Funding and Characteristics of State Mental Health Agencies: 2009

2011·5.2 MB·English

Funding and Characteristics of
State Mental Health Agencies, 2009
Funding and
Characteristics of State
Mental Health Agencies,
2009
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
Substance Abuse and Mental Health Services Administration
Center for Mental Health Services
www.samhsa.gov
1 Choke Cherry Road
Rockville, MD 20857

Acknowledgments
This report was prepared for the Substance Abuse and Mental Health Services Administration (SAMHSA)
by the National Association of State Mental Health Program Directors Research Institute, Inc. (NRI),
under Contract No. 280-03-3205, with SAMHSA, U.S. Department of Health and Human Services (HHS).
The authors of the report are: Theodore C. Lutterman, Azeb Berhane, Robert Shaw, Kristin Roberts,
and Verda Rana. Joanne Atay, M.A., Division of State and Community Systems Development, served as
the Government Project Officer.
Disclaimer
The views, opinions, and content of this publication are those of the authors and do not necessarily reflect
the views or policies of SAMHSA or HHS.
Public Domain Notice
All material appearing in this report is in the public domain and may be reproduced or copied without
permission from SAMHSA. Citation of the source is appreciated. However, this publication may not
be reproduced or distributed for a fee without the specific, written authorization of the Office of
Communications, SAMHSA, HHS.
Electronic Access and Printed Copies
This publication may be downloaded or ordered at http://store.samhsa.gov. Or call 1-877-SAMHSA-7
(1-877-726-4727) (English and Español).
Recommended Citation
Substance Abuse and Mental Health Services Administration, Funding and Characteristics of State
Mental Health Agencies, 2009. HHS Publication No. (SMA) 11-4655. Rockville, MD: Substance Abuse
and Mental Health Services Administration, 2011.
Originating Office
Survey, Analysis and Financing Branch, Division of State and Community Systems Development, Center for
Mental Health Services, Substance Abuse and Mental Health Services Administration, 1 Choke Cherry Road,
Rockville, MD 20857.
HHS Publication No. (SMA) 11-4655
Printed 2011
iv Funding and Characteristics of State Mental Health Agencies, 2009

Contents

Acknowledgments........................................................................................................................................................................iii

Executive Summary .................................................................................................................................................................... xi

I. Introduction ...............................................................................................................................................................................1

1.1 Background ...............................................................................................................................................................1

1.2 Methods ....................................................................................................................................................................2

1.2.1 SMHA Profiling System ....................................................................................................................................2

1.2.2 S MHA-Controlled Revenue and Expenditure Study ...........................................................................................2

1.2.3 The Uniform Reporting System ........................................................................................................................3

1.2.4 Limitations .......................................................................................................................................................3

1.3 Overview of the Rest of the Report ...........................................................................................................................4

II. Organization and Structure of SMHAs ..................................................................................................................................5

2.1 SMHA Location in State Government ........................................................................................................................5

2.2 Other Responsibilities of SMHAs ..............................................................................................................................7

2.2.1 Substance Abuse .............................................................................................................................................7

2.2.2 Intellectual Disability ........................................................................................................................................7

2.2.3 Medicaid .........................................................................................................................................................7

2.2.4 Housing ...........................................................................................................................................................7

2.2.5 Health .............................................................................................................................................................7

2.3 SMHA Mental Health Responsibilities ......................................................................................................................7

2.3.1 Forensic Mental Health Services ....................................................................................................................10

2.3.2 Mental Health Services for Children and Adolescents .....................................................................................10

2.3.3 Brain Impaired (Including Traumatic Brain Injury) and Organic Brain Syndrome

(Including Alzheimer’s Disease) Services .................................................................................................................................. 10

2.3.4 Operation of State Psychiatric Hospitals .........................................................................................................10

2.3.5 Housing Services ..........................................................................................................................................11

2.4 Reorganization of SMHAs .......................................................................................................................................11

2.5 Number of Mental Health Organizations Operated and/or Funded by SMHAs .......................................................11

2.6 SMHA Management Information Systems and Research Functions ......................................................................12

2.6.1 Organization of MIS .......................................................................................................................................12

2.6.2 MIS Staffing and Budgets ..............................................................................................................................13

2.6.3 Types of Mental Health Information Collected by SMHAs ................................................................................13

2.6.3.1 Client-Level Data ................................................................................................................................13

2.6.3.2 Claims/Encounter Data.......................................................................................................................13

2.6.3.3 Medications Information .....................................................................................................................14

2.6.3.4 Client Outcomes .................................................................................................................................14

2.7 Electronic Health Records ......................................................................................................................................15

2.7.1 Implementation of EHR Components ...............................................................................................................15

2.7.2 Sharing EHR Information ................................................................................................................................16

2.7.3 Electronic Personal Health Records ................................................................................................................16

2.7.4 Telemedicine ..................................................................................................................................................16

2.8 Linking SMHA Data With Data of Other State Agencies .........................................................................................16

Funding and Characteristics of State Mental Health Agencies, 2009 vi
2.9 Characteristics of Mental Health Consumers Served by SMHA Systems (2008) ...................................................17

2.9.1 Consumers Served, by Age and Gender ..........................................................................................................18

2.9.1.1 Children (0 to 12) and Adolescents (13 to 17) .......................................................................................18

2.9.1.2 Young Adults (18 to 20) and Adults (21 to 64) .....................................................................................19

2.9.1.3 Older Adults (65 and Above) ................................................................................................................19

2.9.2 Consumers Served, by Race/Ethnicity and Gender .........................................................................................20

2.9.2.1 Children (0 to 12) and Adolescents (13 to 17) ......................................................................................20

2.9.2.2 Young Adults (18 to 20) and Adults (21 to 64) .....................................................................................20

2.9.2.3 Older Adults (65 and Above) ...............................................................................................................22

2.9.3 Adults With Serious Mental Illnesses and Children With Serious Emotional Disturbances Served ....................22

2.10 SMHA Financing of Mental Health Services ..........................................................................................................23

2.10.1 Major Funding Sources, FY 2007 ..................................................................................................................26

2.10.2 Trends in Financing of Mental Health Services Over Time .............................................................................30

2.10.3 Medicaid ......................................................................................................................................................32

2.10.4 SMHA Mental Health Expenditures Over Time ...............................................................................................32

2.10.5 Trends in Community Mental Health and State Hospital Expenditures Over Time ..........................................35

2.10.6 Shift From State Psychiatric Hospital-Based Services to Community Mental Health Services ........................36

2.11 Summary ...............................................................................................................................................................37

III. SMHA Policies ........................................................................................................................................................................39

3.1 Eligibility for Mental Health Services ......................................................................................................................39

3.2 Collaboration With Other State Agencies ...............................................................................................................39

3.3 Consumer- and Family-Driven Care........................................................................................................................40

3.4 Elimination of Disparities in Mental Health Services ..............................................................................................41

3.4.1 Cultural Competency ......................................................................................................................................41

3.4.2 Dual Diagnosis ...............................................................................................................................................41

3.4.3 Rural Mental Health Initiatives .......................................................................................................................41

3.5 Mental Health Screening, Assessment, and Service Referral ................................................................................42

3.5.1 Trauma ..........................................................................................................................................................42

3.5.2 Older Adults ...................................................................................................................................................42

3.5.3 Dual Diagnosis ...............................................................................................................................................43

3.6 Outpatient Commitment Statutes ...........................................................................................................................43

3.7 Awareness of Mental Health Issues .......................................................................................................................43

3.8 Suicide Prevention ..................................................................................................................................................43

3.9 Services for Armed Forces Veterans and National Guard Members ......................................................................43

3.10 Use of Medicaid Options To Fund Mental Health Services ....................................................................................44

3.11 Evidence-Based Practices ....................................................................................................................................44

3.11.1 Assertive Community Treatment ...................................................................................................................44

3.11.2 Supported Employment ................................................................................................................................45

3.11.3 Medication Algorithms ..................................................................................................................................46

3.11.3.1 Schizophrenia ...................................................................................................................................46

3.11.3.2 Bipolar Disorder ................................................................................................................................46

3.11.4 Family Psychoeducation ...............................................................................................................................46

3.11.5 Integrated Dual Diagnosis Treatment (Mental Illness and Substance Abuse) ..................................................47

3.11.6 Illness Self-Management ..............................................................................................................................47

3.11.7 Supported Housing .......................................................................................................................................47

3.11.8 Consumer-Operated Services .......................................................................................................................48

3.11.9 Multisystemic Therapy ..................................................................................................................................48

3.11.10 Functional Family Therapy ..........................................................................................................................48

3.11.11 School-Based Interventions ........................................................................................................................49

3.11.12 Older Adult EBPs .........................................................................................................................................49

Funding and Characteristics of State Mental Health Agencies, 2009 vii
3.11.13 Training for EBPs ........................................................................................................................................49

3.11.14 Barriers to Implementing EBPs ....................................................................................................................49

3.11.15 SMHA Initiatives To Promote the Adoption of EBPs ......................................................................................50

3.11.16 Emerging EBPs ...........................................................................................................................................50

3.12 Summary ...............................................................................................................................................................50

IV. Community Mental Health Services ...................................................................................................................................51

4.1 SMHA Relationships to Community Mental Health Providers .................................................................................51

4.1.1 Controlling Entry to State Psychiatric Hospitals ...............................................................................................51

4.2 Initiatives To Restructure Community-Based Mental Health Service Delivery .......................................................52

4.3 Community Mental Health Services Provided ........................................................................................................52

4.4 Consumer-Operated Services .................................................................................................................................52

4.4.1 Types of Consumer-Operated Services Funded by SMHAs ..............................................................................53

4.5 Clinical Practice Guidelines ....................................................................................................................................53

4.6 SMHAs’ Relationship to Criminal and Juvenile Justice ..........................................................................................53

4.6.1 Provision of Mental Health Services to Persons in Prison or Jails ....................................................................53

4.7 Characteristics of Persons Served in Community Settings ....................................................................................54

4.7.1 Consumers Served, by Age Groups .................................................................................................................54

4.7.2 Utilization Rates of Consumers Served in Community Settings, by Age and Gender.........................................54

4.7.3 Employment Status of Consumers Served ......................................................................................................55

4.7.4 Living Situation of Mental Health Consumers Served ......................................................................................56

4.8 Financing of Community Mental Health Services ...................................................................................................56

4.8.1 Overall Expenditures for Community Mental Health Services, FY 2007 ...........................................................56

4.8.2 Trends in Community Mental Health Expenditures ..........................................................................................59

4.8.3 Overall Revenues of Community Mental Health Services, FY 2007 .................................................................60

4.8.4 Trends in Financing of Community Mental Health Services .............................................................................60

4.8.5 Initiatives To Transform Financing of Mental Health Services ..........................................................................63

4.9 Summary ................................................................................................................................................................63

V. Psychiatric Hospitalization and Forensic Services ..........................................................................................................65

5.1 Characteristics of Persons Served in State Hospitals ............................................................................................66

5.2 Role of State Psychiatric Hospitals .........................................................................................................................66

5.3 The Closing and Reorganization of State Psychiatric Hospitals .............................................................................69

5.4 Shortages of Inpatient Psychiatric Beds ................................................................................................................69

5.5 Forensic Mental Health Services ...........................................................................................................................71

5.5.1 State Psychiatric Hospital Expenditures per Patient Day .................................................................................74

5.5.2 Organization of State Forensic Mental Health Services ...................................................................................74

5.5.3 Not Guilty by Reason of Insanity and Guilty but Mentally Ill Statutes ...............................................................75

5.5.4 Sex Offenders ...............................................................................................................................................75

5.6 Financing of SMHA Operated and Funded Psychiatric Hospitals ...........................................................................76

5.6.1 Overall Expenditures for State Hospitals, FY 2007 ..........................................................................................76

5.6.2 Trends in State Psychiatric Hospital Expenditures ..........................................................................................79

5.6.3 Overall Revenues of State Psychiatric Hospitals, FY 2007 ..............................................................................79

5.6.4 Trends in Financing of State Psychiatric Hospitals ..........................................................................................83

5.7 Summary ................................................................................................................................................................83

VI. Summary ................................................................................................................................................................................85

Glossary ......................................................................................................................................................................................87

References ..................................................................................................................................................................................93

Appendix

viii Funding and Characteristics of State Mental Health Agencies, 2009
List of Tables
Table 1: Organization of SMHAs Within State Government ...............................................................................................5

Table 2: SMHA Relationship to Other State Agencies ........................................................................................................8

Table 3: SMHA Mental Health-Related Responsibilities .....................................................................................................9

Table 4: Number of Mental Health Organizations Operated and/or Funded by SMHAs .....................................................12

Table 5: Organizational Locations of Information Management Functions .......................................................................12

Table 6: Number of SMHAs Monitoring Client Outcome Measures ...................................................................................14

Table 7: EHR Functions Implemented in State Psychiatric Hospitals and Community Mental Health Providers .................15

Table 8: Number of SMHAs Linking SMHA Data Systems With Other State Agencies .....................................................18

Table 9: Utilization Rate of SMHA Mental Health Services, by Age, Gender, and Race/Ethnicity, 2008 .............................19

Table 10: S MHA Mental Health Actual Dollar and per Capita Expenditures for Mental Health Services,

FY 2007 .........................................................................................................................................................24

Table 11: S MHA-Controlled Mental Health Revenues, by Funding Sources and State,

FY 2007 (in millions) ........................................................................................................................................28

Table 12: T otal SMHA-Controlled Expenditures, in Current and Constant Inflation-Adjusted Dollars,
FY 2001 to FY 2007 (in millions) ....................................................................................................................33

Table 13: SMHA Collaboration With Other Agencies .........................................................................................................39

Table 14: Number of SMHAs Implementing or Planning To Implement EBPs ...................................................................45

Table 15: Types of SMHA-Funded Consumer-Operated Services ....................................................................................53

Table 16: S MHA-Controlled Mental Health Expenditures for Community-Based Programs,

by Age, FY 2007 (in millions) ...........................................................................................................................57

Table 17: S MHA-Controlled Mental Health Expenditures for Community-Based Programs,

by Service Type (in millions) ...........................................................................................................................58

Table 18: S MHA-Controlled Community Mental Health Revenues, by Funding Sources and State,
FY 2007 (in millions) .......................................................................................................................................61

Table 19: State Operated and Funded Psychiatric Hospitals ............................................................................................67

Table 20: N umber of SMHAs Using State Psychiatric Hospitals, by Age and Service,
2009 (55 SMHAs reporting) ...........................................................................................................................69

Table 21: S MHA-Controlled Mental Health Expenditures for Forensic and Sex Offender Services in State Psychiatric

Hospitals, FY 2007 (in millions) ......................................................................................................................72

Table 22: Responsibilities for Sex Offender Services ......................................................................................................75

Table 23: S MHA-Controlled Mental Health Expenditures for State Psychiatric Hospitals, by Age,
FY 2007 (in millions) ......................................................................................................................................76

Table 24: SMHA-Controlled State Psychiatric Hospital Expenditures, by Service Type, FY 2007 (in millions) ...................77

Table 25: S MHA-Controlled State Psychiatric Hospital Revenues, by Funding Sources and State,
FY 2007 (in millions) .......................................................................................................................................81

Funding and Characteristics of State Mental Health Agencies, 2009 ix
List of Figures
Figure 1: Percent Distribution of Consumers Served, by Age ...........................................................................................18

Figure 2: Utilization Rates of Persons Served, by Age and Gender (rate per 1,000) ..........................................................20

Figure 3: Percentage of Consumers Served, by Race/Ethnicity ......................................................................................21

Figure 4: Utilization Rates of Children and Adolescents, by Race/Ethnicity and Gender (rate per 1,000) ...........................21

Figure 5: Utilization Rates of Young Adults and Adults, by Race Ethnicity and Age (rate per 1,000) ..................................22

Figure 6: Utilization Rates of Older Adults, by Race/Ethnicity and Gender (rate per 1,000) ...............................................23

Figure 7: Total SMHA-Controlled per Capita Expenditures for Mental Health, FY 2007 ....................................................24

Figure 8: S MHA-Controlled per Capita Expenditures for Mental Health, by SMHA Responsibility

for Setting Medicaid Rates, FY 2007................................................................................................................25

Figure 9: S MHA-Controlled per Capita Expenditures for Mental Health, by Primary Method Used

To Fund Community Services, FY 2007 ...........................................................................................................27

Figure 10: P ercentage of SMHA-Controlled Revenues for Mental Health Services,
by Funding Sources, FY 2007 ........................................................................................................................27

Figure 11: Percentage of SMHA-Controlled Revenues From Major Funding Sources, FY 1981 to FY 2007 ......................30

Figure 12: SMHA-Controlled Revenues for Mental Health Services, FY 1981 to FY 2007 .................................................31

Figure 13: Percentage of New SMHA-Controlled Revenues, by Major Funding Sources, FY 1981 to FY 2007 ..................31

Figure 14: S MHA-Controlled Medicaid Funds as a Percentage of Total State Medicaid Spending,

FY 1981 to FY 2007 ......................................................................................................................................32

Figure 15: Trends in SMHA-Controlled Mental Health Spending, FY 1981 to FY 2007 .....................................................33

Figure 16: A verage Annual Percent Change in SMHA-Controlled Mental Health Expenditures,
by Decade and Type of Program, FY 1981 to FY 2007 ....................................................................................35

Figure 17: S MHA Expenditures for State Psychiatric Hospital Inpatient and Community-Based Mental Health Services,

FY 1981 to FY 2007 ..................................................................................................................................................36

Figure 18: Extent to Which City/County Authorities Administer Community Mental Health Services ................................51

Figure 19: Percent Distribution of Consumers Served in Community Settings, by Age Groups .........................................54

Figure 20: U tilization Rates (per 1,000 Population) of Persons Served in Community Settings,

by Age and Gender ........................................................................................................................................55

Figure 21: Employment Status of Adult Consumers, by Diagnosis ...................................................................................55

Figure 22: Living Situation of Consumers Served ............................................................................................................56

Figure 23: Trends in SMHA-Controlled Spending for Community Mental Health Services, FY 1981 to FY 2007................59

Figure 24: A verage Annual Change in SMHA-Controlled Community Mental Health Expenditures,

by Decade, FY 1981 to FY 2007 .....................................................................................................................60

Figure 25: P ercentage of SMHA-Controlled Revenues for Community Mental Health Services,

by Funding Sources, FY 2007 ........................................................................................................................61

Figure 26: P ercentage of SMHA-Controlled Revenues for Community Mental Health Services
From Major Funding Sources, FY 1981 to FY 2007 ........................................................................................62

Figure 27: State Psychiatric Hospital Residents per 100,000 Population .........................................................................65

Figure 28: Breakdown of Consumers Served in All State Psychiatric Hospitals, by Age and Gender .................................66

Figure 29: Number of States Experiencing Shortages of Psychiatric Beds Over the Last 1 and 5 Years ...........................70

Figure 30: A verage and Median State Psychiatric Hospital Expenditures per Patient Day,

by Type of Patient, FY 2007 ...........................................................................................................................74

Figure 31: Trends in SMHA-Controlled Spending for State Psychiatric Hospitals, FY 1981 to FY 2007 .............................79

Figure 32: Average Annual Change in SMHA-Controlled State Psychiatric Hospital Expenditures,
by Decade, FY 1981 to FY 2007 ....................................................................................................................80

Figure 33: SMHA-Controlled Revenues for State Psychiatric Hospitals, by Funding Sources, FY 2007 .............................80

Figure 34: P ercentage of SMHA-Controlled State Psychiatric Hospital Mental Health Revenues,
by Major Sources, FY 1981 to FY 2007 ..........................................................................................................83

x Funding and Characteristics of State Mental Health Agencies, 2009