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Solutions at work: Where there's the will …

The mentally ill are the modern lepers. They are exhausting burdens to their families, are feared and shunned by society, and have virtually no voice in public affairs or politics.

It is one of the tragedies of their lives, then, that it is completely unnecessary for them to bear this awful stigma, or for their families to suffer as they do, or for society to be saddled with such high costs as a consequence of a small minority's mental illnesses.

For decades there have been treatment programs and drug therapies that can and, when availed of, do help the mentally ill to become productive members of society and sources of pride and happiness to themselves and their families. These programs and therapies are improving all the time, and can achieve extraordinary successes.

Standing in the way are an extreme shortage of funding to support mental health services, psychiatric beds and the latest and best medicines; a fragmentary delivery structure and dearth of accountability; and a weakness in the Baker Act, Florida's mental health law, that often prevents the state from acting in the best interests of the mentally ill.

But the situation is far from hopeless. The solution lies in finding the political will to improve funding and the way it is allocated, strengthen the mental health leadership structure and the integration and delivery of services, and reform the Baker Act.

The political will shouldn't be hard to muster, for this is an issue with built-in appeal both for compassionate liberals who want to help a disadvantaged and poorly represented minority, and for fiscally prudent conservatives who want the mentally ill to stop sleeping on sidewalks, urinating in public, distracting law enforcement from other duties and bleeding the taxpayers. Besides, the law already requires that the state provide a consistently high level of care for the indigent mentally ill, a level that currently is not being provided.

Of course, there is considerable will, political and otherwise, at the local level. Both DCF and the Henderson Mental Health Center, for instance, have strategic plans designed to improve their ability to make the most of limited resources. Two mental health courts, one for misdemeanors and one for felonies, have been established in Broward County and have been modestly successful as a means of pre-trial intervention, giving mentally ill and substance-abusing defendants a chance to get treatment and keep their records clean. These steps by the state, the providers and the courts are welcome signs of movement toward solutions.

Best of all, if political will can be galvanized, there is substantial consensus among mental health experts, advocates for the mentally ill, law enforcement, the courts, federal government advisers and even the Florida Legislature about what constitute the ingredients of an effective mental health system. That consensus must be converted into action backed by sufficient financial support, preferably from both public and private sources.

Broward County and the rest of Florida are not facing this challenge alone. Last July, the President's New Freedom Commission on Mental Health, in a letter to President Bush announcing completion of its report, wrote:

"Today's [national] mental health care system is a patchwork relic -- the result of disjointed reforms and policies. . . . State-of-the-art treatments, based on decades of research, are not being transferred from research to community settings. In many communities, access to quality care is poor, resulting in wasted resources and lost opportunities for recovery. More individuals could recover from even the most serious mental illnesses if they had access in their communities to treatment and supports that are tailored to their needs. . . . The nation must replace unnecessary institutional care with efficient, effective community services that people can count on [emphasis added]. It needs to integrate programs that are fragmented across levels of government and among many agencies. . . . The commission recommends fundamentally transforming how mental health care is delivered in America."

Sadly, the transformation of which the commission speaks has been under way for decades, at least in theory. It just hasn't been very successful. It is failing because of insufficient funding, political commitment and follow-through. The good news, though, is that paradigms of more effective treatment systems do exist and, if properly funded, can bring fulfillment of the promise of the deinstitutionalization movement.

Providing care 24/7 One such paradigm is the Program of Assertive Community Treatment. PACT, developed at Mendota State Hospital in Madison, Wis., in the late 1960s, is a service-delivery model for providing comprehensive community-based treatment to people with severe and persistent mental illness (SPMI). It is championed by NAMI (National Alliance for the Mentally Ill), an advocacy group that also had its origins in Madison.

PACT consists of "a multidisciplinary mental health staff organized as an accountable, mobile mental health agency or group of treaters who function interchangeably to provide the treatment, rehabilitation and support services that persons with severe mental illnesses need to live successfully in the community. . . . The PACT team works collaboratively to deliver the majority of the treatment, rehabilitation, and support services required by each client to live in the community. The team provides these necessary services 24 hours a day, seven days a week and 365 days a year [emphasis added]."

In other words, full-service mental health care. This is what the presidential commission means when it refers to "services that people can count on." The PACT model offers the continuity of care that is absolutely essential to the treatment of mental illness and to the ability of the mentally ill to live functional lives in the community. Indeed, with the right kind of housing support and enough PACT slots, there'd be little need ever to hospitalize the mentally ill, some experts say.

There are assertive community treatment teams in Florida, based on the PACT model, but they are called FACT teams, for Florida Assertive Community Treatment. There is one FACT team in Broward County, affiliated with the Henderson Mental Health Center. There are also two less formally organized ACT teams.

There is no better way to serve the SPMI population than through the PACT/FACT paradigm. Each FACT team, usually consisting of between six and 12 members, is responsible for no more than 100 clients (and no more than 10 per team member), and provides each client with the consistency and continuity of care and support services they need.

This is the most intensive and effective form of treatment for the severely and persistently mentally ill, but each FACT team costs about $1 million to staff and operate. It helps that FACT teams help reduce recidivism and thus save money. But with an estimated 10,000 indigent mentally ill in Broward County, it's obvious there can never realistically be enough FACT teams to go around. Then again, experts say the PACT/FACT approach is not therapeutically effective for everyone anyway.

The key is to accurately identify those who can best be helped by it, and then to secure funding for as many FACT teams as possible. One potential obstacle is that federal approval and Medicaid funding are necessary, and they are no sure thing. Those holding the purse strings at the federal, state and local levels should bear in mind, though, that this community is spending a fortune -- about $65 million a year -- in the criminal justice system dealing with the consequences of untreated or poorly treated mental illness. Spending more money up front on things like FACT teams should be considered an investment, not a mere cost.

But while the PACT/FACT model is by all accounts the Cadillac of mental health care, not everyone can drive a Cadillac. That's where Scott Russell comes in. He drives a police car.

Officer Scott Russell heads the Homeless Outreach Program and its offspring, the Crisis Intervention Team, for the Fort Lauderdale Police Department. He and his teammates are achieving remarkable results through a combination of schmoozing, cajoling, scolding and providing incentives to the homeless and the mentally ill to get themselves to a shelter or a program and begin turning their lives around. Russell says about 30 percent of the homeless are mentally ill and 68 percent are substance abusers.

Effective, buy not costly

The beauty of these two programs is that, first, they work, and second, they cost little or nothing. Russell says the city has recorded about 2,400 fewer arrests a year since homeless outreach began. There have been no new hires for either program, nor any new equipment. Crisis Intervention Team members are trained on how to respond to situations in which the mentally ill are in crisis, and to either prevent a crime or avoid an arrest. The training is done pro bono by experts in various mental health fields.

Are you listening, cities? (Not you, Wilton Manors. You've got a CIT. Good for you!) These programs work, and are as cost-effective as it gets. Moreover, they're an investment that is sure to produce savings in both the short and long terms. Fewer arrests. Lower court costs. Fewer "frequent fliers" in the county jail, needing mental health or substance abuse treatment, needing to see expensive psychiatrists, needing a bottomless supply of medications.

None of those functions should be the job of law enforcement. Russell is proving that if you can reduce the need for all of that without additional spending, you are doing a tremendous service to law enforcement, the courts, the community at large and the homeless and mentally ill themselves. Best of all, he is proving that unless and until enough FACT teams can be created and funded to care for the most severely mentally ill, there is a no-cost alternative that can at least get some of the homeless and the mentally ill started on therapeutic programs.

Of course, that still leaves them entangled in a partly dysfunctional system that may well let them slip through the cracks and end up in jail after all. This is why FACT teams must be considered the ideal, and the political will to radically increase funding for them must be found.

One thought is for the Florida Legislature to have a little talk with the state's 67 sheriffs to determine whether they'd be willing to see some of their funding for mental health services shifted to DCF for allocation at the front end so that more of the mentally ill could be helped before getting arrested. Bet most sheriffs would be all for it.

Some experts have suggested a single-payer system for mental health and substance abuse services, and that might make sense as a way to reduce redundancies. The payer could be either Medicaid or the state itself -- not the county, because the payer should not also be a provider of health care. The single payer also should be the monitoring agency, so it would be sensible for Medicaid, which is administered and monitored in Florida by the Agency for Health Care Administration, to be the single payer if such a system were adopted. It certainly should be considered.

But a remedy short of such a wholesale change in the financial system may be preferable. Pat Kramer, the Department of Children & Families' supervisor of mental health and substance abuse programs for District 10, Broward County, says a single payer could save money but may not be necessary, that things could improve substantially "if we can have better bridges between agencies."

Kramer, a well-respected administrator, may be right. Certainly it is always better to first try to improve an existing system than to create an entirely new one, and certainly better inter-agency cooperation is urgently needed. But the single payer should remain on the table as an option for simplifying the financial aspects of the mental health system, reducing redundancies and saving money.

It should be clear, however, that no matter what changes are made in the mental health system, its financial structure, funding levels and service delivery, the wheels of government turn slowly, and those of the health care bureaucracy perhaps even more slowly. No doubt there will continue to be substantial numbers of mentally ill or substance-abusing inmates in law enforcement custody for the immediate future, and they are unlikely ever to be completely diverted to pre-arrest treatment programs.

What to do, then, about a potentially chronic mentally ill jail population, albeit possibly a smaller one if things improve?

Establishing a forensic hospital, run jointly by the North and South Broward Hospital Districts, with the Broward Sheriff's Office providing security, would be the perfect way to stabilize troubled inmates before they were placed in therapeutic programs.

Besides, the hospital districts are already collecting taxes from Broward County residents. Why should the taxpayers have to pay Wexford Medicine in Corrections, which provides mental health services for the jail on a contractual basis, when the hospital districts to which they're already paying taxes could be providing the same services, and perhaps providing them better and less expensively?

In a forensic hospital, mentally ill or substance-abusing inmates, or those with co-occurring disorders (the hospital would be worthless if it didn't treat co-occurring disorders), would remain securely in law enforcement custody, but would get the kind of mental health and substance abuse treatment the jail cannot provide as effectively. It is, after all, not supposed to be a mental institution, although as far as jails go, the Broward County facility is well thought of by mental health care providers.

Geri Pipitone, director of the House of Hope, one of the few community-based facilities treating co-occurring disorders in forensic clients, says the jail's mental health unit, run by Dr. Timothy Ludwig, BSO's mental health coordinator, does "phenomenal evaluations" that minimize the problem of misdiagnosis and facilitate proper placement.

Perhaps some of the agencies that are supposed to be more expert in mental health than the jail can get Ludwig to show them what he's doing right, because misdiagnosis is something that plagues the system and is a chief obstacle to successful treatment. Better evaluations and placement would enhance mental health treatment and help keep the mentally ill from being arrested and jailed -- again and again.

There are three ways to keep "frequent fliers" out of jail and in treatment programs that will cure their illness or at least alleviate their symptoms.

One is to radically improve the community-based system of mental health and substance abuse treatment, thus creating a vehicle for keeping those populations out of trouble. Another is to establish a forensic hospital to treat those who cannot be helped prior to arrest, but who still are more likely to get better in a hospital than in a jail.

Another is to reform the Baker Act.

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