1. Policy Research Shop Support for the Policy Research Shop is provided by the Ford Foundation and by the Fund for the Improvement of Postsecondary Education, U.S. Department of Education. Policy Research Shop Assessing the Consequences of a Decade of Funding Cuts to New Hampshire State Mental Health Services March 29, 2011 Caroline Buck David Lumbert

2. Policy Research Shop Project Goal & Method Examine impacts of recent budget cuts on mental health services in New Hampshire. Contacted health professionals at all ten Community Mental Health Centers (CMHCs). Analyzed past reports on NH mental health system services from the last decade.

3. Policy Research Shop Presentation Overview 1.CMHC organization & funding structure. 2.Internal effects of funding changes. 3.External effects of funding changes. 4.Other state examples & policy options.

4. Policy Research Shop History In the 1980s, New Hampshire boasted a model U.S. community-based mental health care system. In 2008, $4.6 million in Medicaid payments was cut. In 2009, $3 million was cut. NH mental-health centers were forced to choose between cutting services or reducing the quality of services.

5. Policy Research Shop Organizational Structure of the Mental Health Care System Community mental health centers (CMHCs) are private not-for- profit facilities that have been contracted out by the government. NH Department of Health and Human Services (Bureau of Behavioral Health). There are ten centers located in New Hampshire o Each serves a specific region in NH.

6. Policy Research Shop Community Mental Health Care Centers The centers combined serve 47,000 patients annually. Required to be open 24 hours a day, seven days a week for emergency psychiatric care.

7. Policy Research Shop Funding Structures CMHCs are private, non-profit organizations. 85% of funding comes from consumer fees. About ¾ of these fees are paid by federal Medicaid money. State of NH provides very little Medicaid funding to CMHCs.

8. Policy Research Shop River Bend CMHC – Funding Example RevenuesExpenses Federal Support $177,292Wages and Benefits$13,322,410 State & County Support$353,127Contract Services$1,087,326 United Way Support$ 67,313Program Materials$451,900 Contributions$ 99,035Occupancy$1,246,184 Grants$229,493Travel and Insurance$509,459 In-Kind$204,046Staff Development$ 54,192 Self-pay Fees$1,385,690Other Expenses$688,960 Fees$15,057,652 TOTAL REVENUES:$17,573,648TOTAL EXPENSES:$17,360,431 Fiscal Year 2008, Source: River Bend 2008 Annual Report

9. Policy Research Shop Where Money Is Being Lost Serving uninsured and underinsured patients. Mandate to be open 24 hours/day. Staffing costs increased 24% from 2004-2009, while overall expenses increased by 26%. (Kane 2010) Current proposal to amend legislation.

10. Policy Research Shop Internal Impacts of Funding Changes Number of beds available – 236 in 1990, 186 in 2008. Increasing demand for services. Burdens on staff availability and quality. Reduction in types of services offered.

11. Policy Research Shop Impact on Patients Increase in patients over the past decade. 1 in 5 children and 26% of adults in NH have a mental health disorder. Reduction in beds leads to longer wait times. Less time with patients, fewer resources directed toward substance abuse, and less communication with parents. (UNH Survey)

12. Policy Research Shop Impact on Staff Layoffs – 10% of workforce at Riverbend. Increase in caseload – 50-80 at Seacoast. Salary freezes and benefit reductions. Loss of paid vacation. High turnover rate – 20% statewide.

13. Policy Research Shop Impact on Programs Examples of programs that have been eliminated due to budget cuts: – 13-bed, 24 hour residential program at Riverbend. – Assertive Community Treatment team at Riverbend. – Child Respite Program at West Central. – Several satellite clinics and residential facilities.

14. Policy Research Shop External Impacts of Funding Changes Emergency room mental health care. Correctional facilities. Increase in homeless population.

15. Policy Research Shop Impact on Emergency Rooms Overcrowding of CMHCs has increased the burden (and cost) on Emergency Rooms. Wait times have gone from 8 hrs to almost one week. Community-based treatment could cost $200 per patient day vs. $600 to $2,000 per day in the ER.

16. Policy Research Shop Impact on Correctional Facilities Prison population has increased by 31% and spending on correctional facilities has doubled. 65% of inmates in state prison are diagnosed with mental health issues. Lack of care can lead to recidivism.

17. Policy Research Shop Impact on Homeless Shelters Studies show a direct correlation between a shortage of psychiatric beds and high homelessness rates. 50% of clients in New Hampshire homeless shelters have some kind of mental illness.

18. Policy Research Shop How New Hampshire Stacks Up In 2006, NH received a "D" rating from NAMI. In the 2009 NAMI state mental-health ratings, New Hampshire was among 18 states who earned a "C" grade. Top states for mental health: NY, MA, CT, ME, MD, and OK.

19. Policy Research Shop Massachusetts NAMI “B” grade. Forefront of mental health care for over a century. Community-Based Flexible Support Program. Independent living skills training and support for discharged patients and their families.

20. Policy Research Shop New York NAMI “B” grade. Innovative “Housing First” project. New York pledged 9,000 new housing units over a ten-year time span & costs the state $62 per day. More cost effective than hospital care ($479), treatment in correctional facilities ($233) or treatment in homeless shelters ($74).

21. Policy Research Shop Connecticut NAMI “B” grade. Very forward-thinking vision for programs. Electronic monitoring system for recovery of patients & collaboration between CHMCs and jails. Jay Couture (Seacoast MHC) cited the value for mental health centers having better electronic health records.

22. Policy Research Shop Policy Options Maintain current system. Allocate more state Medicaid funding into the mental health system. Institute Community-Based, Transitional Housing Programs (follow example of New York and Massachusetts). Eliminate 24-hour service mandate. State pay for care of uninsured/underinsured patients.

23. Policy Research Shop Questions.