Public Mental Health

Overview
National Press Foundation
Mental Health Session
September 19, 2016

Brian M. Hepburn, M.D.

Executive Director
National Association of State
Mental Health
Program Directors (NASMHPD)

Will Discuss
NASMHPD Strategic Plan
Trends in State Public Mental
Health Systems
Trends in psychiatric
hospitalization
Points to consider
Summary

Represents the $41 Billion Public Mental

Health System serving 7.5 million people
annually in all 50 states, 4 territories, and
the District of Columbia.
Affiliated with the approximately 195 State
Psychiatric Hospitals: Serving 147,000
people per year and 41,800 people at any
one point in time.

NASMHPD Strategic Plan

6/23/2016

NASMHPD will work with states,

federal partners, and
stakeholders to promote wellness,
recovery, and resiliency for
individuals with mental health
conditions or co-occurring mental
health and substance related
disorders across all ages and
cultural groups, including: youth,
older persons, veterans and their
families, and people under the
jurisdiction of the court across the

NASMHPD Strategic Plan Values

Least Restrictive
and Most Integrated
Setting
Human Rights and
Health Equity
Health and Wellness
Recovery and
Person-Centered
Services and
Planning
Unique Role of
Safety Net Services
in the Public Mental

Empowerment
Community
Education
Zero Suicide
Working
Collaboratively
Effective and
Efficient
Management and
Accountability
Culturally and
Linguistically
Responsive

NASMHPD Goals Address

Health, wellness, and resiliency

Integrated care
Prevention and Early Intervention
Zero suicide
The use of trauma-informed approaches
Interventions that minimize individuals
contact with police, jails, prisons, juvenile
correctional facilities, and courts. Sequential
intercept.
Workforce
Employment, housing and reducing
homelessness

NASMHPD Research Institute

works with the states and
territories. Thank you to NRI for
allowing NASMHPD to use the
following slides.
NRI collects and analyzes data
related to federal reporting
requirements for the Mental Health
Block Grant Program, as well as
collection and reporting activities
related to state psychiatric hospitals.
NRI maintains a data base on
financing, quality management and
information systems.
NRI conducts specialty state study

For Additional
Information
Ted Lutterman
703-738-8164
Ted.lutterman@nri-inc
.org

Slide 9

Trends in State
Public Mental
Health Systems

Organization of M/SUD Service

Responsibilities:2015

Combined MH/SA
Separate Department
Separate, In Same Umbrella Dept.
No Response

(35)
(4)
(11)
(1)

State Mental Health

Authority persons
Served Per 1,000
State Population.

4.6 to 16
16 to 22.6
22.6 to 35
35 to 51

(12)
(15)
(12)
(12)

Individuals Served
by State Mental
Health Authority
SMHAs provided mental health
services to over 7.5 million
individuals during FY 2015
2.3% of the US Population
68% of Adults served had a
Serious Mental Illness (SMI)
70% of Children served had a
Serious Emotional Disturbance

Percent of Clients Served,

by Service Setting: 2014
Uniform Reporting System
98% of clients received community-based
mental health services
o 22.3 per 1,000 population (range from
0.8 to 51.2 per 1,000)
2% of clients received services in state
psychiatric hospitals
o Range from less than 1% of clients (in
11 states) to 12% in (2 states) of total
clients served
4.6% of clients received services in other
psychiatric inpatient settings (37 states

Age and Gender Distribution

of Clients Served in
Community Settings: URS
2014
NA; 0%
Age 65 and Over Age NA
0%
5%

Male; 48%

Age 0-17
28%

Female; 52%
Age 21-64
63%

Age 18-20
5%

Age and Gender Distribution

of Clients Served in State
Psychiatric Hospitals: URS
2014

Trends in
Financing State
Public Mental
Health Services

SMHA-Controlled Revenues
for Mental Health Services:
FY 1981 to FY 2014
$45,000,000,000

Other Funds
$40,000,000,000

Other Federal
MH Block Grant

$35,000,000,000
$30,000,000,000
$25,000,000,000
$20,000,000,000
$15,000,000,000
$10,000,000,000
$5,000,000,000
$-

Federal Medicaid
State Medicaid Match
State General Funds
Mental Health Block Grant

State Mental Health Agency Controlled

Expenditures for State Psychiatric Hospital
Inpatient and Community-Based Services as
a Percent of Total Expenditures: FY'81 to
FY'14
80%
Com m unity Me ntal Health
70%
63%
60%

60%

60%

66%

59%

67%

69%

70%

70%

70%

27%

28%

71%

72%

72%

26%

26%

26%

73%

74%

74%

74%

75%

24%

23%

24%

23%

58%
54%
48%

50%

49%
State M ental Hospital Inpatie nt
43%

40%
35%
30%33%

20%

10%

0%

36%

37%

39%

32%

30%

29%

28%

25%

Number and
Characteristics of
Individuals Served by
SMHAs:
2015 community-based
98%
of clients received
mental health services
o 75% of FY 2014 SMHA Expenditures were for CommunityBased Mental Health

2% of clients received services in state

psychiatric hospitals
o 23% of FY 2014 SMHA Expenditures were for state
psychiatric hospital-inpatient services

4.5% of clients received services in other

psychiatric inpatient settings (35 states
reporting)

Note: Clients can be served in multiple settings during the year, thus
percentages of consumers served are greater than 100%

2015 URS Summary Results

69% of SMHA consumers had Medicaid
pay for some or all of their mental health
services
22% of Adult mental health consumers
were competitively employed during the
year
6.6% of consumers with a diagnosis of
schizophrenia were competitively
employed

Change in Medicaid
Status of SMHA
Consumers Since ACA

Since states began expanding Medicaid, the states

that expanded Medicaid have seen an increase in
the percent of their consumers served who have
Medicaid paying for some or all of their mental
health services
In the 24 states that Expanded Medicaid in 2014,
they had an average increase of 10.3% in the
number of consumers with Medicaid coverage.
In the 4 states that Expanded Medicaid in 2015,
they had an average increase of 7.5% in
consumers with Medicaid
The 20 states that had not Expanded Medicaid
had no change (0%).
9 states had an increase in the number of clients with

Psychiatric Hospitals

800,000

Residents in State Psychiatric

Hospitals, Jails, and Prisons,
1950 to 2014

700,000

State Psychiatric
Hospital Residents

600,000

Jail

500,000

Prison

400,000
300,000
200,000
100,000
0
18264 22251 25903 29556 33208 36861 40513 40878 41244 41609 42004

Trend in All Psychiatric

Beds: By Type of Hospital,
1970 to 2015

550,000
500,000

State Hospitals
Private Psychiatric Hospitasl

450,000

VA Psychaitric Services

400,000

General Hospitals
Total Psych Beds

350,000
300,000
250,000
200,000
150,000
100,000
50,000
0
25569

27760

29221

31048

32874

34700

35796

36526

37257

40179

42005

Slide 25

Estimating the Total Psychiatric

Inpatient Capacity
SAMHSA periodically surveys private psychiatric hospitals and general
hospitals with separate psychiatric units. Currently 2010 is the most
recent data available, but 2014 information should be available soon.
NRI combined 2012 URS data on State Psychiatric Hospitals with data on
private psychiatric hospitals and non-Federal general hospitals with
separate psychiatric units (from SAMHSAs 2010 National Mental Health
Services Survey (N-MHSS))

Number
of
Facilities

Number of
Beds/
Residents

195

41,821

Non-Federal General Hospitals with

Separate Psychiatric Units (2010)

1,157

35,351

Private Psychiatric Hospitals (2010)

374

24,919

Total Psychiatric Inpatient Capacity

1,726

102,091

Type of Psychiatric Facility

State Psychiatric Hospitals (2012)

Private Psychiatric Beds

per 100,000 State
Population: 2010
estimate

Psychiatric Bed Rates

per 100,000 population
13.2 to 23.29
26.3 to 33.49
33.5 to 42.99
43 to 81.5

(13)
(13)
(13)
(12)

State Psychiatric Hospital data are residents in state hospitals on the first day of 2012. Private
psychiatric bed counts represent separate psychiatric units in general hospitals and private
Slide 28
psychiatric hospitals from SAMHSA's 2010 Survey

Intended Use of State

Psychiatric Hospitals:
2015
Forensic

35

Elderly

41
39

39

42
42

43
44
41

Adults
15

Adolescents

18
10

Children
0

14
13

21
Acute Care (less than 30 days)
Intermediate Care (30-90 days)
Long-Term Care (more than 90
days)

10 15 20 25 30
Number of States

35

40

45

50

Points to Consider

 The discussion of beds across the

country gets mixed up in terms
of state hospital beds, private
IMD beds, acute general hospital
psychiatric unit beds and
veterans administration beds.
There is also the issue of civil
involuntary admissions, civil
voluntary admissions, and court-

 There is also the insurance, no

insurance issue and the
managed care, no managed care
issue.
Historically, the biggest reason
an individual went to the state
hospital was because they were
uninsured.

 EMTALA has the expectation the

emergency department will stabilize
the individual and the receiving
hospital will admit the individual if
they have a bed when a request is
received.
Even within states, there are acute
general hospitals that would only
admit an individual to a psychiatric
unit while others would admit to a
medical bed and treat the individual

 Almost all involuntary admissions in

some states go to the private sector.
Some states have well-developed
crisis programs which decreases
pressure on Emergency rooms and
inpatient services.
Clozapine underutilization
contributes to the length of hospital
stay.
Lack of housing contributes to the
delay in discharge.

Summary of issues which

may have positive impact on
inpatient care:
Positive message instead of damaging
rhetoric;
Prevention and early intervention;
Zero suicide plan and crisis services;
Safety net, i.e. Housing and supports;
Minimize individuals contact with
police, jails and courts; Sequential
intercept model.

Summary continued
Integrated care, (mental health,
substance use, and physical health)
Correction of the IMD issue;
Parity;
Trauma-informed approaches;
Data and Technology;
Workforce. Peer Services.

Summary continued
EBP including use of Clozapine;
Person centered, comprehensive
treatment plan;
Forensic plan and communication
with court and judges;
Community follow up after discharge;
Use of technology for support after
discharge.

Thank you!
Brian Hepburn
Brian.Hepburn@nasmhpd.org