Final report : House of Representatives Study Committee on Mental Illness Initiative, Reform, Public Health, and Safety

House of Representatives Study Committee on Mental Illness Initiative Reform
Public Health and Safety
Final Report
Chairman Katie Dempsey Representative 13th District Vice Chairman Kimberly Alexander Representative 66th District The Honorable Joyce Chandler Representative 105th District The Honorable Trey Kelley Representative 16th District The Honorable Mary Margaret Oliver Representative 82nd District
2016
Prepared by the House Budget & Research Office

Introduction
The House Study Committee on Mental Illness Initiative Reform Public Health and Safety was created by House Resolution 1093 during the 2016 Legislative Session of the Georgia General Assembly. HR 1093 acknowledges that one in five adults experience mental illness in some form in any given year and data indicates that at least 1.4 million adults in Georgia have some form of mental illness. According to Mental Health America Georgia ranks twenty-ninth for adults with mental illness and ranks near the bottom for spending by state mental health agencies per capita. Additionally Georgia ranks thirtyseventh for uninsured adults with a mental illness and last for the availability of mental health professionals per capita.
HR 1093 also recognizes that mental health care is supported by local officials jails and hospitals. The Georgia Sheriffs Association indicates that in 73 of the state s 159 counties law enforcement officials traveled nearly two million miles and spent more than 12 000 hours transporting mental health patients which impedes law enforcement s availability to respond to their communities. Additionally the closing of mental health hospitals has added to the increase of mentally ill adults housed in the local and county jails requiring law enforcement to maintain and treat mentally ill adults rather than specialized facilities.
The resolution acknowledges that individuals can lead productive lives when mental illness is treated appropriately with medication and supervision. Therefore HR 1093 recommends that a study of initiatives reforms public health and safety concerning mentally ill individuals should be done in order to evaluate the state s efforts in treating and supporting this population.
House Resolution 1093 provides for the membership of the committee consisting of five members to be appointed by the Speaker of the House of Representatives. The Speaker appointed the following members Representative Katie Dempsey Chair Representative Kimberly Alexander Vice Chair Representative Joyce Chandler Representative Trey Kelley and Representative Mary Margaret Oliver.
The study committee held four public meetings at the State Capitol during 2016 occurring on September 29th October 25th November 22nd and November 29th. During these meetings the committee heard testimony from multiple different agencies and organizations involved in mental health in Georgia including the Department of Behavioral Health and Developmental Disabilities Department of Public Health Department of Driver Services Department of Community Affairs Department of Education Fulton County Behavioral Health Grady Health System Tanner Health System Acadia Healthcare Voices for Georgia s Children National Alliance on Mental Illness (NAMI) Georgia and representation from local sheriffs judges and commissioners. This report provides an overview of the issues discussed by these entities throughout the four meetings.
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Committee Findings
The Department of Behavioral Health and Developmental Disabilities (DBHDD) is the primary state agency in Georgia responsible for mental health and provides treatment and support services for adults and youth through a statewide services delivery system that has an emphasis on recovery through community-based care. DBHDD s system is comprised of multiple types of facilities and resources spread across the state including state hospitals behavioral health crisis centers adult crisis stabilization units state contract hospital beds mobile crisis teams and child crisis stabilization units (see Appendix A for a statewide map.) DBHDD s primary access point for consumers is through its Georgia Crisis & Access Line (GCAL) which is a statewide toll-free call center that operates 24/7 and has the capacity to screen and assess callers for intensity of service response. The GCAL has had a positive impact however a lack of awareness by providers and consumers exists and additional promotion of the system is still necessary in order to maximize its benefits.
DBHDD is continuing to work with the resources available to serve the needs of the behavioral health population in Georgia. The study committee has recognized that there are also many other entities in the state that work in conjunction with DBHDD to provide services that support this population. The committee used its four meetings to evaluate these various programs specifically related to the topics of housing photo identification criminal justice and public safety hospitals and children.
Housing
DBHDD is partnering with Georgia s Department of Community Affairs (DCA) to provide supported housing and bridge funding to those with serious and persistent mental illness in Georgia. Its target population is individuals who are being served in state hospitals are frequently readmitted to state hospitals frequently seen in emergency rooms are chronically homeless and those being released from jails or prisons. The agencies entered a Memorandum of Agreement (MOA) in March 2015. The goals of the MOA are to build a unified referral strategy to serve eligible persons determine the need for permanent supportive housing through the Need for Supported Housing Survey (NSH) administered by DBHDD on an ongoing basis maximize the use of DBHDD s Georgia Housing Voucher and maximize all other housing resources.
Georgia Housing Voucher Program DBHDD s Georgia Housing Voucher (GHV) assists individuals with mental illness in attaining and maintaining safe and affordable housing in order to support their incorporation into the community. Supported housing includes integrated permanent housing with tenancy rights linked with flexible community-based services that are available to consumers of behavioral health services when they need them but are not mandated as a condition of tenancy.
The GHV program is fully state funded and does not have federal restrictions making it flexible and quickly responsive to housing needs. The voucher pays Fair Market Rent standard along with a utility allowance. Bridge funding is also provided under the GHV and is used for security and utility deposits household necessities accessibility modifications and other start-up expenses or supports needed for a program participant to transition into supported housing. This funding may also be used to facilitate the
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transition of an individual from a state psychiatric facility into the community. Any individuals in the program with financial means are required to contribute 30 to 40% of their income towards living expenses.
As of September 1 2016 3 851 people have accessed supported housing under the GHV program since its start in 2011. Of those referred in 2016 approximately 55% were homeless 12% were families 11% were out of hospitals 8% were residential 5% were coming out of jails or prisons and 9% were from other circumstances. Approximately 94% of those placed in GHV-funded supported housing remain after six months of placement showing strong housing stability within the program.
Housing Choice Voucher Program The Housing Choice Voucher Program also known as Section 8 is part of Georgia s comprehensive housing program administered by DCA. This is a tenant-based rental assistance program that aids extremely low and low income individuals and families rent safe decent and affordable dwelling units in the private rental market. The program is funded wholly by federal funds from the U.S. Department of Housing and Urban Development (HUD) and no state appropriations are used for the program. Currently DCA serves over 16 000 Georgia families in 149 of the 159 counties (the remaining 10 counties are served by those counties housing authorities.)
One out of every two open vouchers under this program is designated for individuals with severe and persistent mental illness. A DBHDD referral is required and it is both agencies goal to move eligible individuals off of the state-funded GHV program and onto the federally-funded Housing Choice Voucher Program. A total of 600 vouchers have been pledged to eligible clients. As of November 2016 237 are under contract and 22 families are searching for units.
HUD 811 Program The HUD 811 program is targeted to extremely low income individuals (below 30% of Area Median Income) ages 18 to 61 years that have developmental disabilities and severe and persistent mental illness. Georgia was provided $14.4 million from HUD to provide long-term project-based rental assistance to persons with disabilities which provides 500 housing vouchers that are attached to new and existing tax-credit apartment developments around the state. DCA is implementing the program statewide in partnership with DBHDD.
Shelter Plus Care DCA s Shelter Plus Care (S C) program provides permanent housing in connection with supportive services for homeless people with disabilities and their families. S C provides rental assistance for a variety of housing choices accompanied by a range of supportive services. The program is designed to serve a population that has traditionally been hard to reach homeless persons with disabilities such as serious mental illness chronic substance abuse or AIDS and related diseases. A total of 2 855 households have been served by this program reaching 3 459 individuals.
Veterans Affairs Supportive Housing Program The Veterans Affairs Supportive Housing (VASH) program is an inter-agency collaboration effort that assists homeless military veterans secure a decent stable and affordable place to live. The program
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combines Housing Choice Voucher rental assistance for homeless veterans with case management and clinical services provided by the U.S. Department of Veterans Affairs (VA) at its medical centers and community-based outreach clinics. Participants in this program contribute 30% of any income to housing.
Photo Identification
The federal REAL ID Act of 2005 set the guidelines for what is currently required to obtain a valid stateissued identification. An individual must provide the following
Documented proof of identity birth certificate U.S. passport or Certificate of Naturalization Documented proof of Lawful Status for non-U.S. citizens valid immigration document issued
by the Department of Homeland Security or be verifiable through the federal Systematic Alien Verification for Entitlements (SAVE) program Documented proof of social security number social security card W2 or 1099 paystub or be verifiable through the federal Social Security Online Verification (SSOLV) program Documented proof of Georgia residency two documents from two different sources that reflect residency address (no P.O. boxes) including utility bills lease and rental agreements tag receipts and property tax statements Documented proof of any name changes certified copy of marriage certificate divorce decree adoption papers or court orders
For many assistance programs provided by the state and federal government an individual is required to present a valid photo identification to participate and receive services however many homeless and mentally ill people do not have valid identification and do not have the necessary documents required to obtain a Georgia identification card. Costs and system access can be barriers and many in the homeless population go without identification. In addition to the benefit programs a lack of identification can also prove to be an issue in regards to law enforcement and first responders interacting with mentally ill individuals in the community. When arriving at a scene officers are unable to accurately understand who they are encountering when no identification is available.
Because of the difficulties associated with certain populations having all the necessary documentation to receive government-issued ID cards some states have looked to other alternative type of photo identification cards for those in the mental health system. In Butte County California the "white card" project was created to allow people to voluntarily obtain a free photo identification card that lists information such as their diagnosis medication contact numbers for their next of kin and any personal "triggers" that could cause a person to react such as sirens or close contact.1 This project was developed in order to create a better system for responding to calls involving people in a psychotic crisis with the hopes to avoid unintentionally criminalizing the mentally ill. With these cards law enforcement and first responders are able to get much needed information immediately if a card holder is in crisis. In 2016 Florida passed a bill creating a similar identification program statewide.2 While
1 http //www.chicoer.com/general-news/20131019/white-cards-aim-to-ease-law-enforcement-interaction-with2 https //www.flsenate.gov/Session/Bill/2016/936
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these cards do not solve the problem of benefit access they are a step in bridging the gap between those with and without identification in the mental health system.
Criminal Justice & Public Safety
The study committee heard from multiple members of law enforcement and the judicial system about how behavioral health is addressed in their communities. An overarching theme is that the burden is consistently placed on local officers jails hospitals and courts.
Lieutenant Colonel Chad Hunton from Paulding County emphasized that many mentally ill individuals end up in the county jail and cause a burden on the system. In May 2015 the county provided funding to provide mental health services in the jail and 374 people in custody have since been seen for mental health-related issues. However once an individual is released he or she must voluntarily go seek treatment and many are ending up back in jail because they are not finding the services they need.
Sheriff Ramsey Bennett from Pierce County discussed with the committee that money manpower and mileage are the issues in rural areas of the state. Officers are required to provide transport of mentally ill individuals to hospitals and the closest hospital for his county is 141 miles roundtrip (see Appendix B for transport mileage map.) With only two deputies on each shift this can significantly impair the sheriff s office s ability to serve its county.
Lastly Judge Beau McClain from Douglas County emphasized that the state needs to continue to strengthen its accountability courts. The goal of the Georgia Accountability Courts system is to reduce crime and incarceration rates in the state by using a combination of judicial monitoring and effective treatment to compel offenders to change their lives. The system of courts works by identifying certain individuals in the criminal justice system early such as those suffering from serious debilitating mental illness or drug addiction and offering programs to help such as treatment job training education medical stabilization family reunification job placement and anger management. According to Judge McClain a majority of the offenders seen in drug court have a co-occurring issue such as substance abuse and mental illness and the benefit of the accountability courts is that the programs are involuntary unlike many other programs resulting in better outcomes for the individuals involved however expansion of accountability courts is only possible through the provision of additional funding. As of July 2016 the state of Georgia has 57 Felony Drug 35 Mental Health 20 Veterans 25 DUI/Drug 11 Family Dependency Treatment 10 Juvenile Drug and 3 Juvenile Mental Health Courts.3
Hospitals
The study committee heard from a selection of hospitals in regards to the services provided for behavioral health as well as the issues they face.
Grady Health System and Fulton County It is estimated that 6 to 7% of Fulton County s population lives with severe mental illness. This results in a high rate of emergency room visits hospital admissions and incarcerations as well as a high rate of homelessness addictive disease and complicating medical conditions.
3 http //www.gaaccountabilitycourts.org/CACJ%20brochure.pdf
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Approximately 850 individuals access behavioral health services through Grady s Emergency Department each month. Of these some may require involuntary commitment and admission to Crisis Intervention Service (CIS) for two to three days while others might require a six to eight day inpatient stay following a CIS evaluation. Discharge planning for post-hospital care is often complicated by homelessness transportation challenges medical problems or substance abuse and readmission to the emergency room is likely if appropriate case management and aftercare does not occur.
Grady s Behavioral Health department employs 250 staff comprised of social workers professional counselors nurses mental health technicians vocational rehab counselors substance abuse counselors and certified peer specialists. The department houses 40 Morehouse and Emory psychiatrists and psychologists as well as 30 psychiatry residents and psychology interns. Grady trains more psychiatrists and psychologists than any hospital in the state.
Grady s hospital-based behavioral health services include the following
Emergency Room Diversion o Behavioral health clinicians riding with EMS which diverts approximately 20% of the possible emergency room patients o 911 calls diverted to the state crisis line
Dedicated Psychiatric Emergency Service o Dedicated 12-bed unit within the Grady emergency room that evaluates approximately 800 to 900 patients per month which diverts about 60% to a more appropriate level of outpatient care
Crisis Intervention Services (CIS) o Temporary observation unit with a max capacity of 32 patients o Serves between 400 to 500 per month o Length of stay is between two to three days o 50% of admissions (250) are discharged but require aftercare o 50% require inpatient treatment with the uninsured possibly waiting for days while insured are frequently transferred to other hospitals
Inpatient Unit o 24-bed capacity o 13 DBHDD-funded beds o Always fully occupied o Average length of stay is seven days but some patients in need of long-term care have stayed for months because no nursing home or other hospital would serve them o Discharges 80 to 100 patients per month who require aftercare
Consult and Liaison Team o Evaluates and treats mentally ill patients on medical floors o Serves thousands of individuals each year o Once stabilized patients may be referred to Grady s behavioral health inpatient unit or outpatient services
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Grady s community-based behavioral health services include the following
Assertive Community Treatment (ACT) Team (24 000 visits a year) o Three multidisciplinary teams of 12 to 14 staff who provide community and home-based services to a caseload of up to 100 clients for each team o Positive results have been seen through keeping clients out of hospitals or jails and obtaining housing
Intensive Case Management o Five FTEs with a caseload of 30 clients per staff (150 total)
Case Management o Six FTEs with a caseload of 50 clients per staff (300 total)
Projects for Assistance in Transition from Homelessness (PATH) o Three FTEs dedicated to homelessness outreach
Atlanta City Jail o Clinical team dedicated to serving inmates
Grady s clinic-based behavioral health services include the following
Adult Outpatient Clinic (38 000 visits a year) o Provides medication management and individual and group therapy o Post-hospitalization aftercare clinic Primary Care Clinic and Women s Clinic are dedicated to treating behavioral health clients o PSTAR- a program dedicated to treating individuals with severe treatment resistant psychosis o Open Dialog Clinic serves young adults utilizing a European best practice model that engages caretakers and families
Psychosocial Rehabilitation (PSR) and Peer Support Programs (14 000 visits a year) o Provides recovery-oriented services for 80 to 90 patients and helps clients with work readiness and long-term stability
Through a contract with DBHDD Grady Health System receives approximately $10 million annually to assist in serving the uninsured. Medicaid and Medicare represent about 30 to 40% of the payer mix while the uninsured represent 60 to 70%. Due to private psychiatric hospitals not treating uninsured individuals Grady typically retains the uninsured patients and transfers those with insurance to other hospitals. This greatly affects the amount of revenue the hospital generates.
Willowbrooke at Tanner Willowbrooke at Tanner is a private 82-bed inpatient behavioral health facility in Villa Rica Georgia. The facility provides care for adults children and adolescents and has an additional 10 000 square-foot outpatient services building which provides a range of outpatient behavioral health services. The center accepts voluntary and involuntary admissions for patients experiencing emergent psychiatric issues. Additionally Willowbrooke offers screenings in emergency departments of several area hospitals.
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Willowbrooke at Tanner is a self-funded initiative by the Tanner Health System with 85% of its revenue coming from Medicaid and the center believes could be used for other facilities in Georgia. In addition to the programs and treatment offered at the center Willowbrooke at Tanner provides other unique services such as transportation for patients a partial hospitalization program for those who want to remain in their community and an after school program for children that can remain in school. These services along with a focus on community-based care help the center provide a continuum of healthcare services.
Children s Mental Health
According to data from the National Institute of Mental Health one out of five children birth to 18 years of age has a diagnosable mental health disorder and one out of ten children has serious mental health problems that are severe enough to impair how they function at home in school or in the community.
According to data provided by Dr. Garry McGiboney the Deputy State Superintendent of Policy for the Georgia Department of Education (DOE) schools are often one of the first places where mental health crises and mental health needs of students are recognized and initially addressed. Of school-aged children that are getting mental health services approximately 70 to 80% receive them at school. Additionally about 14% of children with mental health problems receive mostly Ds and Fs on school work and 44% of children with mental health problems drop out of high school.
Georgia DOE has implemented Positive Behavioral Interventions and Supports (PBIS) in over 800 schools as a model for school-based mental health programs to improve school climate. Schools that have implemented PBIS have an average College and Career Ready Performance Index (CCRPI) score of 82 compared to a CCRPI score of 57 in schools not implementing PBIS. Additionally DOE has placed an emphasis on training educators so that they can better understand mental illness and know how to identify students with possible mental health issues. DOE has trained 966 educators in Youth Mental Health First Aid (YMHFA) which has led to 4 447 students being referred for follow-up or assessment services. Approximately 400 students have been referred to community-based services and over 700 students have received school-based mental health services through the Georgia APEX Project a pilot program meant to build infrastructure and increase access to mental health services for school-aged youth throughout the state.
Studies show that children and teenagers with a psychiatric disorder have six times higher odds of having health legal financial and social problems as adults if left untreated.4 Early identification and intervention of mental health problems improves outcomes for children before any conditions become more serious as well as costly and difficult to treat. According to the National Health Policy Forum youth with mental emotional and behavioral disorders that are not treated are more likely to use alcohol and drugs and become incarcerated once they reach adulthood.
An issue within Georgia related to children s mental health services is the significant lack of mental health workforce for the state s rapidly growing population. Georgia has approximately 1 050 psychiatrists which is a ratio of approximately one psychiatrist for every 2 380 children. Additionally
4 http //jamanetwork.com/journals/jamapsychiatry/fullarticle/2396495
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the ratios for psychologists and mental health counselors are also dismal with one psychologist for every 781 children and one mental health counselor for every 675 children. According to the 2015 Georgia DOE Certified Personnel Inventory the same concerning ratios are seen in Georgia s schools with one school psychologist for every 2 266 students and one school counselor for every 500 children. With an aging workforce population and a growing student population Georgia s current resources are not currently meeting the recommended ratios of providers to children.
Committee Recommendations
Upon review of the information presented the House Study Committee on Mental Illness Initiative Reform Public Health and Safety recommends the following
1. Creation of the Georgia Children s Mental Health Reform Council Modeled after the Criminal Justice Reform Council the committee recommends that a Children s Mental Health Reform Council be created in order to develop a state strategic plan to provide comprehensive accessible and coordinated mental health prevention early and timely interventions and appropriate treatment services specifically to meet the needs of Georgia s children and to reduce and further prevent the growing number of adults with untreated mental illness.
2. Evaluation of Identification Options for Mental Health System The study committee recommends that the Georgia Department of Driver Services in coordination with the Department of Behavioral Health and Developmental Disabilities evaluates the potential options and alternatives for personal identification cards for individuals within the mental health system who are unable to qualify for the state-issued REAL IDs. The agency shall report back to the study committee on its findings.
3. Community Service Boards Participating in Accountability Courts The committee strongly encourages every Community Services Board (CSB) in Georgia to develop a partnership in each county with the accountability court programs in order to integrate and better provide services to individuals within the courts program.
4. Waive Birth Certificate Fee for Homeless In order to be eligible for a Georgia driver s license or identification card a certified copy of an individual s birth certificate must be provided. It costs $25 in Georgia to get this copy and an additional $8 to request it online. The committee recommends that these fees be waived for homeless individuals in Georgia.
5. Loan Repayment and Fellowships for Psychiatrists Similarly to Georgia s current physician physician assistant and advanced practice registered nurse loan repayment programs it is recommended that a loan repayment program and a fellowship program be created for psychiatrists practicing in rural and underserved areas of the state in order to attract these providers to regions of the state that are significantly lacking in mental health services.
6. Evaluate Reducing Medicaid Lapse for Released Inmates
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Upon release from prison offenders oftentimes face a lapse between the time when services provided within the correctional system end and when the individual can start receiving state benefits such as Medicaid. This lapse can result in mentally ill individuals going without medications and treatment services resulting in a greater chance of that person ending up back in the correctional system. The committee recommends that the Georgia Department of Corrections and the Georgia Department of Community Health evaluate how to reduce or eliminate this lapse in order to provide continuous care for mentally ill individuals when transitioning between systems. 7. Allow for the Execution of Physician s Certificate Based on Certified Paramedic or EMT Observations Police officers and Emergency Medical Services (EMS) are often dispatched to incidents that involve a person who is emotionally disturbed and threatening suicide. If this person refuses transport to an emergency receiving facility and the individual is not committing a crime there is nothing that law enforcement and first responders can do to get the individual the services they need. State law currently requires that a physician have personally examined the individual within the preceding 48 hours in order to have a valid physicians certificate signed which allows for an individual to be transported involuntarily. The committee recommends that a change be considered to allow a physician to sign a certificate allowing for the involuntary transport of a mentally ill person based on the personal observation of a certified paramedic or emergency medical technician (EMT). 8. Encouraging Local Public Private Partnerships to Address Mental Health Housing In Georgia there are supportive housing options providing services to the mental health population through a collaboration of local state and federal resources. Successful examples of this model are the Pine Ridge and Oak Ridge apartments in Rome Georgia. The study committee encourages Georgia counties to partner with local businesses and housing entities to create public private partnerships that develop similar housing solutions for the mentally ill population. 9. Continued Partnership Between Federal State and Local Government The committee recognizes that the partnership between the state and the federal and local levels of government is essential in order to create comprehensive services that assist all of the citizens of Georgia. The study committee recommends that these valuable partnerships continue to be developed in order to advance and improve Georgia s mental health system.
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Mr. Speaker these are the findings and recommendations of your Study Committee on Mental Illness Initiative Reform Public Health and Safety.
Respectfully Submitted
The Honorable Katie Dempsey Representative 13th District
Chairwoman

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Prepared By Tara Boockholdt Fiscal & Policy Analyst House Budget and Research Office

Appendix
Appendix A
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Appendix B 14 P a g e