In 2019, after a four-week trial, Judge Carlton Reeves ruled that Mississippi’s mental health system violates the Americans with Disabilities Act (ADA) because adults with mental illness end up segregated in facilities due to not having the support they need. Judge Reeves then imposed a remedy on the state mental health system, a set of conditions the system must meet to comply with the ADA. He appointed Dr. Michael Hogan to monitor the state’s implementation of the remedy.
The question at the heart of this lawsuit is: Does Mississippi’s mental health system provide the right kind of help so that people with serious mental illnesses can live in the community if they want to? Although the lawsuit concerns adults, this question is relevant to anyone affected by severe mental health challenges, including children.
This week we highlight key findings from Dr. Hogan’s most recent monitoring report that could strengthen the system of care for children and adults.
On page 2, Dr. Hogan writes, “As was true with the Monitor’s initial (March 2021) Report, much has been accomplished, and there is much to be done.” He notes that much of the progress to date relates to new services the state has funded, but there is still very little data about the services themselves—especially the outcomes of those services. The Mississippi Department of Mental Health (DMH) is required to collect data outlined in the remedy and post it on its website by October 1, 2022. We encourage DMH to publish data about children’s services on its website if it does not already plan to do so.
Dr. Hogan shares on page 6: “During the April visit, the Monitoring Team conducted a listening session with families and consumers of mental health care to learn of their experiences. The Monitor appreciates the efforts of the statewide advocacy organizations that organized this session: Disability Rights Mississippi, NAMI Mississippi and Mississippi Families as Allies. The feedback from families and individuals broadly validated the need for the Court’s Order.” We appreciate Dr. Hogan partnering with people receiving services, their families and the organizations that represent them and believe it sets a meaningful example for the state to follow.
Dr. Hogan emphasizes the importance of care coordination in his report, as reflected in these statements:
- Page 10: “Although care coordination is crucial, no explicit overall expectation for this function has been defined by DMH. A review of the DMH Operational Standards for Mental Health, Intellectual/Developmental /Disabilities and Substance Use Community Service Providers did not identify standards or guidelines sufficiently defining requirements for care coordination.”
- Page 16: “Reasonable care coordination would make the Region responsible to participate in all Hospital discharge arrangements, and for coordinating post discharge care to avoid these problems. The anecdotes we heard illustrate the need for care coordination by the responsible CMHC that goes beyond coordinating care in specific programs like crisis care or CSS.”
- Page 17: “Effective care coordination is based on an expectation that each person with SMI is unique and may require a variety of clinical and support services, adjusted as needed to achieve and maintain recovery in the community. Additionally, there must be the expectation that treatment of people with SMI must not only be responsive to crises or well-coordinated for people in certain services (e.g., CSS), but must also be a proactive and ongoing expectation. It can’t be assumed that if someone is not coming in for services it means that all is going well. This requires structured processes to ensure that everyone involved in the person’s treatment is communicating with each other on every relevant aspect of the treatment/care plans. There must be protocols and a management system—usually built into an electronic record—to minimize gaps in treatment (e.g., missed appointments, missed prescription refills, missed injections, no contact for extended periods of time or crises), which for people with SMI frequently lead to worsening of symptoms, psychiatric emergencies and hospitalization.”
We agree that there is a great need for comprehensive standards for care coordination. These standards should be consistent with best practices, federal Medicaid requirements for conflict-free targeted case management and Mississippi state law. For children with the most significant needs, Mississippi law states that families should have access to high-fidelity wraparound care coordination. This means families should be able to choose the services they want—from wherever they want—with help from someone who does not feel pressured to influence families to choose services from a particular provider.
We also agree with Dr. Hogan that Certified Community Behavioral Health Centers (CCBHCs) represent a promising model for care coordination. We note that the model includes wraparound care coordination. However, unless there is a thoughtful and inclusive process to ensure clinical expertise, genuine partnerships with families and peers, and evidence-based practices that are implemented and monitored with fidelity, adopting a CCBHC model may not change the nature and effectiveness of care coordination. We look forward to data from the current CCBHCs in the state to learn more about their effectiveness.
Dr. Hogan provides a thoughtful overview of crisis services in his report and recognizes the services’ complexity and implementation, especially their coordination with the new national 988 call line. As planning and implementation move forward, it will be essential to remember the unique needs of children in crisis. We appreciate the initial work we have done with DMH in this area and look forward to it continuing and including even more families and partners.
We want to publicly thank Dr. Hogan for how much he values and understands peer support. He shares (on page 29), “The ‘lived experience’ of people in recovery from mental illness is now understood as a distinct capability and qualification that should be present in mental health services. This principle is even more strongly established in addiction recovery. People with the qualification of lived experience can validate the experiences of those living with mental illness, catalyze hope by example and encourage engagement. Peers in valued roles also help reduce the stigma of mental illness and assist treatment professionals in understanding recovery.”
Dr. Hogan recognizes that lived experience is a scope of expertise in the same way professional experience is a scope of expertise. We appreciate that. That’s a more profound and broader perspective than seeing peer supporters’ primary role as sharing their stories. We also want to stress that peer supporters are professionals like other employees. Any employee, peer supporter or not, might have a disability. Any employee with a disability has the right to reasonable accommodations under the Americans with Disabilities Act. Providing reasonable accommodations concerns an employee’s disability status, not their job category.
There are many exciting possibilities with peer support. As the state responds to the lawsuit remedy requirements about adult peer support, we believe it’s an opportunity to look at ways to strengthen and grow parent peer support. We look forward to exploring that more with our state partners.