Final report of the Joint Study Committee on Mental Health Access

Mental Health Access Study Committee

Final Report of the Joint Study Committee on Mental Health Access

The Honorable Katie M. Dempsey Co-Chair State Representative District 13
The Honorable Pat Gardner State Representative District 57
The Honorable Kevin Tanner State Representative District 9
The Honorable Stephen S. Goss Superior Court Judge Dougherty Superior Court
The Honorable Garry W. McGiboney PhD. Associate Superintendent of Policy Department of Education

The Honorable Jesse Stone Co-Chair State Senator District 23
The Honorable Josh McKoon State Senator District 29
The Honorable Curt Thompson State Senator District 5
The Honorable Jason Bearden CEO Highland Rivers Health

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Table of Contents
Introduction .................................................................................................................................................. 3 Timeline of Events......................................................................................................................................... 3 COMMITTEE RECOMMENDATIONS .............................................................................................................. 6
1.) Workforce Shortage ..................................................................................................................... 7 2.) Administrative Fragmentation..................................................................................................... 9 3.) Law Enforcement........................................................................................................................ 10 4.) Case Management...................................................................................................................... 12 5.) Involuntary Commitment........................................................................................................... 13 6.) Schools and Children .................................................................................................................. 14 CONCLUSION .............................................................................................................................................. 15 SIGNATURES .................................................................................................. Error Bookmark not defined. Appendix A ................................................................................................................................................. 19 Description of the Fellowship in Community Psychiatry ........................................................................ 19
Eligibility Requirements ...................................................................................................................... 21 Program Budget .................................................................................................................................. 21 Appendix B .................................................................................................................................................. 23 Appendix C .................................................................................................................................................. 24

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Introduction
House Resolution 502 created the Joint Study on Mental Health Access. In response to recent tragedies involving violent individuals with mental illness the Georgia General Assembly has formed the Joint Study Committee on Mental Health Access. This study looks at a variety of contributing factors of mental health violence as well as possible solutions for Georgia. Specifically the study examines public resources funding workforce challenges awareness of available services community infrastructure crisis services geographic gaps and diversity provider development provider accountability and support services.
Representative Katie M. Dempsey from House District 13 and Senator Jesse Stone from Senate District 23 served as Co-Chairs of the Committee. Other members of the Study Committee were House Resolution author Representative Kevin Tanner Representative Pat Gardner Senator Josh McKoon Senator Curt Thompson Judge Steven Goss of the Dougherty County Superior Court Dr. Garry McGiboney of the Department of Education and Jason Bearden of Highland Rivers Health Community Service Board (CSB).
The committee met five times over the course of the year. They heard hours of testimony from all sides of the issue including the Department of Behavioral Health and Developmental Disabilities professionals from the Northeast Georgia Hospital System medical education professors clinicians the Department of Corrections numerous Georgia sheriffs researchers service providers and consumers.
The committee s recommendations fall under six categories. Those categories are as follows
1. Workforce shortage 2. Administrative fragmentation 3. Law enforcement 4. Case management 5. Involuntary commitment and 6. Schools and children.
Timeline of Events
The committee held five public meetings.

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First Meeting When October 24 2013 from 2 00 p.m. - 5 00 p.m. Where CLOB 606 Who Frank Berry Commissioner Department of Behavioral Health and Developmental Disabilities. Judy Fitzgerald Deputy Commissioner Department of Behavioral Health and Developmental Disabilities. Monica Parker Division Director of Community Mental Health Department of Behavioral Health and Developmental Disabilities. Focus Organizational meeting to discuss the scope of study committee planother meetings and educate about current services.
Second Meeting When October 25 2013 f5rom 10 00 a.m. - 1 00 p.m. Where Northeast Georgia Medical Center Who Deb Bailey Director of Government Affairs at Northeast Georgia Medical Center Dr. Van Haygood RN Ph.D NE-BC Director of Emergency Services Northeast Georgia Hospital System. Kevin Lloyd Executive Director of Behavioral Health Services Northeast Georgia Hospital System. Scott Masters MBA NREMT-P Director Emergency Medical Transport Northeast Georgia Hospital System. Mike Raderstorf Director of Security Services and Emergency Preparedness Northeast Georgia Hospital System. Focus Presentation on how to get access to early intervention and crisis intervention services outside of an emergency room setting.
Third Meeting When November 4 2013 from 2 00 p.m. - 5 00 p.m. Where CLOB 606 Who Denise Kornegay Director Area Health Education Center Georgia Regents University. Dr. William McDonald Professor and Faculty Department of Psychiatry Emory School of Medicine. Focus Doctor shortage in rural Georgia including Graduate Medical Education (GME) overview.

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Fourth Meeting When December 10 2013 from 10 00 a.m. - 2 00 p.m. Where Commissioner s Board Room (300 Patrol Road Gibson Hall 3rd Floor Forsyth GA 31029). Who Brian Owens Commissioner Department of Corrections. Gregory C. Dozier Assistant Commissioner/Chief of Staff Department of Corrections. Timothy C. Ward Assistant Commissioner/Chief of Operations Department of Corrections. Dr. Jim DeGroot State Mental Health Director Department of Corrections. Rick Jacobs Deputy Director Facility Operations Department of Corrections. Jack Koon Deputy Director Facility Operations Department of Corrections. Mike Kraft Director Probation Operations Department of Corrections. Sheriff Chris Houston Greene County. Sheriff Howard Sills Putnam County. Sheriff Jeff Watson Taylor County. Sheriff Robert Markley Morgan County. Terry Norris Executive Director Georgia Sheriffs Association. Nora Haynes National Alliance on Mental Illness Savannah. Dr. Michael Compton Opening Doors to Recovery. Focus Challenges in prisons jails transportation and crisis intervention training (CIT).
Fifth Meeting When December 11 2013 from 9 00 a.m. - 12 00 p.m. Where CLOB 606 Who Ellyn Yeager Director of Public Policy and Advocacy for Mental Health America. Coleen Stephens Certified Peer Specialist. Sue Smith Executive Director of the Parent Support Network. Sherry Jenkins Tucker Executive Director of the Consumer Mental Health Network. Jen Benefee Consumer. Dr. Kenneth Fuller Psychiatrist and Clinical Associate with the Medical College of Georgia Georgia Regents University. Gail M. Smith Supervisor of School Counseling Cobb County School District / Presenter of the Georgia School Counselors Association. Tom Ford Chief Executive Officer of Lookout Mountain Community Services CSB. Jennifer Ford Chief Operating Officer of View Point Health CSB. Focus A consumer and provider perspective on mental health services.

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COMMITTEE RECOMMENDATIONS
In the subsequent pages recommendations are presented using the following format Statement of the Problem Committee Recommendation Implementation Requirements Funding Requirements and Timeline.

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1.) Workforce Shortage
Statement of the Issue or Problem
There is a massive shortage in the healthcare workforce. This shortage has greatly affected the behavioral health workforce as well. In some cases there are only 1.5 psychiatrists for a caseload of 3 000 people. There are areas of the state that have a 100-mile radius without a Masters level social worker.
Committee Recommendations
1. Support continued executive and legislative efforts to increase residency slots. 2. Encourage Georgia s Congressional delegation to engage with the Centers for Medicaid &
Medicare Services (CMS) the United States Department of Health and Human Services (HHS) and other federal agencies to address the significant problems with Medicare funded GME since the Balanced Budget Act of 1997. 3. Encourage the GME-Regents Evaluation Assessment Team (GREAT) Committee to create community-based residency slots similar to the McDonald concept referenced in Appendix A. 4. Recommend to the medical colleges in Georgia that efforts be made in graduate medical education to enhance and improve primary care for behavioral health training with a community-based focus rather than a hospital focus. As we move towards a more community-focused system of care for behavioral health the education system for professionals should reflect this adjustment. 5. Recommend to the University System and the Technical College System of Georgia to improve behavioral health training for other health and welfare service providers such as nurses nurse practitioners counselors and social workers. 6. Without cost-shifting or undermining the state s compliance efforts under the U.S. Department of Justice settlement agreement efforts should be made to equalize existing inequities in regional funding for core services in an effort to enhance retention and promote the expansion of providers and access across the state.
How Will the Recommendations Be Implemented A letter and copy of report will be sent to the Governor s Office the medical colleges in Georgia Georgia s Congressional delegation the Board of Regents of the University System of Georgia the GREAT Committee the Department of Behavioral Health and Developmental Disabilities and the commissioner of the Technical College System of Georgia.

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Is Funding Required No funding is required for these recommendations however an estimated $11.9 to $14 million level would immediately address disparities in current reimbursements for core services.
Timeline The study committee will immediately initiate contact with the appropriate persons.

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2.) Administrative Fragmentation
Statement of the Issue or Problem
Testimony from mental health consumers mental health service providers hospitals community service boards and sheriffs revealed that the system of care is fragmented and disjointed. There is confusion about where a person can get mental health services how services are reimbursed and how to transport the patient.
Committee Recommendations
1. Require that the Department of Behavioral Health and Developmental Disabilities update the state s strategic plan to include the following a. Define and update standards for emergency receiving facilities for all levels of care. For example develop standards so nurses and doctors can determine which patients need to be in a forensic setting a state hospital bed a private hospital bed or a crisis stabilization unit. b. Develop a system-wide plan for bed supply and demand for each level of care. c. Update access standards to minimize transport and travel for sheriffs. d. Develop a common platform for utilization management for all public payer sources (External Review Organization Medicaid Managed Care and Fee for Service) to minimize overhead costs and maximize service delivery dollars.
2. Incentivize and encourage various state and local systems (courts Corrections Juvenile Justice CSBs child welfare agencies education entities etc.) to work in concert with one another to optimize the healthcare workforce maximize the utilization of federal and other funds while decreasing the use of state funds and improve the system of care and continuity of care. These efforts to reduce fragmentation can be accomplished in conjunction with the creation of local or regional coordinating councils (Item 4.1. Page 11).
How Will the Recommendations Be Implemented Propose these recommendations to be included in the Department of Behavioral Health and Developmental Disabilities Amended Fiscal Year 2014 and Fiscal Year 2015 budgets.
Is Funding Required No funding is required for these recommendations.
Timeline This plan will be developed by the Department of Behavioral Health and Developmental Disabilities by December 31 2014.

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3.) Law Enforcement
Statement of the Issue or Problem Historically sheriffs deputies have provided transportation for behavioral health consumers in crisis. Since hospitals are not the preferred place for treatment many patients in crisis are prone to wait for hours in emergency rooms until they can secure transportation for care. These calls can take hours or even days and rural counties cannot afford to reallocate existing public safety manpower for that long. Also many of these patients repeatedly commit non-violent and minor legal offenses that require confinement which in turn absorbs costly county jail space and creates a backlog in county jail facilities.
Committee Recommendations
1. Encourage the Department of Corrections to continue to develop capacity to deliver services in communities for on-going behavioral health treatment of probationers in conjunction with community behavioral health providers where possible.
2. Recommend to the Peace Officers Standards and Training (POST) Board to include Crisis Intervention Training (CIT) in the POST certification process for all certifications including law enforcement officers probation officers and parole officers.
3. Recommend to the Georgia Bureau of Investigation the option to allow a mental health consumer to voluntarily request a notation in the Georgia Crime Information Center s (GCIC) network indicating their behavioral health status in order to assist the safety and well-being of the consumer in the community and promote recovery. This option would be entirely voluntary and only available if Health Insurance Portability and Accountability Act (HIPPA) waivers are signed.
4. Recommend the passage of House Bill 205 the Psychiatric Advanced Directive Act. This bill allows an adult or emancipated minor mental health patient to execute a "Psychiatric Advance Directive" to appoint a mental health care agent to make behavioral healthcare decisions when the patient is considered "incapable."
5. Encourage the creation of innovative transportation solutions such as the mental health transport program at Northeast Georgia Hospital System. This program has special vehicles with no interior back locks or door handles a partition between the driver and the patient and audio-video for security purposes. Each transport has at least two specialized staffers who are trained in restraint cardiopulmonary resuscitation (CPR) defensive driving and crisis intervention.

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How Will the Recommendations Be Implemented A letter and copy of the report will be sent to the commissioner of the Department of Corrections the director of the Georgia Bureau of Investigation the director of the Georgia Peace Officer Standards and Training Council and the director of the Georgia Hospital Association. Legislation for the Psychiatric Advanced Directive Act is already filed as House Bill 205.
Is Funding Required No funding is required for these recommendations.
Timeline The study committee will immediately initiate contact with the appropriate persons. The legislation is available for consideration and passage in the 2014 Legislative Session.

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4.) Case Management
Statement of the Issue or Problem Georgia has numerous resources to assist behavioral health consumers with access to services however many people do not know how to manage these systems and find the resources they need. The ability to have stable housing a meaningful day and adequate treatment are some of the most important parts of living successfully in recovery.
Committee Recommendations
1. Recommend the Behavioral Health Coordinating Council facilitate the creation of regional or local coordinating councils to coordinate and manage the regional system of care.
2. Recommend that the Department of Behavioral Health and Developmental Disabilities create a flexible funding source to incentivize case managers to meet the real needs of the consumer and not just the needs that are reimbursable.
3. Support the utilization of care management entities (CME) to coordinate and provide services for children and families with behavioral health needs.
4. Recommend to the Appropriations Committees of the House and Senate to continue the funding of the Opening Doors to Recovery s Phase 1 operations as well as begin funding Phase 2 of the program.
How Will the Recommendations Be Implemented A letter and copy of the report will be sent to the Behavioral Health Coordinating Council the Department of Behavioral Health and Developmental Disabilities the House and Senate Appropriations chairmen and Opening Doors to Recovery.
Is Funding Required Yes. Opening Doors to Recovery would need $360 000 per year for three years of research to ensure that the project can be fully developed as an evidence-based practice for state-wide replication. To complete Phase 2 of the project approximately $110 000 is needed per year for three years for three peer community navigation specialists (CNS) teams and a supervisor. See Appendix B.
Timeline The study committee will immediately initiate contact with the appropriate persons. The funding requests should be considered during the 2014 Session s budget process.

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5.) Involuntary Commitment
Statement of the Issue or Problem As the type of mental health service providers continue to evolve the existing laws regarding involuntary commitment ("Form 1013" laws) have become outdated.
Committee Recommendation
1. Recommend that a joint study committee be formed to study the reform of these Code sections (O.C.G.A. 37-3-41 37-3-42 and 37-3-101) including outpatient civil commitment and the outpatient commitment and supervision for defendants found incompetent to stand trial and non-restorable.
How Will the Recommendation Be Implemented A resolution will be drafted during the 2014 Legislative Session to create a Joint Study Committee on Involuntary Commitment Laws.
Is Funding Required No funding is required for this recommendation.
Timeline The legislation will be initiated in the 2014 Legislative Session.

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6.) Schools and Children
Statement of the Issue or Problem Following the recent school tragedies surrounding mental health patients it is obvious to the committee members that Georgia must to do something to stabilize and secure the school environment.
Committee Recommendations
1. Support the expansion of Positive Behavioral Intervention and Supports (PBIS) to stabilize the school environment and enhance and support behavior outcomes for all students thus creating a safer school environment.
2. Direct and maximize existing as well as new training resources and intervention tools for schools counselors social workers and psychologists to help address potential and/or existing behavioral health issues quickly. Service models in every system should be streamlined to allow for coordinated sustainable services from Pre-K to graduation.
3. Recommend to local school systems to explore barriers between mental health providers as a complement to school resources (counselors nurses etc.).
4. Encourage the heightened use of Early and Periodic Screening Diagnostic and Treatments (EPSDT) screenings as a method for identifying children who have experienced traumatic incidents before behavioral problems develop.
How Will the Recommendations Be Implemented A letter and copy of the report will be sent to the state school superintendent and the House and Senate Appropriations Committees.
A copy of the report will be sent to the Department of Community Health (DCH) requesting a study on the utilization of EPSDT in comparison to other states existing barriers in Georgia around the utilization of this service and recommendations from the DCH to the legislature on how to improve utilization of this service for children and adolescents.
Is Funding Required No funding is required for these recommendations at this time.
Timeline The study committee will immediately initiate contact with the appropriate persons and request feedback from the DCH.

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CONCLUSION

The Joint Study Committee on Mental Health Access was charged with looking at a huge array of issues surrounding mental health access. Although there will never be a complete one-size-fits-all solution for preventing unexplainable tragedies it is important to analyze our own state s resources and determine what is best for the citizens of Georgia. Through this process the committee heard from experts as well as advocates. The committee heard stories of heart-breaking tragedy and extraordinary recoveries.

Through these testimonies six general problems are consistently identified. These problems are centered on the workforce shortage administrative fragmentations law enforcement case management involuntary commitment laws and services for children in schools.

To address the problems in the workforce shortage it was realized that medical education must be more comprehensive and include behavioral health training. Also Georgia s Congressional delegation must address problems in Washington that have "capped" Georgia s residency slots. The committee applauds the governor the Board of Regents and the legislature for their recognition of the shortage and initiating an on-going increase in residency slots in Georgia since 2012.

To address the problems with administrative fragmentation it was determined that the Department of Behavioral Health and Developmental Disabilities must regularly update the state s strategic plan since two hospitals have closed. The supply and demand of resources and beds must be mapped geographically to minimize long transports.

To address the problems that law enforcement officers are facing the committee has recommended that all POST certifications include crisis intervention training. The committee also recommends that the GBI allow for voluntary notations in their GCIC system to assist those mental health consumers living in recovery. Legislatively the committee recommends passing House Bill 205 the Psychiatric Advanced Directive Act to encourage and promote personal responsibility for those individuals living in recovery.

To address the case management issues that this population frequently encounters it is recommended that case management services be enhanced. To address children and families care management entities have had great success coordinating and providing services for

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children and families with behavioral health needs. To address the adult population the Opening Doors to Recovery project has proven to be a very innovative method of providing successful case management needs. The committee recommends the funding of the ODR project so their methods can become an evidence-based practice pilot and be implemented state-wide in the future.

Taking into consideration the large scope of this study committee it was decided that another study committee must be formed to best address the reform of involuntary commitment laws. This subject is so vast and intensive that this committee did not believe it had the knowledge or resources needed to write a comprehensive reform bill.

Additionally the study committee realizes the need for the stabilization of the school environment. This leads to the committee s support of the use of Positive Behavioral Intervention and Supports as well as Early and Periodic Screening Diagnostic and Treatment (EPSDT). It is also recommended that existing resources and training be fully maximized for schools counselors social workers and psychologists so they can provide intervention services and/or coordinate services for children throughout the entire spectrum of their years in school. Because the committee advocates for these qualified personnel to spend more time with students and less time doing clerical or administrative duties the committee favorably notes the recommendations regarding school counselors from the fifteen-month study by the of the Joint Commission on School Finance (HB 192 2011-2012) which includes a three-year phase in of additional counselor funding to lower the counselor to student ratios.

Lastly the study committee wanted to note the large growth and great successes in Georgia s Accountability Courts. The study committee supports the continued development of these courts.

The following organizations will receive an official copy of this report and the committee s recommendations
Emory University School of Medicine Georgia Regents University School of Medicine Georgia s Congressional Delegation Georgia s State School Superintendent House Appropriations members Senate Appropriations members Mercer University School of Medicine

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Morehouse School of Medicine Opening Doors to Recovery The Behavioral Health Coordinating Council The Board of Regents of the University System of Georgia The Department of Behavioral Health and Developmental Disabilities The Department of Community Health The Department of Corrections The Georgia Bureau of Investigations The Georgia Hospital Association The Georgia Peace Officer Standards and Training Council The Governor s Office The GREAT Committee The Technical College System of Georgia
The following legislation should be considered during the 2014 Legislative Session The Psychiatric Advanced Directive Resolution creating the Joint Study Committee on Involuntary Commitment Laws
The following budget items should be considered during the 2014 Legislative Session Funding for the Opening Doors to Recovery Project Funding for school counselors school social workers and school psychologists Review the DBHDD Equity Funding Brief and begin discussion and potential action for funding a multi-year plan to address the disparity in funding for core services across the state of Georgia. (Appendix C)

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Appendix A
Description of the Fellowship in Community Psychiatry
The Emory University School of Medicine Department of Psychiatry and Behavioral Sciences proposes a two-year Community Psychiatry fellowship that includes completing a Master of Public Health (MPH) at the Rollins School of Public Health. Two fellows a year--one adult psychiatrist and one child psychiatrist--will be enrolled in this two-year fellowship.
The Emory University Fellowship in Community Psychiatry/Public Health will provide integrated experiences in community mental health settings including Grady Health System s Crisis Intervention Service and medical/psychiatric outpatient care clinic Community Service Boards Behavioral Health Link/ Georgia Crisis and Access and Grady EMS mobile crisis services Pathways to Housing (housing first model) Assertive Community Treatment Gateway Shelter and St. Jude s detox and outpatient substance abuse. Emory is open to developing other clinical experiences (e.g. rural Community Services Boards crisis stabilization and mobile crisis) in collaboration with the Department of Behavioral Health and Developmental Disabilities in an effort to address the State s work force needs and the objectives of the Fellowship. The Fellowship provides rich community psychiatry experiences a course of study leading to an MPH degree and longitudinal administrative didactic scholarly and mentoring experiences. Fellows begin the program during their fourth post-graduate year (PGY-4) of psychiatric residency training with an additional year of fellowship training (PGY-5) or in two years after residency training (PGY-5 and PGY-6). The following components of the Fellowship occur concurrently.
1. Community mental health activities centered at community sites
The first year of the Fellowship offers a broad-based community mental health experience including providing clinical services as well as administration and program development. Fellows spend half of their time at these clinical/administrative rotation sites. Possible areas of clinical experience include working with multi-agency collaboratives to provide social services and mental health care to homeless individuals transitioning to housing following patients involved in Peer Support and Wellness Services day programs working with supportive employments programs providing care for those with mental illnesses who are or have been incarcerated or otherwise institutionalized and are transitioning back into the community working to further develop state-of-the-art holistic treatment programs at private community mental health centers which serve special populations such as persons with autism developmental disabilities and the aging. Administrative activities may include participation in local state and national community psychiatry and public health association activities and development of new programs evaluation tools or research projects at the Fellow s clinical sites including partnerships with local regional and national mental health policy makers.
Prior to the start of the second year of the Fellowship each Fellow meets with a mentor to develop a clinical project for the second year. This project will be in a particular area of interest consistent with the goals of the Fellowship. This project culminates in a special studies project or thesis in collaboration with advisory faculty at the School of Public Health with possible publication or presentation of the scholarly project.

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2. Master of Public Health Degree at the Rollins School of Public Health
At the Rollins School of Public Health (RSPH) of Emory University students learn to identify analyze and intervene in contemporary public health issues. RSPH is located in Atlanta "the public health capital of the world " which is home to the Centers for Disease Control and Prevention (CDC) the national home of the American Cancer Society (ACS) the Carter Center numerous state and regional health agencies and the clinical teaching and health-related research programs of Emory University s Woodruff Health Sciences Center. This setting is ideal for hands-on research collaborations with the world s leading public health agencies and interdisciplinary work with national and international organizations. Students join the RSPH community from all 50 states and over 40 foreign countries to contribute to the school s mission which is to acquire disseminate and apply knowledge to promote health and prevent disease in human populations. Fellows will join and contribute to the "mental health certificate" track which focuses inquiries into public health onto behavioral and mental health issues.
Fellows are required to complete 42 credits and a special studies/research project focusing on a community mental health issue. The Fellowship provides tuition for 42 credits and it is expected that Fellows complete all course work by June 30 two years after matriculation into the Fellowship. In addition to the four regular semesters of coursework available over the course of these two years Fellows make take courses up to four short summer sessions. The Fellowship prospectively pays for the Fellow s Master of Public Health degree with the assumption that the Fellow completes the Fellowship in the course of two years. However if during the two years of training the Fellow decides to discontinue the Fellowship program the Fellow would be responsible for the tuition and fees paid towards the degree. Fellows are encouraged to take all relevant and beneficial mental health courses offered at RSPH and to complete any other requirements of the Mental Health Concentration. It is recommended that the applicant apply to either the Behavioral Sciences and Health Education (BSHE) department of the Health Policy and Management (HPM) department at RSPH. If the applicant has a special interest in biostatistics epidemiology global health or other areas of public health alternative curriculum options may be considered contingent upon securing a mentor willing to help shape focus of the suggested curriculum.
Fellows participate in longitudinal administrative didactic and mentoring experiences. Fellows
Participate in a longitudinal didactic series that focuses on a variety of topics including the public mental health system in Georgia prevention of mental illnesses Recovery advocacy and service models (e.g. assertive community treatment crisis intervention services psychosocial rehabilitation) and other topics that are not specifically included in the Master of Public Health curriculum.
Fellows conduct site visits to community mental health related state agencies in the Metropolitan Atlanta area in conjunction with the didactic series.
Each Fellow meets regularly with a selected mentor for career development activities. Fellows are strongly encouraged to (1) prepare for and sit for the American Board of Psychiatry and
Neurology Board certification examination (2) join the American Association of Community Psychiatrists (3) attend the annual symposium sponsored by the Carter Center Mental Health Program and (4) participate in the activities at least one community agency or organization relevant

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to community mental health 5) attend and present at the annual American Psychiatric Association s Institute on Psychiatric Services.

Eligibility Requirements Applicants to the Fellowship must have completed at least three years of a psychiatry residency training program accredited by the Accreditation Council for Graduate Medical Education (ACGME) and be very interested in pursuing a career in community psychiatry.

Applications to both the Emory University Department of Psychiatry and Behavioral Sciences and the Rollins School of Public Health are required and will ensure recruitment of the most capable candidates.

These applications must be submitted as far in advance as possible in order to be considered for entry into the Fellowship which begins in July of each year. Selected applicants are invited to interview with faculty and staff and tour the Rollins School of Public Health Emory School of Medicine Department of Psychiatry and Behavioral Sciences Grady Health System and other program sites. A personal statement letters of recommendation and a clearly outlined plan for how the training opportunity will inform and propel applicants future careers as leaders in community and public psychiatry will be heavily weighted in application evaluations. Minority candidates and applicants from communities with high needs and underrepresented psychiatric representations are strongly encouraged to apply for these training programs.

Program Budget The program leadership will include a Program Director (.25 FTE) and a part time administrative assistant (.2 FTE). The Program Director will be recruited in a national search with an emphasis on a leader in the field of community psychiatry who has experience in the State of Georgia. This individual will have an appointment in the Emory Department of Psychiatry and Behavioral Health with a secondary appointment in the Rollins School of Public Health (RSPH). They will be responsible for recruitment of applicants development of rotation sites and the didactic curriculum.

The core of the didactic curriculum will be the Masters of Public Health (MPH) program at the Rollins School of Public Health. The fellows will be enrolled at RSPH for two academic years. The school comprises six academic departments behavioral sciences and health education--biostatistics environmental health epidemiology health policy and management global health--and hosts over two dozen interdisciplinary centers. The program is community oriented and takes advantage of the close proximity to the Center for Disease Control. Students are required to do a thesis on graduation and it is expected that the fellows will be engaged in community psychiatry projects focused on their primary rotation sites. More than 180 full-time doctoral-level faculty members teach in the school.

The costs of the program are outlined below in Table 2 and more detail is added in Appendix 3. Two fellows

will be recruited each year one adult psychiatrist and one child psychiatrist. Averaged over a year it is

expected that the fellows will spend 60% of their time community sites and 40% of their time in didactic

activities including their MPH coursework. In the first year of the program the expenses are lower primarily

due to the fact that there is not a full complement of fellows until the second year. The second year

represents the full recurring cost of the program.

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Category

Total first year

Total second year1

Director and Admin Assistant salaries and fringe Fellow salaries and fringe2

$73 950 $149 462

$76 168 $311 199

RSPH tuition and fees

$45 256

$89 912

Supplies (e.g. books and travel)

$1 600

$3 200

Subtotal

$270 268

$480 479

Emory School of Medicine Administrative charge

$27 027

$48 048

Budget total

$297 295

$528 527

Notes

1. Includes 3% increase per year

2. The fellows are in their post graduate years (PGY). A residency program is four years so a fellow who has

graduated from that program is in their PGY-5 year in year one and PGY-6 year in year two. A fellow who has

graduated from a child psychiatry program (which is five years long) would be in their PGY-6 year in year one

and PGY-7 year in year two. Each year the program will recruit one PGY-5 and one PGY-6.

In keeping with how other fellowship programs have developed their funding streams the budget includes full funding for the Community Psychiatry Fellowship Program across the first two years. During this pilot phase data will be gathered to evaluate the program with a focus on three outcomes
1. Retention in Georgia s public sector Assessing the percentage of fellows who take jobs in the CSBs or other public psychiatry positions.
2. Fellows clinical activities Evaluating the number and types of services provided by the fellows including the different roles they take on and the value added to the community sites.
3. Net revenue generated Measuring the amount and types of services billed by the fellows.
The results of this evaluation will be used to inform the budget development for subsequent years of the program. It is expected that the costs to the state will be lower in future years because the fellows will generate revenue from providing services at the community sites.
In conclusion the proposed Fellowship in Community Psychiatry at Emory University offers several features that are unique among public psychiatric fellowships. First this program would be the only in the country to include a Master s Degree in Public Health which will provide fellows with in-depth training and credentials to serve as leaders in public psychiatry settings. Second whereas other fellowships have focused exclusively on training adult community psychiatrists the fellowship will include both adult and child/adolescent community psychiatrists. Third while most community psychiatry fellowships include field placements in urban areas this fellowship will also provide training in rural settings including opportunities to offer telepsychiatry as part of the training program. Fourth the strong consumer presence in Georgia will insure that the program is grounded in principles of recovery. Finally the unique partnership with both the state mental health authority and the Georgia Community Service Board will enhance both training and placement opportunities for fellows in the program. Taken together these strengths will provide the program national visibility and allow it to become a model for other community psychiatry programs across the country.

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Appendix B

ASK for Continuation of the Opening Doors to Recovery Project
Phase 1 Over 3 million from the state and our partners has been spent to develop ODR. From Phase One of ODR of the 100 hospitalized participants discharged to an ODR team who received at least one year of ODR support results yielded significantly reduced recidivism and enhanced recovery.
Phase 2 Using the ODR model with 100 individuals (and a control group) with serious and persistent mental illness released from the Georgia Department of Corrections beginning Winter 2014 a three-year trial will be launched to determine if recidivism and revocation will be reduced and recovery enhanced thus making ODR Georgia s very own evidence based practice.
Ask For support from the Commission the Georgia Legislature and Governor for all agencies and
departments to be educated and participate in MOUs with the ODR Phase 2 Community Navigation Specialists (CNS) and Project to assure the participants do not fall through the gaps and get lost back into the "deep ends." This includes but is not limited to
DBHDD P & P GA Hospital Association Sheriffs & Jails Chiefs and other Law enforcement in Region 5 Board of Regents and Higher education DFACS DCH DCA DNR GDE Social Security Vocational Rehab GA DOL DHS and others.
Ask Funds for three years 2014-2016 to complete ODR & Research
$360 000 per year for three years for research
$110 000 per year for three years for the 3 Peer CNS and supervisor

Ask Once Phase 2 is complete (should the results be positive) ODR could be implemented statewide.

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Appendix C

Georgia Department of Behavioral Health & Developmental Disabilities (DBHDD) State-funded Basic Outpatient Services Equity Issue Brief to General Assembly (HB102 Line 62.6)

Assuring fair and equitable access to services throughout Georgia is critical to the mission of the DBHDD and to Georgia s citizens. Several factors impact access to services resulting in a mixed picture of funding access and service utilization throughout the state.
In response to a request for actionable strategies to promote access and equity the DBHDD is presenting the following information for discussion and consideration. We offer this analysis with a fundamental premise The community behavioral health system in Georgia as in most states is not adequately funded. As a result the DBHDD does not wish to achieve equity through removing funds and decreasing access in certain areas and shifting those funds to other areas to achieve an equalized but underfunded system. This reallocation approach would remove funds from counties which are significantly below the national per capita funding average leading to disruption of already compromised behavioral health access. Consider the following

The federal Substance Abuse and Mental Health Services Administration also finds that just over half (58.7 percent) of adults in the United States with a serious mental illness (SMI) received treatment for a mental health problem 1
Georgia is ranked 43rd in the country on Mental Health per capita spending per the Healthcare Georgia Foundation 2
More specifically when reviewing the States mental health authorities GA ranks 47th in total services Per Capita Mental Health Expenditures 3
Since 2009 mental health services utilization has increased from 15.2 per 1 000 residents in 2009 to 17.0 in 2010.4
Georgia s DBHDD state-funded regional basic "core" behavioral health outpatient services funding5 also reflects considerable disparity in and among its regional areas

DBHDD Regional Funding Per Capita

for Basic Outpatient Services

$15.24

16.00 14.00 12.00 10.00 8.00

$8.04

$13.09

$8.47

$12.31 $10.30

6.00

4.00

2.00

0.00

1

2

3

4

5

6

Regions

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A more detailed analysis of the distinct service areas reveals that the disparity is even greater with per capita funding ranging from $3.52 per person to more than $22 per person.

$25.00

Three Lowest and Highest Funded Areas Per Capita

$20.00

$19.01

$15.00 $10.00 $5.00

Average Per $5.59 $3.52 $4.66

$-

As a result of these disparities DBHDD is studying options which could incrementally equalize per capita area funding while not reducing capacity in any single geographic area. This is critical to the preservation of the state s safety net. The Department is using Georgia s adult population (18 ) in each service area of the state as the foundation to provide this comparison.

After considerable analysis by the DBHDD our recommendation is a funding equalization plan which considers the following

Assessment of the current Georgia adult population by current service area boundaries Determination for each service area the percent of total population that is represented by that population
count Analysis of basic outpatient service funding levels for those distinct service areas calculating the percent of this
current funding by % of the total funding Calculation of the difference between current funds and an equity amount based upon the per capita target
amount which is the average per capita funding of $10.06.

In this analysis 11 service areas which are currently underfunded per capita would be allocated funds to achieve a balanced distribution based upon adult population. This would represent an increase of $11.9M.6

Additionally recognizing Georgia s low per capita funding ranking as compared to other states the DBHDD strategy considers a 5% increase to those providers who would not receive an increase in the equity distribution. This request would enhance behavioral health service access to Georgia s adult citizens across all areas and further addresses Georgia s low funding ranking in and among its peer states. This additional amount equals $2.1M.

Equity Deficit General Access Increase Total for Consideration

$11.9M7 $ 2.1M $14.0M

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It should be noted that even though DBHDD and its provider network have had an infusion of funds from the General Assembly for the ADA settlement with the federal Department of Justice those services target a limited population with highly specialized services largely focused on individuals already in crisis. Settlement funds did not include any enhancement or expansion to basic outpatient behavioral health services which are considered essential for a viable safety net.
DBHDD is committed to the development of a strong public behavioral health system that is accessible accountable and offers high quality service delivery throughout the state. The equity reallocation is a critical step toward achieving that goal.

1 SAMHSA s National Survey on Drug Use and Health (NSDUH) 2008. 2 Healthcare Georgia Foundation website (http //www.healthcaregeorgia.org/uploads/publications/HGF_chart_white_4.pdf) Accessed December 4 2013. 3 Kaiser Family Foundation website (http //kff.org/other/state-indicator/smha-expenditures-per-capita/ map) accessed December 4 2013. 4 Georgia Office of Planning and Budget (http //opb.georgia.gov/sites/opb.georgia.gov/files/related_files/site_page/GIP%204%20Healthy%2001%2028%202013.pdf) 5 Basic Outpatient services are typically referred to as "core" services and represent the basic behavioral health services which almost anyone with a behavioral health condition might qualify (e.g.
Assessments Individual Counseling etc.). 6 Final financial data is pending in order to complete more thorough analysis of current Fulton county funding distribution.

Physician s

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