w r o F y a W e h T

Serious Mental Illness

ee t Commit ating n i d

Early psychosis treatment is critical, as is peer support. Peer support has an emerging evidence Coor

departmental

base demonstratingInter reduced use of acute services, decreased substance abuse, and increased Illness Mental ious r

engagement. Se

partmental e d Approximately 5-20 percent of people with SMI die by suicide. The highest risk follows discharge Inter

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. partmental e d Inter

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 ious r Se

partmental e d Inter Interdepartmental Disparities and Closing the Treatment Gap Treatment ee t the Closing and Commit Disparities ating n i d Coor Illness Mental ious r Se Serious Mental Illness ee t Commit ating n i d Coor Coordinating Commit t a h T em t s y tS ee a for n ctio A eral d Fe : d ar w r o F y a W e h T ir e h T d n a D SE d n a SMI With ing v i L le p o Pe l Al or f Works rs rs e iv g e ar C d n a s e i l Fami t t a h T em t s y S a for n ctio A eral d Fe : d ar w r o F y a W e h T The Way Forward: Federal Action for a System That ir e h T d n a D SE d n a SMI With ing v i L le p o Pe l Al or f Works Works for All People Living With SMI and SED and Their rs rs e iv g e ar C d n a s e i l Fami Families and Caregivers

7 1 20 , 3 1 ber m e c e D

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 7 1 20 , 3 1 ber m e c e D Decemcounterparts ber 13, 201age-matched 7 their than earlier years 10 roughly die SMI with people that show Data

, 2017 ecember 13 EngagingD people with 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

7 1 20 , 3 1 ber m e c e clinical settings improves access D 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

lies and Caregivers disseminateFami community-defined

evidence. Public health messaging

for All People Living With SMI and SED and Their

shouldWorks be inclusive and respectful

he Way Forward: Federal Action for a System That of diversity.T

rs rs e iv g e ar C d n a s e i l Fami

ir e h T d n a D SE d n a SMI With ing v i L le p o Pe l Al or f

The Challenges and Opportunities for Improving the System Works

Coordinating Committee t t a h T em t s y S a for n ctio A eral d Fe : d ar w r o F y a W e h

That Supports the Care of People With SMI and SED T

rious Mental Illness JosephSe Parks, Medical Director, National Council for Behavioral Health

ee t Commit ating n i d

Dr. Parks indicated that many Coor departmental

effectiveInter services are available for Illness Mental ious r people with SMI. Peer support and Se

population health management

partmental e d services are especially important. Inter

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 partmental e d Inter

Community providers also report report also providers Community

Illness loss. Mental ious r Se

partmental e d Inter Interdepartmental financial to due care providing

ee t not or beds closing Commit hospitals ating n i d Coor

Illness Mental ious r Se Serious Mental Illness with treatment, psychiatric indicate a shortage of available available of shortage a indicate

ee t Commit ating n i d Coor Coordinating Commit t a h T em t s y tS ee a for n Reports ctio A severe. eral d Fe : particularly d ar w r o F y a W e h T

ir e h T d n a D SE d n a is SMI With shortage ing v i L psychiatry le p The o Pe l Al or f Works

with SMI are uninsured. are rs e SMI iv g with e ar C d n a s e i l Fami

t t a h T em t s y S a for n ctio A eral d Fe : d ar w r o F y a W e h T Thpeople eof Way number Forwarsubstantial d A : Federalcommunity. Aand ctio state n by forvary a Sysservices temand Thattreatment of quality

ir e h T d n a D SE d n a SMI With ing v i L le p o Pe l Al or f Works and Worksavailability forthe All PeGenerally, opcrisis. le in LivSED ingand WithSMI with SMI people aof n d SEneeds Dthe andaddress Tto heir 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

rs rs e iv g e ar C d n a s e i l Fami Famipeople lof ie s aneeds ndthe Caregaddressing iv efor rs 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 7 1 20 , 3 1 ber m e c e D

behavioral health disorders disorders health behavioral

approximately three or four four or three approximately

people with SMI have have SMI with people 7 1 20 , 3 1 ber m e c e D December 13, 2017 most that is news bad The

, 2017 ecember 13 The newD Certified Community 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-

7 1 20 , 3 1 ber m e c e services, but it remains a demonstration program care Act (PAMA) creates and evaluates a 2-year D 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 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 coverage for evidence-based services. Families and Caregivers

for All People Living With SMI and SED and Their Finally,Works Dr. Parks outlined technical ways to address psychiatric service shortages, such as revising

the Conrad 30 Waiver Program, which allows medical doctors to apply for a waiver for the 2-year

The Way Forward: Federal Action for a System That

rs rs e iv g e ar C d n a s e i l residence requirement upon completion of the J-1 exchange visitor program, so waivers provided Fami

to psychiatrists do not count toward the ceiling of 30 slots; revising the Group on Educational

ir e h T d n a D SE d n a SMI With ing v i L le p o Pe l Al or f

Affairs (Association of American Medical Colleges) graduate medical education calculation for Works

Coordinating Committee t t a h T em t s y S a for n ctio A eral d Fe : d ar w r o F y a W e h supporting psychiatry residents to be the same as for obstetrician- gynecologists or primary care T

physicians; revising redistribution requirements for unused Medicare direct graduate medical

rious Mental Illness educationSe 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 willingness to ee t Commit ating n i d

exert executive powers in areas such as payments rates and performance measurement. Coor

Interdepartmental

Illness Mental ious r

Areas to Be Explored by the ISMICC Se

partmental e d The federal and expert presentations described above provide an important overview of key areas Inter

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

• partmental e d Inter

Mental health courts health Mental •

Justice Criminal

Jail diversion Jail •

Illness Intervention: Mental ious r Se Family-based treatments Family-based •

Intensive behavioral peer intervention for attention deficit hyperactivity disorder hyperactivity deficit attention for intervention peer behavioral Intensive

partmental e d Inter Interdepartmental •

Behavioral parent training training parent Behavioral

ee t • Commit ating n i d Coor Behavioral classroom management; management; classroom Behavioral •

Multisystemic therapy Multisystemic Illness Mental ious r Se 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 ee t Commit ating n i d Coor Coordinating Commit t a h T em t s y tS ee a for n ctio A • eral d Fe : d ar w r o F y a W e h T

Coordinated specialty care for youth with first-episode psychosis first-episode with youth for care specialty Coordinated

ir e h T d n a D SE d n a SMI With • ing v i L le p o Pe l Al or f Works Interpersonal therapy for adolescents with depression with adolescents for therapy Interpersonal • Youth

CBT; trauma-focused CBT trauma-focused CBT; •

rs rs and e iv g Children e ar C d n a s e i l Fami

High-fidelity wraparound wraparound High-fidelity • t t a h T em t s y S a for n ctio A eral d Fe : d ar w r o F y a W e h T The Way Forward: Federal Action for a System Tha t 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 ir e h T d n a D SE d n a SMI With ing v i L le p o Pe l Al or f Works Works for All People Living With SMI and SED a• nd Their

Coordinated specialty care for adults with first-episode psychosis first-episode with adults for care specialty Coordinated

rs rs e iv g e ar C d n a s e i l Fami 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 7 1 20 , 3 1 ber m e c e D

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 7 1 20 , 3 1 ber m e c e D December 13 , 2017 Meetings Future During Explore to ISMICC the for Areas

, 2017 ecember 13 Table 2.1.D Areas 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

7 1 20 , 3 1 ber m e c e Recovery • Telemedicine D (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

lies and Caregivers

Fami • Supported education

• Housing first

for All People Living With SMI and SED and Their

Access Worksto • System of care approach for children’s behavioral health

Services and • Comprehensive coordinated care; integration approaches

The Way Forward: Federal Action for a System That

Supports • Standards included in the Certified Community Behavioral Health Clinic demonstration rs rs e iv g e ar C d n a s e i l

• Specialized services and cultural competence training to address disparities among underserved Fami

ir e h T d n a D SE d n a SMI With ing v i L le p o Pe l Al or f

groups such as people of color, and lesbian, gay, bisexual and transgender individuals Works

• Health navigator programs such as the Peer Bridger Program and other family- and youth-led

Coordinating Committee t t a h T em t s y S a for n ctio A eral d Fe : d ar w r o F y a W e h programs T

• Findings from Meadows Mental Health Policy Institute continuum of crisis services, and related adult

and child crisis stabilization services

rious Mental Illness Se • Arizona model for connecting law enforcement to facility-based crisis stabilization

ee t Commit ating n i d

• Use of secret shopper surveys to assess network adequacy Coor

• Level of care instruments such as LOCUS and CALOCUS

Interdepartmental

Illness Mental ious r

Additionally, advances in our understanding of genetic, environmental, and developmental Se

factors across the lifespan hold great promise for earlier diagnosis of SMI and SED. Research partmental e d

on early intervention and treatment demonstrates the potential to improve the course of the Inter

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.

partmental e d Inter

t t a h T em t s y S a for n ctio A eral d Fe : d ar w r o F y a W e h T The Way Forward: Federal Action for a System That ir e h T d n a D SE d n a SMI With ing v i L le p o Pe l Al or f Works Works for All Peocaregivers. pleand Livingfamilies Withtheir and SMISED and a ndSMI SEwith D aliving nd TheAmericans ir serve

rs rs e iv g e ar C d n a s e i l Fami Famieffectively to lies aneeded nd Carresources ethe g iversdefine 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 7 1 20 , 3 1 ber m e c e D

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 7 1 20 , 3 1 ber m e c e D Dethat ceso mber 13, 20mechanisms, 17 delivery on focus a included have development drug in advances Recent

, 2017 ecember 13 ChapterD 3: Setting the Stage for Evaluation of Federal

Programs Related to SMI and SED

7 1 20 , 3 1 ber m e c e D

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.

lies and Caregivers Those effortsFami begin now. Over the next five years, the ISMICC will work in collaboration with

federal interdepartmental leadership to build shared accountability for a system that provides for All People Living With SMI and SED and Their

the fullWorks range of treatments and supports needed by individuals and families living with SMI and

he Way Forward: Federal Action for a System That

SED. T rs rs e iv g e ar C d n a s e i l Fami

ir e h T d n a D SE d n a SMI With ing v i L le p o Pe l Al or f

This will be a challenging undertaking. ISMICC members recognize that it will require Works

partnerships with all levels of government and a diverse array of other stakeholders. Mental health

Coordinating Committee t t a h T em t s y S a for n ctio A eral d Fe : d ar w r o F y a W e h care and treatment is not solely a federal responsibility, but rather one shared across federal, T

state, tribal, and local governments; private insurers; diverse provider organizations; advocates;

rious Mental Illness

caregivers;Se families; and people with SMI and SED. Figure 3.1 illustrates this point by showing the

ee t Commit ating n i d

complexity of funding for treatment of mental health and substance use disorders in the United Coor

departmental States. Inter

Illness Mental ious r

In the course of their deliberations, ISMICC members have emphasized that this review of federal Se

initiatives must rise above the level of simply looking at individual programs. The ISMICC vision

partmental e d

calls for federal interdepartmental leadership in collaboration with others to build responsive Inter 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 partmental e d Inter

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 ious r Se

partmental e d Inter Interexample, dFor epartmentalconstituents. 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. ee t and SMI with people Commit of needs ating n i d Coor

Illness Mental ious r Se Sethe riousaddress 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: ee t Commit ating n i d Coor Coormore grow to dprojected indisorders atinguse substance and Commit t mental a on h T Spending em t (2014). s y M. tS C. ee a Chow, & for T., n Yee, R., K. ctio A Levit, L., T. eral d Mark, Fe : d ar w r o F y a W e h T

ir e h T d n a D SE d n a SMI With ing v i L le p o Pe l Al or f Works

5.8 % % 5.8

Other Federal Other rs e iv g e ar C d n a s e i l Fami

12.6 % % 12.6 2.8 % % 2.8 Medicare

t t a h T em t s y S a for n ctio A eral d Fe : d ar w r o F y a W e h T TPrivate h eOther 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 ir e h T d n a D SE d n a SMI With ing v i L le p o Pe l Al or f Works WorksInsurance Private for All People Living With SMI and SED and Their

rs rs e iv g e ar C d n a s e i l Fami 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

7 1 20 , 3 1 ber m e c e D

Substance Use Disorder (SUD) Treatment (SUD) Disorder Use Substance

3.1. Figure 7 1 20 , 3 1 ber m e c e D D ecand e mber(MH) 13, Health 20 17 Mental for Sources Funding Private and Government

, 2017 ecember 13 The reviewD of federal 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

7 1 20 , 3 1 ber m e c e as a major source of funding for treatment and recovery support services for people with SMI and D 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 lies and Caregivers

of peopleFami with SMI and SED. The Assistant Secretary must work across HHS and the federal

for All People Living With SMI and SED and Their governmentWorks so people with SMI and SED receive the highest possible standard of care—care that

he Way Forward: Federal Action for a System That is deeplyT informed by our knowledge of science and medicine.

rs rs e iv g e ar C d n a s e i l

These eight departments have made a commitment to align their policies, assess their Fami

ir e h T d n a D SE d n a SMI With ing v i L le p o Pe l Al or f

programming, and improve care for people with SMI and SED. Their collaboration will be Works

Coordinating Committee t t a h T em t s y S a for n ctio A eral d Fe : d ar w r o F y a W e h informed and strengthened by the participation of non-federal ISMICC members, including T

national experts on health care research, mental health providers, advocates, and people with

rious Mental Illness mentalSe health conditions and their families.

ee t Commit ating n i d Coor

departmental

Direct Interand Indirect Levers of Federal Influence Illness Mental ious r Se

As the ISMICC undertakes the challenging work of evaluating and recommending ways to

partmental e d strengthen federal policies and programs, a key goal will be to ensure that changes made at the Inter 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, partmental e d Inter

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 ious r Se partmental e d Inter Interbeen has dflexibility e partmentalthis 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 ee t which program, Home Commit ating n i d Coor 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

Illness Mental ious r Se Secounties r ious(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

ee t Commit ating n i d Coor Coornext. the to dstate i none atingfrom Commit t substantially a h vary T can em t s y tservices S ee for a for n payment of ctio A methods eral d Fe : d ar w r o F y a W e h T

by the federal and state governments, the configuration of reimbursable services and and services reimbursable of ir e h T configuration d the n a D SE d governments, n a state and SMI federal With the by ing v i L le p o Pe l Al or f 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 rs e iv g e ar C d n a s e i l Fami

t t a h T em t s y S a for n ctio A eral d Fe : d ar w r o F y a W e h T 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, ir e h T d n a D SE d n a SMI With ing v i L le p o Pe l Al or f Works Works for All People Living With SMI and SED and The• ir

rs rs e iv g e ar C d n a s e i l Fami 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 7 1 20 , 3 1 ber m e c e D

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 7 1 20 , 3 1 ber m e c e D December 13, 2017 •

, 2017 ecember 13 D enable people 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

7 1 20 , 3 1 ber m e c e the lives of people with SMI and SED and their families. A partial list of examples would include: D

• 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

lies and Caregivers

Famiconduct ongoing major national surveys to help us understand patterns and

for All People Living With SMI and SED and Their Worksprevalence of a broad range of health and behavioral health disorders, patterns of care,

as well as some of the contributing social factors.

The Way Forward: Federal Action for a System That

rs rs e iv g e ar C d n a s e i l

• Demonstrations and evaluations of prevention, treatment, and support models Fami

ir e h T d n a D SE d n a SMI With ing v i L le p o Pe l Al or f

that can improve the lives of people with SMI and SED. SAMHSA, the Office of Works

dinating Committee

Coorthe Assistant Secretary for Planning and Evaluation, and the Centers for Medicare & t t a h T em t s y S a for n ctio A eral d Fe : d ar w r o F y a W e h

Medicaid Services have collaborated on relevant demonstration programs, such as T

the Certified Community Behavioral Health Clinic (CCBHC) program that provides

rious Mental Illness

Sealternative payment models and more integrated, comprehensive care for people with

ee t Commit ating n i d

SMI and SED. The Center for Medicare and Medicaid Innovation has implemented Coor

departmental

Interand is assessing an extensive roster of alternative delivery and payment programs,

Illness Mental ious r including many that impact health and behavioral health care for people with SMI and Se

SED.

partmental e d

• Time-limited grant programs to fund development of promising models at Inter 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 partmental e d Inter

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 ious r Se partmental e d Inter Interde partmentalevaluation. 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 ee t begun have we meeting, Commit ISMICC ating n i d Coor

Illness Mental ious r Se first Sethe riousSince 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 ee t Commit ating n i d Coor Coordinating Commit t a h T em t s y tS ee a for n ctio A eral d Fe : d ar w r o F y a W e h T

ir e h T d n a D SE d n a SMI With ing v i L le p o Pe l Al or f Works in the years ahead. rs years e iv the g in e ar C d n a s e i l Fami

t t a h T em t s y S a for n ctio A eral d Fe : d ar w r o F y a W e h T 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

ir e h T d n a D SE d n a SMI With ing v i L le p o Pe l Al or f Works as Worksserve can forthey All which Pein opways lethe Livand ing Withprograms, SMIand apolicies nd these SE D anExamining d TSED. heand ir SMI

rs rs e iv g e ar C d n a s e i l Fami Famiwith liepeople s for a nd Csupports ar eand giversservices 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 7 1 20 , 3 1 ber m e c e D

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 7 1 20 , 3 1 ber m e c e D December 13, 2017 •

, 2017 ecember 13 D behavioral 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

7 1 20 , 3 1 ber m e c e SED? In addition to the ISMICC, what structures are in place to develop and sustain D 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

lies and Caregivers

Famicircumstances. It also may occur simply as the result of inadequate funding—a

for All People Living With SMI and SED and Their Worksuniversally important consideration that may be difficult to address. What can 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

rs rs e iv g e ar C d n a s e i l

4. Are there important gaps in knowledge or information that make it difficult Fami

ir e h T d n a D SE d n a SMI With ing v i L le p o Pe l Al or f

to assess the extent to which we are achieving goals related to public health Works

Coordinating Committee t t a h T em t s y S a for n ctio A eral d Fe : d ar w r o F y a W e h outcomes for people with SMI and SED? Given the context of our complex system T

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

rious Mental Illness

Sekey issues or progress in resolving problems. What can be done to improve access to ee t Commit ating n i d

public health indicators in such areas? For example, the need to involve the criminal Coor

departmental

Interjustice system is widely viewed as a sign of failure of community treatment systems,

Illness Mental ious r yet we have no way to obtain comprehensive information on such incidents. In other Se

cases, programs that serve people with SMI and SED do not collect information that

partmental e d

allows identification of that segment of program participants. Inter 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

partmental e d Inter

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 ious r Se

9. partmental e d Inter Interdimplementing epartmentalstates or regions for guidance clearer where areas there Are ee t Commit ating n i d Coor

Illness Mental ious r Se 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. ee t Commit ating n i d Coor Coor of dprinciples i nthe atingapply Commitprogram t a the h T does em t s y tS programs, ee a for n treatment ctio A direct For eral d Fe : d ar w r o F y a W e h T

ir e h T d n a D SE d n a SMI With ing v i L le p o Pe l Al or f 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 rs e iv g e ar C d n a s e i l Fami

t t a h T em t s y S a for n ctio A eral d Fe : d ar w r o F y a W e h T 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

ir e h T d n a D SE d n a SMI With ing v i L le p o Pe l Al or f Works WorksAre forprogram? Althe lin People Lparticipation ivingand Withprogram the SMIof areach ndthe SEDincrease ato nd steps Their

rs rs e iv g e ar C d n a s e i l Fami Famiactive take lit iesDoes and them? C aregreceiving iv eare rswho 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 7 1 20 , 3 1 ber m e c e D

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 7 1 20 , 3 1 ber m e c e D Decundergone e mber 1program 3, the 20 1Has 7 it? evaluate to plans there are or evaluated, been program

, 2017 ecember 13 10.D Are there 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

7 1 20 , 3 1 ber m e c e across departments and programs. This could facilitate the collection of data D 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 lies and Caregivers

Famiand the Medical Expenditure Panel Survey. Is it feasible to use these data to monitor

for All People Living With SMI and SED and Their

Worksthe effectiveness of efforts to improve the care and quality of life for SMI and SED

he Way Forward: Federal Action for a System That T populations over time?

rs rs e iv g e ar C d n a s e i l

It will be critical to identify gaps that occur either through the absence of essential policies or Fami

ir e h T d n a D SE d n a SMI With ing v i L le p o Pe l Al or f

programs, or through programs that fail to reach all of those in need. The 21st Century Cures Works

Coordinating Committee t t a h T em t s y S a for n ctio A eral d Fe : d ar w r o F y a W e h

Act created new programs and initiatives to address the needs of people with SMI and SED. If T

Congress provides funding to implement or continue these programs, the ISMICC can examine

rious Mental Illness them toSe assess what is working and where additional improvements are called for.

ee t Commit ating n i d

This work will require a level of commitment from the departments that participate in the Coor

departmental

ISMICCInter process, and will benefit from the expertise and guidance of the full membership. A key

Illness Mental ious r concern will be how to ensure that improvements developed at the federal level are implemented Se

comprehensively throughout the states, tribes, and localities across the nation. Given the complex

partmental e d and multilayered federal, state, and local funding streams that support services needed by the Inter

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

• partmental e d Inter

IDEA Parent Information Parent IDEA

•

Elementary and Secondary School Counseling Program Counseling School Secondary and Elementary •

Illness (IDEA) Act Mental ious r Se

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

partmental e d Inter Interdepartmental •

Department of Education of Department

ee t Commit ating n i d Coor

TRICARE

Illness Mental ious r Se 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

ee t Commit ating n i d Coor Coordinating Commit t a h T em t s y tS ee a for n ctio A eral d Fe : • d ar w r o F y a W e h T

In-Transition •

Direct Care (DC) System Mental Health Services Health Mental System (DC) Care Direct ir e h T d n a D SE d n a SMI With ing v i L le • p o Pe l Al or f Works

Army Behavioral Health Residential Treatment Facilities Treatment Residential Health Behavioral Army

rs rs e iv g • e ar C d n a s e i l Fami

t t a h T em t s y S a for n ctio A eral d Fe : d ar w r o F y a W e h T The Way Forward: Federal Action for a System ThDefense aof t Department

ir e h T d n a D SE d n a SMI With ing v i L le p o Pe l Al or f Works Works for All People Living WithSED SMIand SMI andWith SEDPeople and Support T heCan ir That

Federal Programs Related to SMI and SED Programs Programs SED and SMI to Related Programs Federal 3.1. Table

rs rs e iv g e ar C d n a s e i l Fami 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 7 1 20 , 3 1 ber m e c e D 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 7 1 20 , 3 1 ber m e c e D December 13, 2017 Programs Federal About Date to Known Is What

, 2017 ecember 13 Table 3.1.D Federal Programs Related to SMI and SED Programs That Can Support People With SMI and SED (continued)

Department of Health and Human Services

7 1 20 , 3 1 ber m e c e Administration for Children and Families D • 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 lies and Caregivers

SystemFami

for All People Living With SMI and SED and Their • EmpoweringWorks Parents: National Research Center for Parents with Disabilities and their Families

• Enhancing the Community Living and Participation of Individuals with Psychiatric Disabilities

The Way Forward: Federal Action for a System That

rs rs e iv g e ar C d n a s e i l • Evaluating the Impact of Employment Services in Supportive Housing Fami

• Identifying Enabling Environments Affecting Adults with Psychiatric Disabilities

ir e h T d n a D SE d n a SMI With ing v i L le p o Pe l Al or f

• Increasing Community Participation Among Adults with Psychiatric Disabilities Through Intentional Peer Support Works

Coordinating Committee t t a h T em t s y S a for n ctio A eral d Fe : d ar w r o F y a W e h • Increasing Community Participation in Adults with Schizophrenia T

• Integrated Program to Improve Competitive Employment in Dually Diagnosed Clients

• Integrated Scaling Approach: A Model for Large Scale Implementation of Effective Interventions for Employment. rious Mental Illness

• ManualSe and Training Program to Promote Career Development Among Transition Age Youth and Young Adults with

ee t Commit ating n i d

Psychiatric Conditions Coor

departmental • RecoveryInter 4 US – Development of a Photovoice-Based Social Media Program to Enhance the Community

Participation and Recovery of Individuals with Psychiatric Disabilities Illness Mental ious r

• Rehabilitation Research and Training Center on Improving Employment Outcomes for Individuals with Psychiatric Se

Disabilities

partmental e d • Rehabilitation Research and Training Center on Self-Directed Recovery and Integrated Health Care Inter

• 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 partmental e d Inter

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 •

Administration Illness Drug and Food Mental ious r Se

Center for Medicare and Medicaid Innovation Demonstration Projects Demonstration Innovation Medicaid and Medicare for Center

partmental e d Inter Interdepartmental • Children’s Health Insurance Program (CHIP) Program Insurance Health Children’s •

ee Services t Community-Based and Commit Home- – ating n i d Coor

Illness Mental ious r Se 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 –

ee t Commit ating n i d Coor Coordinating Commit t Tool a h T Analytic Data em t SMI s – y tS ee a Program for n Accelerator ctio A Innovation eral d Medicaid Fe – : d ar w r o F y a W e h T

– Health Homes Health –

ir e h T d n a D SE d n a Innovation for SMI With Opportunities on ing v i L Guidance – le p o Pe l Al or f Works

– Certified Community Behavioral Health Clinics Health Behavioral Community rs e Certified iv – g e ar C d n a s e i l Fami

Selected Programs Focused on SMI on Focused Programs Selected t t a h T em t s y S a for n ctio A eral d Fe : d ar w r o F y a W e h T The Way Forward: Federal Action for a System That •

Medicaid

ir e h T d n a D SE d n a SMI With ing v i L le p o Pe l Al or f Works Works for All People Living With SMI and SED and Their •

Care Management and Coordination Services Coordination and Management Care •

Medicare rs rs e iv g e ar C d n a s e i l Fami 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 7 1 20 , 3 1 ber m e c e D

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 7 1 20 , 3 1 ber m e c e D December 13, 2017 3.1. Table

, 2017 ecember 13 Table 3.1.D Federal Programs Related to SMI and SED Programs That Can Support People With SMI and SED (continued)

Department of Health and Human Services (continued)

7 1 20 , 3 1 ber m e c e – Teaching Health Center Graduate Medical Education Program D – 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)

lies and Caregivers • AppliedFami Research Towards Zero Suicide Healthcare Systems (R01)

• Bipolar-Schizophrenia Network for Intermediate Phenotypes

Works for All People Living With SMI and SED and Their

• Detecting and Preventing Suicide Behavior, Ideation and Self-Harm in Youth in Contact with the Juvenile Justice

he Way Forward: Federal Action for a System That SystemT (R01)

rs rs e iv g e ar C d n a s e i l • Effectiveness Trials for Post-Acute Interventions and Services to Optimize Longer-term Outcomes (R01 and R34) Fami

• Exploratory Clinical trials of Novel Interventions for Mental Disorders (R61/R33)

ir e h T d n a D SE d n a SMI With ing v i L le p o Pe l Al or f

• Improving Health Outcomes and Reducing Premature Mortality in Serious Mental Illness Works

Coordinating Committee t t a h T em t s y S a for n ctio A eral d Fe : d ar w r o F y a W e h • North American Prodrome Longitudinal Study T

• Pilot Studies to Detect and Prevent Suicide Behavior, Ideation, and Self-Harm in Youth in Contact with the Juvenile

Justice System (R34) rious Mental Illness

• ProductsSe to Support Applied Research Towards Zero Suicide Healthcare Systems (R43/R44) ee t Commit ating n i d

• Psychiatric Genomics Consortium Coor

departmental

• RAISEInter Recovery after an Initial Schizophrenia Episode

Illness Mental ious r • Reducing the Duration of Untreated Psychosis in the United States (R01 and R34) Se

• Temporal Dynamics of Neurophysiological Patterns as Potential Targets for Treating Cognitive Deficits in Brain

Disorders (R01) partmental e d

• Using the NIMH Research Domain Criteria (RDoC) Approach to Understand Psychosis (R21/R01) Inter 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 • partmental e d Inter

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

Illness • Mental ious r Se Suicide Prevention Resource Center Resource Prevention Suicide •

Statewide Family Networks Family Statewide partmental e d Inter Interdepartmental •

Statewide Consumer Networks Consumer Statewide

ee t Commit • ating n i d Coor

Service Members, Veterans, and their Families – Technical Assistance Center Assistance Technical – Families their and Veterans, Members, Service

Illness Mental ious r Se 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

ee t Commit ating n i d Coor Coordinating Commit t a h T em t s y tS ee a for n ctio A eral d Fe : • d ar w r o F y a W e h T 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

ir e h T d n a D SE d n a SMI With ing v i L le • p o Pe l Al or f Works

Projects for Assistance in Transition from Homelessness from Transition in Assistance for Projects

rs rs e iv g • e ar C d n a s e i l Fami

Programs to Achieve Wellness Achieve to Programs

t t a h T em t s y S a for n ctio A eral d Fe : d ar w r o F y a W e h T 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

ir e h T d n a D SE d n a SMI With ing v i L le p o Pe l Al or f 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 rs rs e iv g e ar C d n a s e i l Fami 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 • 7 1 20 , 3 1 ber m e c e D

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 7 1 20 , 3 1 ber m e c e D December 13, 2017

, 2017 ecember 13 Table 3.1.D Federal Programs Related to SMI and SED Programs That Can Support People With SMI and SED (continued)

Department of Justice

7 1 20 , 3 1 ber m e c e Bureau of Justice Assistance D • 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

lies and Caregivers • JuvenileFami Drug Treatment Court Program

• Formula Grants for All People Living With SMI and SED and Their

• JuvenileWorks Accountability Block Grant

he Way Forward: Federal Action for a System That

• SecondT Chance Act Reentry

rs rs e iv g e ar C d n a s e i l

Department of Labor Fami

ir e h T d n a D SE d n a SMI With ing v i L le p o Pe l Al or f

Office of Disability Employment Policy Works

• Campaign for Disability Employment

Coordinating Committee t t a h T em t s y S a for n ctio A eral d Fe : d ar w r o F y a W e h

• Job Accommodation Network T

• State Leadership Mentoring Programs

rious Mental Illness

• WorkforceSe Recruitment Program

ee t Commit ating n i d

Employment and Training Administration Coor

departmental • AmericanInter Job Center Network

• Employer Technical Assistance Center Illness Mental ious r

• Reentry Employment Opportunities Se

• State Leadership Mentoring Program

partmental e d

• Workforce Innovation and Opportunity Act Programs Inter • 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 partmental e d Inter Programs Federal Evaluate to ISMICC the of Work Future

Illness Mental ious r Se

Work Incentives Planning and Assistance and Planning Incentives Work partmental e d Inter Interdepartmental •

Supported Employment Demonstration Employment Supported

ee t Commit • ating n i d Coor

Supplemental Security Income Security Supplemental

Illness Mental ious r Se Serious Mental Illness •

Social Security Disability Insurance Disability Security Social •

SOAR – SSI/SSDI Outreach Access and Recovery and Access Outreach SSI/SSDI – SOAR

ee t Commit ating n i d Coor Coordinating Commit t a h T em t s y tS ee a for n ctio A eral d Fe : • d ar w r o F y a W e h T Protection and Advocacy and Protection •

PROMISE – Promoting Readiness of Minors in SSI in Minors of Readiness Promoting – PROMISE

ir e h T d n a D SE d n a SMI With ing v i L le • p o Pe l Al or f Works

Military Casualties/Wounded Warriors Casualties/Wounded Military

rs rs e iv g • e ar C d n a s e i l Fami

Homeless with Schizophrenia Presumptive Disability* Presumptive Schizophrenia with Homeless t t a h T em t s y S a for n ctio A eral d Fe : d ar w r o F y a W e h T The Way Forward: Federal Action for a System That •

ir e h T d n a D SE d n a SMI With ing v i L le p o Pe l Al or f Works Works for All People Living With SMI and SED anAdministration d TheSecurity ir Social Therapeutic and Supported Employment Services Employment Supported and Therapeutic •

Substance Use Disorder Treatment Disorder Use Substance rs rs e iv g e ar C d n a s e i l Fami 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 7 1 20 , 3 1 ber m e c e D

That Can Support People With SMI and SED (continued) SED and SMI With People Support Can That

3.1. Table 7 1 20 , 3 1 ber m e c e D December 13, 20 17 Programs SED and SMI to Related Programs Federal

, 2017 ecember 13 ChapterD 4: Recommendations From Non-Federal ISMICC

Members

7 1 20 , 3 1 ber m e c e D

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

lies and Caregivers and “boarding”Fami of people with acute psychiatric conditions in emergency departments for

for All People Living With SMI and SED and Their hours orWorks days. We hope that coordinated federal efforts will enable our partners in states and

communities to strengthen their efforts in support of these goals.

The Way Forward: Federal Action for a System That

rs rs e iv g e ar C d n a s e i l

On the following pages we present these Fami

Source of Recommendations ir e h T d n a D SE d n a SMI With ing v i L le p o Pe l Al or f

recommendations. The recommendations call Works

dinating Committee for specificCoor actions that we see as important and t t a h T em t s y S a for n ctio A eral d Fe : d ar w r o F y a W e h These recommendations reflect the views of the T 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

rious Mental Illness

indicateSe whether we believe it could be achieved in 1 federal processes, but the final list of recom-

mendations are the product of the non-federal ee t Commit ating n i d

year or less (short term), 2-3 years (medium term), or members. These recommendations do not repre- Coor

departmental 4-6 yearsInter (longer term). sent federal policy, and the federal departments

represented on the ISMICC have not reviewed Illness Mental ious r

All of the recommendations call for actions to be the recommendations to determine what role they Se

could play in the future activities of the depart-

taken by federal departments represented on the partmental e d ments. The recommendations should not be Inter

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 partmental e d Inter

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

Illness d. Mental ious r Se

partmental e d Inter 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 ee t sessions, working are Commit ating n i d Coor

Illness Mental ious r Se Semeetings riousThese 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.

t t a h T em t s y S a for n ctio A eral d Fe : d ar w r o F y a W e h T ee t Commit ating n i d Coor Coordinating Commitneeded. as teeServices Rehabilitative and

Invite sub-agencies such as the Bureau of Prisons and the Office of Special Education Education Special of Office the and ir e h T Prisons d of n a D Bureau SE the as d n a such SMI sub-agencies With Invite ing v i L le p o Pe l Al or f Works

Conduct regularly occurring interdepartmental meetings of federal ISMICC members. members. ISMICC federal of meetings interdepartmental occurring regularly Conduct rs rs e b. iv g e ar C d n a s e i l Fami

t t a h T em t s y S a for n ctio A eral d Fe : d ar w r o F y a W e h T The Way Forward: Federal Action for a System That

actively participate. actively

ir e h T d n a D SE d n a SMI With ing v i L le p o Pe l Al or f Works Worksto forempowered be All Peshould ople Livingrepresentatives With Department SMI anmeetings. d SED and Tinterdepartmental heir

Obtain commitment by all ISMICC federal departments to participate in in participate to departments federal ISMICC all by commitment Obtain rs rs e iv g e ar C d n a s e i l Fami 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 7 1 20 , 3 1 ber m e c e D

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 7 1 20 , 3 1 ber m e c e D final DeThe c ember 13, accomplished. 20 1been 7 has what on data include will Congress to Report ISMICC final The

, 2017 ecember 13 1.2. DevelopD and implement 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

7 1 20 , 3 1 ber m e c e planning” language in the 21st Century Cures Act, extend to all the federal ISMICC partners, D 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

lies and Caregivers

Famion people with SMI and SED or play a significant role in the service system for people with

for All People Living With SMI and SED and Their WorksSMI and SED. [Short-term recommendation]

he Way Forward: Federal Action for a System That

1.4. THarmonize and improve policies to support federal coordination. The federal

rs rs e iv g e ar C d n a s e i l

departments participating in the ISMICC will address specific issues that impede Fami

ir e h T d n a D SE d n a SMI With ing v i L le p o Pe l Al or f

coordination and effectiveness. Activities include but are not limited to the following. Works

dinating Committee Coor[Short-term recommendation] t t a h T em t s y S a for n ctio A eral d Fe : d ar w r o F y a W e h T

a. Establish uniform definitions of SMI and SED and a shared lexicon across federal

rious Mental Illness

Sedepartments to promote understanding, coordination, and integration of services

ee t Commit ating n i d

and supports for people with SMI and SED. Include definitions that support inclusion Coor

departmental Interof individuals who have SMI or SED with co-occurring substance use disorders,

Illness Mental ious r developmental disabilities, and traumatic brain injury. Se

b. Identify federal policies or other barriers across federal departments that preclude or

partmental e d

impede access to services, treatments, or continuity of care. Assess whether federal Inter 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 partmental e d Inter

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 ious r Se partmental e d Inter Intermeasures, quality departmentalexisting 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 ee t coordinate and harmonize Commit to ating n i d Coor 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. Illness Mental ious r Se Se riousexisting Use Mental Illness

experiencing SMI. SMI. experiencing ee t Commit ating n i d Coor Coordinating Commit t a h T em recommendation] t s y tS ee a for [Medium-term n ctio A eral d Fe : d ar w r o F y a W e h T

for all federal health programs for children and youth experiencing SED and for adults adults for and SED experiencing ir e h youth T d and n a D children SE for d n a programs SMI health With federal ing all v i for L le p o Pe l Al or f 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 rs The e iv g e ar C d n a s e i l Fami

t t a h T em t s y S a for n ctio A eral d Fe : d ar w r o F y a W e h T The Wtransparently. ay Foprogress rwardmeasure : Fecan deralcounties Aand ctiotribes, n forstates, a Sysagencies, tem federal T hatwhich by ir e h T d n a D SE d n a SMI With ing v i L le p o Pe l Al or f Works Worksmeasures for recovery Allcore Peof oset plethis Livingincluding With SMIdashboard anational n a d SEDEstablish and Thintegration. eir

rs rs e iv g e ar C d n a s e i l Fami Familiecommunity s aand n d Cillness, ar egivmental eof rs 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 7 1 20 , 3 1 ber m e c e D

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. 7 1 20 , 3 1 ber m e c e D Desystems, cemberEvaluate 13, 2017

, 2017 ecember 13 Focus D2: Access and 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 7 1 20 , 3 1 ber m e c e SAMHSA publication, Crisis Services: Cost Effectiveness and Funding Strategies. Develop D 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

lies and Caregivers

Famia continuum of services that includes inpatient psychiatric care, when needed, with

for All People Living With SMI and SED and Their Workscommunity-based resources also available. Ensure that people with SMI and SED receive

care in the least-restrictive safe setting available that meets their mental health service

The Way Forward: Federal Action for a System That

rs rs e iv g e ar C d n a s e i l needs. [Longer-term recommendation] Fami

ir e h T d n a D SE d n a SMI With ing v i L le p o Pe l Al or f

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

dinating Committee

Coorand caregivers about the Health Insurance Portability and Accountability Act t t a h T em t s y S a for n ctio A eral d Fe : d ar w r o F y a W e h

of 1996 (HIPAA) and other privacy laws, including 42 CFR Part 2, in the context T

of psychiatric care. There is a need for clarification and guidance regarding the value

rious Mental Illness

Seand need for communication with family members and caregivers. For example, there

ee t Commit ating n i d

are permitted disclosures of protected health information in the context of psychiatric Coor

departmental

Intercrises. There is justification for engaging families and caregivers in responding to the

Illness Mental ious r needs of their loved ones. Technical assistance and training is needed on how to involve Se

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 partmental e d

while empowering people with SMI to direct their own care, such as psychiatric advance Inter

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 partmental e d Inter

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 ious r Se partmental e d Inter Intercross- (e.g., departmentaltelemedicine 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 ee t and SED and SMI Commit with ating n i d Coor 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

Illness Mental ious r Se Sestandards riousEstablish Mental Illness

ee t Commit ating n i d Coor Coordinating Commit t a h T em t s y tS ee a for n ctio A eral d recommendation] Fe : d ar w r o F y a W e h T accordance with the Workforce Innovation and Opportunity Act and IDEA. IDEA. and Act Opportunity and Innovation Workforce the with accordance

[Longer-term [Longer-term ir e h T d n a D SE d n a SMI With ing v i L le p o Pe l Al or f 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 rs to e iv g e ar C d n a s e i l Fami

t t a h T em t s y S a for n ctio A eral d Fe : d ar w r o F y a W e h T The psychosis, W ay Forwfirst-episode aror d: FeSED/SMI deralwith A16-25 ctioages n forstudents aall Sfor y stem planning That transition ir e h T d n a D SE d n a SMI With ing v i L le p o Pe l Al or f Works WorksProvide SED). fand or AlSMI l Pewith oplestudents Lfor iving Withmeetings [IEP] SMI aprogram nd SEeducation D and Thindividualized eir

rs rs e iv g e ar C d n a s e i l Fami Famiin liespecialists s andsupport Carfamily e givand ers 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 7 1 20 , 3 1 ber m e c e D

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. 7 1 20 , 3 1 ber m e c e D Dececonsumer m berof 13, 201monitoring 7 and care of level for assessments standardized Establish

, 2017 ecember 13 Db. Incentivize 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

7 1 20 , 3 1 ber m e c e there are severe shortages, such as child psychiatry and in addressing underserved D 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

lies and Caregivers Famiaddressing the needs of people with SMI and SED.

for All People Living With SMI and SED and Their

Worksg. Enable health care providers to practice to the full extent of their education and

he Way Forward: Federal Action for a System That T training. For example, remove barriers that prevent advanced practice registered nurses

rs rs e iv g e ar C d n a s e i l

from prescribing medication. Fami

ir e h T d n a D SE d n a SMI With ing v i L le p o Pe l Al or f

h. Develop a workforce that is representative of the populations served (including racial Works

Coordinating Committee t t a h T em t s y S a for n ctio A eral d Fe : d ar w r o F y a W e h

and ethnic minorities, people in rural areas, and populations facing health disparities T

such as lesbian, gay, bisexual, or transgender individuals) and able to provide services

rious Mental Illness Sein a culturally competent manner.

ee t Commit ating n i d

i. Develop standards for network adequacy in health plans, and identify and implement Coor

departmental

Interprocesses to monitor access to services and adherence to established standards.

Illness Mental ious r

2.9. Support family members and caregivers. Develop and disseminate programs for non- Se

partmental e d professional caregivers of children with SED and adults with SMI. Programming should be Inter

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 partmental e d Inter e.

services; care primary and health mental integrated Bidirectional

outpatient civil commitment and assisted outpatient treatment; outpatient assisted and commitment civil Illness outpatient Mental ious r Se

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

partmental e d Inter Interdepartmental d.

family support specialists as a matter of routine practice; routine of matter a as ee t specialists support family Commit ating n i d Coor

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 Illness Mental ious r Se Serious Mental Illness c.

Supportive services, such as supportive housing, employment, and education; and employment, housing, supportive as such services, Supportive

ee t Commit ating n i d Coor Coordinating Commit t a h T em t s y tS ee a for n ctio A eral d b. Fe : d ar w r o F y a W e h T

ir e h T d n a D SE d medications; n a SMI antipsychotic With injectable ing v i L le p o Pe l Al or f 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 rs e iv g e ar C d n a s e i l Fami

Guidance on effective use of psychopharmacological medications, including taking taking including medications, psychopharmacological of use effective on Guidance t t a h T em t s y S a for n ctio A eral d Fe : d ar w r o F y a W e h T The Way Forward: Federal Action for a System That a.

ir e h T d n a D SE d n a SMI With ing v i L le p o Pe l Al or f Works Works for All People Living With SMI and SED and Their following. following. [Medium-term recommendation] [Medium-term

rs rs e iv g e ar C d n a s e i l Fami the Famileast at liesinclude andmust Carestandards g iveThese rs 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 7 1 20 , 3 1 ber m e c e D

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 7 1 20 , 3 1 ber m e c e D De cemberExpand 13, 2017

, 2017 ecember 13 j. D Comprehensive and integrated systems of care for people who need varying levels of intensive services and supports on an ongoing basis, including community-delivered

services.

7 1 20 , 3 1 ber m e c e 3.2. Make screening and early intervention among children, youth, transition- D 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

lies and Caregivers

Famibenefit programs, including Medicaid, Medicare, Department of Defense, the Veterans

for All People Living With SMI and SED and Their WorksAdministration, and TRICARE. Continue the SAMHSA block grant set-aside requirements,

and provide guidance to facilitate payment by all public and private insurance programs.

The Way Forward: Federal Action for a System That

rs rs e iv g e ar C d n a s e i l [Medium-term recommendation] Fami

ir e h T d n a D SE d n a SMI With ing v i L le p o Pe l Al or f

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

Coordinating Committee t t a h T em t s y S a for n ctio A eral d Fe : d ar w r o F y a W e h systems of care for people with SMI and SED. Adverse childhood experiences and T

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.

rious Mental Illness

SePeople with SMI and SED commonly experience problems with health, substance use ee t Commit ating n i d

disorders, and the need for supportive housing, employment, and education. To address Coor

departmental

Interthe mortality gap, we must provide access to integrated health and behavioral health care

Illness Mental ious r that identifies and addresses all health and social determinants in every treatment setting. Se

[Longer-term recommendation]

partmental e d

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

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 partmental e d Inter

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 ious r Se

3.7. Advance the national adoption of effective suicide prevention strategies. prevention suicide effective of adoption national the Advance partmental e d Inter Interfederal All departmental

ee t Commit ating n i d Coor facilities, nursing homes, or board and care homes. homes. care and board or homes, nursing facilities, [Medium-term recommendation] [Medium-term

Illness Mental ious r Se 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.

ee t Commit ating n i d Coor Coor housing d ifair natingfederal with Commit t consistent a h T SMI, with em t s y tS people ee a for n non-elderly for ctio A eral d preferences Fe : d ar w r o F y a W e h T

issue guidance for state and local housing authorities on establishing tenant selection selection tenant establishing on ir e h T d authorities n a D housing SE d local n a and state SMI for With guidance ing v i issue L le p o Pe l Al or f 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 rs have e iv g e ar C d n a s e i l Fami

t t a h T em t s y S a for n ctio A eral d Fe : d ar w r o F y a W e h T 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,

ir e h T d n a D SE d n a SMI With ing v i L le p o Pe l Al or f Works Worksproviding foron All Peemphasis oplespecial Lwith i vingSED, Withand SMI SMIwith anpeople d for SED atreatment nd Thoriented eir

rs rs e iv g e ar C d n a s e i l Fami Famirecovery- liof e s part a nd Cstandard ar a eas givershousing 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.

7 1 20 , 3 1 ber m e c e D

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 7 1 20 , 3 1 ber m e c e D December 13, 2017 c.

and substance use disorders and the disproportionate share of opioid prescriptions that

7 1 20 , 3 1 ber m e c e go to people with mental illnesses, people with SMI and SED often do not have access D 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 lies and Caregivers

Famiadequately addressed. As a consequence, we find a huge gap between what is known

for All People Living With SMI and SED and Their

Worksto be effective and what is available in communities throughout the nation. Several

he Way Forward: Federal Action for a System That Tstates (including New York, Ohio, and Vermont) have used block grant funds to develop

rs rs e iv g e ar C d n a s e i l technical assistance centers to support widespread implementation of effective practices. Fami

Implement these models more widely with national support, to bring implementation of ir e h T d n a D SE d n a SMI With ing v i L le p o Pe l Al or f

evidence-based and effective practices to scale.[Medium-term recommendation] Works

Coordinating Committee t t a h T em t s y S a for n ctio A eral d Fe : d ar w r o F y a W e h T

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

rious Mental Illness

InvolvedSe in the Criminal and Juvenile Justice Systems

ee t Commit ating n i d

Support interventions to correspond to all stages of justice involvement. Consider Coor departmental 4.1. Inter

all points included in the sequential intercept model. Pay particular attention to Illness Mental ious r

the “zero intercept”—the avoidance of initial arrest. Provide funding opportunities for Se

communities to map their systems, develop programs and services, and promote diversion

partmental e d

of people with SMI and SED along the continuum of the sequential intercept model.8 Inter [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 partmental e d Inter

diversion programs. programs. diversion

[Longer-term recommendation] [Longer-term Illness Mental ious r Se

partmental e d Inter Interjustice local dwithin epartmentalpeople 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 ee t resources, health Commit behavioral ating n i d Coor

Illness Mental ious r Se 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 ee t Commit ating n i d Coor Coormental dde-escalate ito natingtraining have and Commit t SED a h and T SMI em t s with y tS ee a people of for n needs ctio and A eral d symptoms Fe : d ar w r o F y a W e h T

effectively to people with SMI and SED. All law enforcement staff should be aware of the the of aware be should staff ir e enforcement h T law d All n a D SED. and SE d SMI n a with SMI people to With ing v i effectively L le p o Pe l Al or f 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. rs law e iv g e ar C d n a s e i l Fami

SED. t t a h T em t s y S a for n ctio A eral d Fe : d ar w r o F y a W e h T Thinvolving e Wawithout y Forwresolved arbe d: Feshould dSED eral and ASMI ctio with n forpeople a Syamong stemcrises ThIdeally, a t

4.3.

ir e h T d n a D SE d n a SMI With ing v i L le p o Pe l Al or f Works Worksand SMI with for Alpeople l Pewith o plework Lto ivinghow on With SMIresponders anfirst d all SEDtrain aand nd ThPrepare eir

rs rs e iv g e ar C d n a s e i l Fami 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 7 1 20 , 3 1 ber m e c e D

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. 7 1 20 , 3 1 ber m e c e D DSED e cemand berSMI 13,with 2017 people divert to system response crisis integrated an Develop

, 2017 ecember 13 Dpeople with mental 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

7 1 20 , 3 1 ber m e c e and expand wraparound services such as case management; forensic assertive community D 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 lies and Caregivers

Famiaccordance with procedures developed in the Stepping Up Initiative.9 Establish procedures

for All People Living With SMI and SED and Their

Worksfor serving people identified through the screening process, including immediate crisis

he Way Forward: Federal Action for a System That Tresponse for those with a high risk of suicide, diversion services to behavioral health

rs rs e iv g e ar C d n a s e i l

services for lower severity offenses, and adequate jail-based behavioral health services for Fami

those who remain incarcerated. [Longer-term recommendation] ir e h T d n a D SE d n a SMI With ing v i L le p o Pe l Al or f Works

Coordinating Committee t t a h T em t s y S a for n ctio A eral d Fe : d ar w r o F y a W e h

4.7. Strictly limit or eliminate the use of solitary confinement, seclusion, restraint, T

or other forms of restrictive housing for people with SMI and SED. Develop and

rious Mental Illness Seimplement a plan to reduce and eventually eliminate the use of solitary confinement and

other forms of segregation, seclusion, restraint, and isolation of people with SMI within ee t Commit ating n i d

Federal Bureau of Prison facilities. This plan must include implementation of mental and Coor

departmental

Intersubstance use disorder treatment services to alleviate symptoms and, when appropriate, Illness Mental ious r to help prepare people to reenter communities. Build on this policy to support similar Se

measures for people with SMI and SED in state and local jurisdictions, while ensuring

partmental e d that effective mental health services are available within juvenile and adult correctional Inter 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 partmental e d Inter

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 ious r Se

5.1. partmental e d Inter Interprograms. dbenefit epartmentalhealth federal in models payment health population Implement ee t Commit ating n i d Coor

Illness Mental ious r Se SeriousCare of MentalAffordability and IllnessAvailability Increase to Strategies Finance Develop 5: Focus

maximize resources and provide services. provide and resources maximize ee t Commit ating n i d Coor Coordinatingrecommendation] Commit t a h [Short-term T em t s y tS ee a for n ctio A eral d Fe : d ar w r o F y a W e h T

juveniles and adults to identify opportunities to coordinate at the state and local level to to level local and state the at ir e h coordinate T to d n a D opportunities SE d n a identify to SMI adults and With ing v i juveniles L le p o Pe l Al or f 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 rs opportunities e iv g e ar C d n a s e i l Fami

Offender Treatment and Crime Reduction Act and the 21 the and Act Reduction Crime and Treatment Offender t t a h T em t s y S a for n ctio A eral d Fe : d ar w r o F y a W e h T Theidentify to W aAct y FCures o rwarCentury d : Federal Action for a System That

ir e h T d n a D SE d n a SMI With ing v i L le p o Pe l Al or f Works Works Ill forMentally Althe lof Peoplanguage le the L ivingreview Withstrategy, SMI and SEinterdepartmental D afederal n a dof Thpart eir of people with mental illness and co-occurring substance use disorders. use substance co-occurring and illness mental with people of

rs rs e iv g e ar C d n a s e i l Fami Fami As lies 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 7 1 20 , 3 1 ber m e c e D

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. 7 1 20 , 3 1 ber m e c e D Decservices ember 1recovery 3, 20and 17 treatment to access immediate impede that barriers Reduce

, 2017 ecember 13 5.3. DFully enforce 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

7 1 20 , 3 1 ber m e c e recommendations made by the President’s Commission on Combating Drug Addiction D 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 lies and Caregivers

Famipayment rate setting processes. [Medium-term recommendation]

for All People Living With SMI and SED and Their

5.4. WorksEliminate financing practices and policies that discriminate against behavioral

The Way Forward: Federal Action for a System That

rs rs e iv g e ar C d n a s e i l health care. Identify and eliminate programs, practices, and policies that make it hard to Fami

deliver good mental health care. This includes ending the exclusion for reimbursement

ir e h T d n a D SE d n a SMI With ing v i L le p o Pe l Al or f

of services to adults under age 65 in Institutions for Mental Diseases (IMD exclusion) Works

Coordinating Committee t t a h T em t s y S a for n ctio A eral d Fe : d ar w r o F y a W e h

and ending the 190-day lifetime limit on Medicare psychiatric inpatient hospitalization. T

In addition, provide incentives for behavioral health providers to adopt electronic health

rious Mental Illness Serecords similar to incentives that other health care providers have received. [Medium-term

recommendation] ee t Commit ating n i d Coor

departmental

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

Illness Mental ious r other health care services. In many states, reimbursement by public programs for Se

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 partmental e d

and hospitalization) at a loss. As a result, many mental health service providers do not Inter 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.

partmental e d Inter

Illness Mental ious r Se

partmental e d Inter Interdepartmental

ee t Commit recommendation] ating n i d Coor models of care delivery, even states not funded by the CCBHC program. program. CCBHC the by funded not states even delivery, care of models

Illness Mental ious r Se 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

ee t Commit ating n i d Coor the Coor Evaluate dmodel. i natingpayment Commit sustainable t a a h T offers em and t s y tS ee a framework for n health ctio A population a eral d in Fe : d ar w r o F y a W e h T

nationwide. nationwide.

The CCBHC program provides a framework to support effective services services effective support to ir e h framework T a d n a D provides SE d program n a CCBHC SMI The With ing v i L le p o Pe l Al or f Works

5.8.

Expand the Certified Community Behavioral Health Clinic (CCBHC) program program (CCBHC) Clinic Health Behavioral Community Certified the rs Expand e iv g e ar C d n a s e i l Fami

t t a h T em t s y S a for n ctio A eral d Fe : d ar w r o F y a W e h T The Way Forward: Federal Action for a System That language. language. [Medium-term recommendation] [Medium-term

ir e h T d n a D SE d n a SMI With ing v i L le p o Pe l Al or f Works Workscontract care for Almanaged l Peomodel pas le Lsuch iving Withavailable, SMImaterials and and SEassistance D andtechnical Thmake eir

rs rs e iv g e ar C d n a s e i l Fami and Famistates lieacross s andpractices Carbest egivehighlight rs 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 7 1 20 , 3 1 ber m e c e D

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. 7 1 20 , 3 1 ber m e c e D Decmental emto ber 13related , 2017 services engagement and outreach for reimbursement Provide

, 2017 ecember 13 AppendixD A U.S. Department of Health & Human Services

Interdepartmental Serious Mental Illness Coordinating Committee 7 1 20 , 3 1 ber m e c e

Members D

Families and Caregivers

Works for All People Living With SMI and SED and Their

The Way Forward: Federal Action for a System That

rs rs e iv g e ar C d n a s e i l Fami

ir e h T d n a D SE d n a SMI With ing v i L le p o Pe l Al or f Works

Coordinating Committee t t a h T em t s y S a for n ctio A eral d Fe : d ar w r o F y a W e h T

Serious Mental Illness

ee t Commit ating n i d Coor

Interdepartmental

Illness Mental ious r Se

partmental e d Inter

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 partmental e d Inter

Associate Deputy Director, Bureau of Justice Assistance, Department of Justice of Department Assistance, Justice of Bureau Director, Deputy Associate

M.P.A. Illness Qazilbash, Ruby Mental ious r Se

partmental e d Inter Interdepartmental Affairs Veterans Director, Serious Mental Illness Treatment Resource and Evaluation Center, Department of of Department Center, Evaluation and Resource Treatment ee t Illness Mental Serious Commit Director, ating n i d Coor

Illness Mental ious r Se 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

ee t Commit ating n i d Coor Coordinating Commit t a h T em t s y tS ee a for M.P.P. n ctio A McCaffery, eral d Fe : Thomas d ar w r o F y a W e h T

Lead Medical Officer, Office of Health Services Policy and Oversight, Department of Defense of Department Oversight, ir and e h T Policy d n a Services D SE Health d n of a Office SMI With Officer, ing v i L Medical le p Lead o Pe l Al or f Works Captain Robert DeMartino, M.D. DeMartino, Robert Captain

rs e iv g e ar C d n a s e i l Fami

t t a h T em t s y S a for n ctio A eral d Fe : d ar w r o F y a W e h T The Way Forward: Federal Action for a System That Deputy Associate Attorney General, Department of Justice of Department General, Attorney Associate Deputy

ir e h T d n a D SE d n a SMI With ing v i L le p o Pe l Al or f Works Works for All People Living With SMI and SED anJ.D. d TCox, heir Stephen

rs rs e iv g e ar C d n a s e i l Fami FamiliServices e s andMedicaid C& aregivMedicare efor rs 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

7 1 20 , 3 1 ber m e c e D

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 7 1 20 , 3 1 ber m e c e D December 13, 2017 Members Federal

, 2017 ecember 13 Non-FederalD Members

Linda Beeber, Ph.D., P.M.H.C.N.S.-B.C., F.A.A.N.

7 1 20 , 3 1 ber m e c e

Linda Beeber, Ph.D., P.M.H.C.N.S.-B.C., F.A.A.N., is a doctorally prepared D 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

lies and Caregivers

NursesFami Association (APNA) as the Chair of the Research Council, and more recently as President-

for All People Living With SMI and SED and Their Elect, andWorks as the past Co-Chair of the Psychiatric Mental Health and Substance Abuse Expert

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

rs rs e iv g e ar C d n a s e i l mental health, and to improve the lives of people living with symptoms of mental illness through Fami

models of recovery, culturally congruent symptom management, social support mobilization, and

ir e h T d n a D SE d n a SMI With ing v i L le p o Pe l Al or f

healthy lifestyle patterning. Dr. Beeber has disseminated her work through peer-reviewed papers, Works

Coordinating Committee t t a h T em t s y S a for n ctio A eral d Fe : d ar w r o F y a W e h national and international presentations, and service on national policymaking panels. T

rious Mental Illness

Ron L. SeBruno

ee t Commit ating n i d

Ron L. Bruno is a Utah law enforcement officer with over 22 years of experience. Mr. Coor departmental

InterBruno has dedicated much of his career working with adult and child populations Illness Mental ious r

dealing with serious mental illness and emotional disturbances. Mr. Bruno is a Se

founding board director of CIT International and currently is the corporation’s second

partmental e d

vice president; a founding board director of CIT Utah, Inc. and the corporation’s Inter 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, partmental e d Inter 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 ious r Se “Zero Suicide,” “Crisis Now,” and “Peer 2.0.” A licensed professional counselor, counselor, professional licensed A 2.0.” “Peer and Now,” “Crisis Suicide,” “Zero

partmental e d Inter Interinitiatives deinternational partmental 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 ee t International RI Commit ating n i d Coor

David Covington, L.P.C., M.B.A., L.P.C., Covington, David Illness Mental ious r Se of SerPresident ious and MentalOfficer Executive Chief Illnessis

ee t Commit ating n i d Coor Coordinating Commit t a h T em t s y tS ee a for M.B.A. n ctio L.P.C., A eral d Covington, Fe : David d ar w r o F y a W e h T

ir e h T d n a D SE d n a SMI With ing v i L le p o Pe l Al or f 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 rs e integration, iv g care e ar C d n a s e i l Fami

t t a h T em t s y S a for n ctio A eral d Fe : d ar w r o F y a W e h T Thehealth Wof ay areas Fothe rwin ard: trainings Fe deral Ainternational ction forconducted has a Salso ysHe tem ThaAssociation. t Psychiatric ir e h T d n a D SE d n a SMI With ing v i L le p o Pe l Al or f Works WorksAmerican the forfrom AllAward PeoM.D., ple LiWilliams, v ing WithWarren the SMIreceived anand d SEHealth D andBehavioral Thfor eir Council

rs rs e iv g e ar C d n a s e i l Fami FamiNational lthe ieby s andLeader CareVisionary g ive2012 rsthe 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 7 1 20 , 3 1 ber m e c e D

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 7 1 20 , 3 1 ber m e c e D December 13, 2017 M.D. Chau, Clayton

, 2017 ecember 13 MaryannD Davis, Ph.D.

Maryann Davis, Ph.D., is Research Associate Professor of Psychiatry

(Psychology) and Director of the Systems and Psychosocial Advances Research

7 1 20 , 3 1 ber m e c e Center and the Transitions Research and Training Center (RTC) at the D 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

lies and Caregivers

on transition-ageFami youth with serious mental health conditions before Congress, and served on

for All People Living With SMI and SED and Their multipleWorks committees of the National Academy of Sciences, Engineering, and Medicine.

The Way Forward: Federal Action for a System That

rs rs e iv g e ar C d n a s e i l

Pete Earley Fami

ir e h T d n a D SE d n a SMI With ing v i L le p o Pe l Al or f

Pete Earley is a New York Times bestselling author and former reporter for The Works

Coordinating Committee t t a h T em t s y S a for n ctio A eral d Fe : d ar w r o F y a W e h

Washington Post. A 1973 graduate of Phillips University in Oklahoma, he previously T

worked for the Emporia Gazette in Kansas and the Tulsa Tribune in Oklahoma.

rious Mental Illness

Se From 1980 until 1986, Mr. Earley worked as a reporter at The Washington Post before

ee t Commit ating n i d

writing books full-time. He is the author of six novels and 11 non-fiction books, Coor

departmental Interincluding 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 Illness Mental ious r

Mental Illness, serves on the board of the Corporation for Supportive Housing, and was appointed Se

to a Virginia Supreme Court task force that recommended changes to that state’s involuntary partmental e d

commitment laws and is currently serving on a committee investigating ways to improve Virginia Inter 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 partmental e d Inter

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 ious r Se

partmental e d Inter an Interand dPractitioner e partmentalRehabilitation 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 ee t Commit ating n i d Coor Illness Mental ious r Se Serious Mental Illness Kravitz M. Elena

t t a h T em t s y S a for n ctio A eral d Fe : d ar w r o F y a W e h T ee t Commit ating n i d Coor 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 ir Policy e h T Public d of n a D Director SE the d as n a served SMI Giliberti With Ms. ing v that, i L to le p Prior o Pe l Al or f 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 rs e section iv a g as e ar C d n a s e i l Fami t t a h T em t s y S a for n ctio A eral d Fe : d ar w r o F y a W e h T Thworked e Wshe ay FNAMI, oof rwarCEO d: Febecoming d eralBefore ActioLaw. n Health for aMental Sfor y stemCenter ThaBazelon t

ir e h T d n a D SE d n a SMI With ing v i L le p o Pe l Al or f Works the Worksat attorney for Alsenior a l as Pe and o ple LPensions ivingand WithLabor, SMIEducation, and Health, SE on D 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

rs rs e iv g e ar C d n a s e i l Fami Famithe in lieyears s 20 a ndover Cof aretenure g ivher ers 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 7 1 20 , 3 1 ber m e c e D

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) 7 1 20 , 3 1 ber m e c e D Detherapist c emberfamily 1and 3 , 201marital 7 licensed a as licensed dually is Emrich Dr. Psychology. Family in B.A.

, 2017 ecember 13 KennethD Minkoff, M.D.

Kenneth Minkoff, M.D., is a Senior System Consultant for ZiaPartners, Inc.,

a part-time Assistant Professor of Psychiatry for Harvard Medical School, and

7 1 20 , 3 1 ber m e c e Director of Systems Integration for the Meadows MH Policy Institute in Dallas, D 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

lies and Caregivers

psychiatrists,Fami he is co-chair of the Committee on Psychiatry and the Community for the Group for

for All People Living With SMI and SED and Their the AdvancementWorks of Psychiatry, and is an incoming board member for the College for Behavioral

he Way Forward: Federal Action for a System That Health TLeadership.

rs rs e iv g e ar C d n a s e i l Fami

ir e h T d n a D SE d n a SMI With ing v i L le p o Pe l Al or f

Elyn R. Saks, J.D., Ph.D. Works

Coordinating Committee t t a h T em t s y S a for n ctio A eral d Fe : d ar w r o F y a W e h

Elyn R. Saks, J.D., Ph.D., is Orrin B. Evans Professor of Law, Psychology, T

and Psychiatry and the Behavioral Sciences at the University of Southern

rious Mental Illness

Se California Gould School of Law. Dr. Saks is also Director of the Saks

ee t Commit ating n i d

Institute for Mental Health Law, Policy, and Ethics. She is an adjunct Coor

departmental Inter professor of psychiatry at the University of California, San Diego, School

of Medicine, and faculty at the New Center for Psychoanalysis. Dr. Saks Illness Mental ious r

received her J.D. from Yale Law School, and a Ph.D. in Psychoanalytic Science from the New Se

Center for Psychoanalysis. She writes extensively on law and mental health, having published five partmental e d

books and more than fifty articles and book chapters. Her memoir,The Center Cannot Hold: My Inter 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 partmental e d Inter 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 ious r Se 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

partmental e d Inter InterKessler-Eidson dLaw e of partmental 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 ee t faculty as served has Commit Stroud Judge ating n i d Coor

Illness Mental ious r Se Seyears. 7 r iousfor 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

ee t Commit ating n i d Coor and CoorCourt dHealth inatingMental CommitMisdemeanor t a h T em t s y tS ee a for n ctio A eral d Fe : d ar w r o F y a W e h T 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 ir e h T d graduated n a she D GA, SE d n Atlanta, a of SMI native With ing v i L le p o Pe l Al or f 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 rs e iv g e ar C d n a s e i l Fami

Judge Rhathelia Stroud, J.D., Stroud, Rhathelia Judge t t a h T em t s y S a for n ctio A eral d Fe : d ar w r o F y a W e h T The WMagistrate ay FGeorgia orwarCounty, d: FeDeKalb da eralis Action for a System That ir e h T d n a D SE d n a SMI With ing v i L le p o Pe l Al or f Works Works for All People Living With SMI and SED and Their

rs rs e iv g e ar C d n a s e i l Fami 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 7 1 20 , 3 1 ber m e c e D

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 7 1 20 , 3 1 ber m e c e D December 13, 2017 J.D. Snook, John

, 2017 ecember 13 Conni WellsD

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

7 1 20 , 3 1 ber m e c e with health and mental health challenges, she served as a consultant and D 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

lies and Caregivers

for SystemsFami of Care. The former Chair for the National Certification for Parent Family Peers

for All People Living With SMI and SED and Their

Commission,Works Ms. Wells currently works as a consultant on projects focusing on multiple systems

he Way Forward: Federal Action for a System That of care Tvalues and has multiple publications, including Straight Talk: Families Speak to Families

rs rs e iv g e ar C d n a s e i l about Child and Youth Mental Health. Fami

ir e h T d n a D SE d n a SMI With ing v i L le p o Pe l Al or f Works

Coordinating Committee t t a h T em t s y S a for n ctio A eral d Fe : d ar w r o F y a W e h T

Serious Mental Illness

ee t Commit ating n i d Coor

Interdepartmental

Illness Mental ious r Se

partmental e d Inter

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partmental e d Inter

7 1 20 , 3 1 ber m e c e D

7 1 20 , 3 1 ber m e c e D December 13, 2017

, 2017 ecember 13 AppendixD B U.S. Department of Health and Human Services

Interdepartmental Serious Mental Illness Coordinating Committee 7 1 20 , 3 1 ber m e c e

Glossary of Terms Used in Report D

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

rs rs e iv g e ar C d n a s e i l Fami

ir e h T d n a D SE d n a SMI With ing v i L le p o Pe l Al or f Works

Coordinating Committee t t a h T em t s y S a for n ctio A eral d Fe : d ar w r o F y a W e h T

Serious Mental Illness

ee t Commit ating n i d Coor

Interdepartmental

Illness Mental ious r Se

partmental e d Inter

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104

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 partmental e d Inter

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 ious r Se Cognitive behavioral therapy: therapy: behavioral Cognitive

partmental e d Inter Interself- or dnegative epartmentalmodify to seeks that approach therapeutic A

providers while addressing a person’s health and wellness (CIHS, n.d.). (CIHS, wellness and health ee person’s t a addressing while Commit providers ating n i d Coor

Coordinated care: care: Coordinated Illness Mental ious r Se Serservice ioussocial and Mentalhealth, behavioral Illnessmedical, of efforts the Integrating

Health Services Block Grant (MHBG) (SAMHSA, 2017b). t a 2017b). h T em t s (SAMHSA, y S a (MHBG) for n Grant ctio Block A eral Services d Fe : Health d ar w r o F y a W e h T ee t Commit ating n i d Coor CoorMental dinCommunity atingthe and (SABG) CommitGrant Block teeTreatment and Prevention Abuse Substance

receive the formula-based funding. SAMHSA is responsible for two block grant programs: the the programs: grant block two for ir e h T d n responsible a is D SE SAMHSA d n a funding. SMI With formula-based ing v i the L le p receive o Pe l Al or f 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 rs an e iv g submit e ar C d n a s e i l Fami

Block grant: grant: Block

t t a h T em t s y S a for n ctio A eral d Fe : d ar w r o F y a W e h T Thmust e Waentities y ForEligible ward: FeCongress. by deral Amandated ctiogrant n for formula a System Tnoncompetitive, hA at

ir e h T d n a D SE d n a SMI With ing v i L le p o Pe l Al or f Works Works for All People Living With SMIn.d.-a). and SE(MedlinePlus, D anirritable dor Thecross ir being

rs rs e iv g e ar C d n a s e i l Fami or Famiactive, and lies happy a ndvery Carbeing eof giversperiods 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 7 1 20 , 3 1 ber m e c e D

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 7 1 20 , 3 1 ber m e c e D D ecehealth m berbest 1the 3 , 2017achieve to services health personal of use timely the Having

, 2017 ecember 13 CoordinatedD care: Integrating 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

7 1 20 , 3 1 ber m e c e of specialists who work with the client to create a personal treatment plan. The specialists D 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

lies and Caregivers

crisis stabilization,Fami mobile crisis services, 24/7 crisis hotlines, warm lines, psychiatric advance

for All People Living With SMI and SED and Their directiveWorks statements, and peer crisis services (SAMHSA, 2014).

he Way Forward: Federal Action for a System That

CulturalT appropriateness: In the context of public health, sensitivity to the differences among rs rs e iv g e ar C d n a s e i l

ethnic, racial, and/or linguistic groups and awareness of how people’s cultural background, Fami

ir e h T d n a D SE d n a SMI With ing v i L le p o Pe l Al or f

beliefs, traditions, socioeconomic status, history, and other factors affect their needs and how Works

Coordinating Committee t t a h T em t s y S a for n ctio A eral d Fe : d ar w r o F y a W e h they respond to services. Generally used to describe interventions or practices (SAMHSA, n.d.). T

Culturally competent treatment: Cultural competence is the ability to interact effectively with

rious Mental Illness

people Seof different cultures. In practice, both individuals and organizations can be culturally

ee t Commit ating n i d

competent. Culture is a term that goes beyond just race or ethnicity. It can also refer to such Coor

departmental characteristicsInter as age, gender, sexual orientation, disability, religion, income level, education,

Illness Mental ious r geographical location, or profession. Cultural competence means being respectful and responsive Se

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 partmental e d

occurs along a continuum (SAMHSA, 2016a). Inter

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 partmental e d Inter

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 ious r Se

Intervention: Intervention: partmental e d Inter Inter(preventive deoutcome partmentalundesirable an prevent to intended approach or strategy A

ee t Commit ating n i d Coor 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 Illness Mental ious r Se 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 ee t Commit ating n i d Coor Coord inating Commit t a h T em t s y tS ee a for n ctio A eral d Fe : d ar w r o F y a W e h T

ir e h T d n a D SE d n a SMI With ing v i L le p o Pe l Al or f 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 rs e iv g e ar C d n a s e i l Fami

t t a h T em t s y S a for n ctio A eral d Fe : d ar w r o F y a W e h T The Way Forward: Federal Action for a System That

ir e h T d n a D SE d n a SMI With ing v i L le p o Pe l Al or f Works Works for All People Living With SMI n.d.). a nd SED(SAMHSA, anmodel d its T hto eir 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,

rs rs e iv g e ar C d n a s e i l Fami service Fami or liestreatment aof nd Cnumber ar egivexplicit ean rs 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 7 1 20 , 3 1 ber m e c e D

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 7 1 20 , 3 1 ber m e c e D D ec(see e mber 1psychosis 3 ,of 2017 episode an experiences person a time first The

, 2017 ecember 13 terms ofD level of responsibility 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.).

7 1 20 , 3 1 ber m e c e D 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

lies and Caregivers who mayFami have substance use disorders and engage them in substance abuse treatment (CSAT,

for All People Living With SMI and SED and Their 2005). Works

he Way Forward: Federal Action for a System That

Peer: InT the context of peer support, a peer is a person who has lived experience with a

rs rs e iv g e ar C d n a s e i l

psychiatric, traumatic, and/or addiction challenge, and may benefit from peer support (CIHS, Fami

ir e h T d n a D SE d n a SMI With ing v i L le p o Pe l Al or f n.d.). Works

Coordinating Committee t t a h T em t s y S a for n ctio A eral d Fe : d ar w r o F y a W e h

Peer support: The process of giving and receiving nonclinical assistance to achieve long-term T

recovery from severe psychiatric, traumatic, or addiction challenges. This support is provided by

rious Mental Illness

peer supporters—peopleSe who have “lived experience” and have been trained to assist others in

ee t Commit ating n i d

initiating and maintaining long-term recovery and enhancing the quality of life for people and Coor

departmental their families.Inter Peer support services are inherently designed, developed, delivered, evaluated, and

Illness Mental ious r supervised by peers in long-term recovery (CIHS, n.d.). Se

Person-centered care (also known as patient-centered care): Means consumers have control

partmental e d

over their services, including the amount, duration, and scope of services, as well as choice of Inter 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 partmental e d Inter

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 ious r Se

partmental e d Inter 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 ee t disorder mental A Commit ating n i d Coor

Illness Mental ious r Se Serious Mental Illness behavioral, or social), organ system, or diagnosis (CIHS, n.d.). n.d.). (CIHS, diagnosis or system, organ social), or behavioral,

ee t Commit ating n i d Coor Coor(biological, diorigin n atingproblem by Commitlimited t not a h T patient) em t s y tS ee a for n “undifferentiated” ctio (the A concern eral d Fe health : or d ar w r o F y a W e h T 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

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rs rs e iv g e ar C d n a s e i l Fami t t a h T em t s y S a for n ctio A eral d Fe : d ar w r o F y a W e h T The Way Forward: Federal Action for a System That n.d.).

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Selective prevention strategies prevention Selective • rs rs e iv g e ar C d n a s e i l Fami risk Fami higher lat ie s abeing nas d Carviewed egivgroups ers 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 7 1 20 , 3 1 ber m e c e D

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 7 1 20 , 3 1 ber m e c e D Decegenerally mber 13standards , 2017Practice practice. of field a legitimize to way important one is standards of

, 2017 ecember 13 significantlyD impairing 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.).

7 1 20 , 3 1 ber m e c e

Serious emotional disturbance (SED): Refers to children and youth who have had a D 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,

lies and Caregivers schizophrenia,Fami and bipolar disorder, and other mental disorders that cause serious impairment

for All People Living With SMI and SED and Their (SAMHSA,Works 2017d).

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SolitaryT confinement:See “restrictive housing” (DOJ, 2017). rs rs e iv g e ar C d n a s e i l Fami

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Stigma: A negative association attached to an activity or condition. A cause of shame or Works

embarrassment (CSAT, 2005). Coordinating Committee t t a h T em t s y S a for n ctio A eral d Fe : d ar w r o F y a W e h T

Sustainability: The long-term survival and continued effectiveness of an intervention (SAMHSA,

rious Mental Illness n.d.). Se

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Symptomatology: The combined symptoms or signs of a disorder or disease (SAMHSA, n.d.). Coor

Interdepartmental

Illness Mental ious r Transition-age youth: People between ages 16 to 25. People in this age group are at high risk for Se

substance use and mental health disorders, but they are also among those least likely to seek help

partmental e d (Development Services Group, Inc., 2016). Inter 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.

109

110

https://info.nmhss.org/Definitions/index.asp from Retrieved .

terms used in the N-MHSS questionnaire. National Mental Health Services Survey (N-MHSS). (N-MHSS). Survey Services Health Mental National questionnaire. N-MHSS the in used terms

Substance Abuse and Mental Health Services Administration (SAMHSA). (2017a). Definitions for for Definitions (2017a). (SAMHSA). Administration Services Health Mental and Abuse Substance

. care-coordination/person-family-centered

family-centered care and peer support. Retrieved from from Retrieved support. peer and care family-centered https://www.samhsa.gov/section-223/

Substance Abuse and Mental Health Services Administration (SAMHSA). (2016b). Person- and and Person- (2016b). (SAMHSA). Administration Services Health Mental and Abuse Substance

. cultural-competence

https://www.samhsa.gov/capt/applying-strategic-prevention/ competence. Retrieved from from Retrieved competence.

Cultural (2016a). (SAMHSA). Administration Services Health Mental and Abuse Substance

www.samhsa.gov/gains-center/grants-grantees/early-diversion .

enforcement and behavioral health partnerships for early diversion. Retrieved from from Retrieved diversion. early for partnerships health behavioral and enforcement https:// partmental e d Inter

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

Rockville, MD: Substance Abuse and Mental Health Services Administration. Services Health Mental and Abuse Substance MD: Illness Rockville, Mental ious r Se

HHS Publication No. (SMA)-14-4848. (SMA)-14-4848. No. Publication HHS

partmental e d Inter Interdepartmentalstrategies. funding and cost-effectiveness, Effectiveness,

Substance Abuse and Mental Health Services Administration (SAMHSA). (2014). (2014). (SAMHSA). Administration Services Health Mental and Abuse Substance

Crisis services: services: Crisis ee t Commit ating n i d Coor

nimh.nih.gov/health/topics/schizophrenia/raise/glossary.shtml

Illness Mental ious r Se Serious Mental. Illness

Schizophrenia Episode (RAISE): A research project of the NIMH. Retrieved from from Retrieved NIMH. the of project research A (RAISE): Episode Schizophrenia https://www.

ee t Commit ating n i d Coor Coor Initial d an inAfter ating Recovery Commit t Glossary. a h T (n.d.) em t s y (NIMH). t S ee a Health for n Mental of ctio A Institute eral d Fe : National d ar w r o F y a W e h T

https://medlineplus.gov/ency/article/000945.htm from Retrieved

. ir e h T d n a D SE d n a SMI With ing v i L le p o Pe l Al or f Works MedlinePlus. (n.d.-b). Major depression. depression. Major (n.d.-b). MedlinePlus. U.S. National Library of Medicine. Medicine. of Library National U.S.

Medical encyclopedia. Medical rs e iv g e ar C d n a s e i l Fami

https://medlineplus.gov/ency/article/000926.htm from Retrieved

t t a h T em t s y S a for n ctio A eral d Fe : d ar w r o F y a W e h T The Way Forw. ard: Federal Action for a System That

MedlinePlus. (n.d.-a). Bipolar disorder. disorder. Bipolar (n.d.-a). MedlinePlus. U.S. National Library of Medicine. Medicine. of Library National U.S.

ir e h T d n a D SE d n a SMI With ing v i L le p o Pe l Al or f Works Works for All People Living encyclopedia. With SMIMedical and SED and Their

Literature%20%20Review_Transition-age%20Youth.pdf .

http://nrepp.samhsa.gov/Docs/Literatures/NREPP%20Learning%20Center%20 rs rs e iv g e ar C d n a s e i l Fami Families and Caregivers from

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

Development Services Group, Inc. (2016). (2016). Inc. Group, Services Development NREPP Learning Center literature review: Transition-age Transition-age review: literature Center Learning NREPP

MD: Substance Abuse and Mental Health Services Administration. Services Health Mental and Abuse Substance MD:

Treatment Improvement Protocol (TIP) Series, No. 42. Rockville, Rockville, 42. No. Series, (TIP) Protocol Improvement Treatment with co-occurring disorders. co-occurring with

Center for Substance Abuse Treatment (CSAT). (2005). (2005). (CSAT). Treatment Abuse Substance for Center Substance abuse treatment for persons persons for treatment abuse Substance

. https://www.healthcare.gov/glossary

Centers for Medicare & Medicaid Services (CMS). (n.d.). Glossary. HealthCare.gov. Retrieved from from Retrieved HealthCare.gov. Glossary. (n.d.). (CMS). Services Medicaid & Medicare for Centers

https://www.integration.samhsa.gov/glossary from Retrieved Solutions. Health Integrated .

Center for Integrated Health Solutions (CIHS). (n.d.). Glossary. SAMHSA-HRSA Center for for Center SAMHSA-HRSA Glossary. (n.d.). (CIHS). Solutions Health Integrated for Center 7 1 20 , 3 1 ber m e c e D

Rockville, MD: U.S. Department of Health and Human Services. Human and Health of Department U.S. MD: Rockville, report.

Agency for Healthcare Research and Quality (AHRQ). (2011). (2011). (AHRQ). Quality and Research Healthcare for Agency National healthcare disparities disparities healthcare National 7 1 20 , 3 1 ber m e c e D December 13, 2017 References

, 2017 ecember 13 SubstanceD Abuse and Mental Health Services Administration (SAMHSA). (2017b). Glossary of terms and acronyms for SAMHSA grants. Retrieved from https://www.samhsa.gov/grants/ grants-glossary.

Substance Abuse and Mental Health Services Administration (SAMHSA). (2017c). Homelessness

7 1 20 , 3 1 ber m e c e and housing. Retrieved from https://www.samhsa.gov/homelessness-housing. D Substance Abuse and Mental Health Services Administration (SAMHSA). (2017d). Mental and substance use disorders. Retrieved from https://www.samhsa.gov/disorders. Substance Abuse and Mental Health Services Administration (SAMHSA). (n.d.). Glossary of National Registry of Evidence-based Programs and Practices. Rockville, MD: Substance Abuse and Mental Health Services Administration. Retrieved from https://nrepp-learning.samhsa. gov/glossary.

United States Census Bureau. (2017). How the Census Bureau measures poverty. Retrieved from

https://www.census.gov/topics/income-poverty/poverty/guidance/poverty-measures.html.

lies and Caregivers

UnitedFami States Department of Justice (DOJ). (2017). Report and recommendations concerning the

use of restrictive housing. Retrieved from https://www.justice.gov/archives/dag/report-andfor All People Living With SMI and SED and Their

recommendations-concerning-use-restrictive-housing#definitionsWorks .

The Way Forward: Federal Action for a System That

rs rs e iv g e ar C d n a s e i l Youth.gov. (n.d.). Juvenile justice. Retrieved from https://youth.gov/youth-topics/juvenile-justice. Fami

ir e h T d n a D SE d n a SMI With ing v i L le p o Pe l Al or f Works

Coordinating Committee t t a h T em t s y S a for n ctio A eral d Fe : d ar w r o F y a W e h T

Serious Mental Illness

ee t Commit ating n i d Coor

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Illness Mental ious r Se

partmental e d Inter

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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