Grading the States 2006: Massachusetts - Narrative
Massachusetts is home to world-class resources that could support the finest public mental healthcare systems in the nation, but unfortunately, due to tens of millions of dollars of cuts in the last five years, it falls short of its potential.
The state has many advantages. It is geographically small and relatively wealthy. It does not depend on county bureaucracies to deliver mental health services. With four medical schools, its density of psychiatrists and psychiatric residents is among the highest in the country, and it is home to many of the best psychiatric training facilities. Boston University's Center for Psychosocial Rehabilitation is a national incubator for innovation.
Historically, Massachusetts is sometimes better at innovating than in learning from others. In 1972, Wisconsin established the nation's first Assertive Community Treatment (ACT) team. Massachusetts did not launch its own statewide initiative until almost 30 years later. Memphis, Tennessee, pioneered police Crisis Intervention Teams (CIT), which are expanding nationwide, but in Massachusetts this program still needssubstantial expansion. The work is just beginning.
Money is needed to put good ideas into practice. For over a decade, the system has been grossly underfunded, resulting in long waiting lists for case management,residential, and support services.
Today, Republican Governor Mitt Romney, a potential presidential candidate in 2008, is positioning the state to lead the nation in achieving universal healthcarecoverage. The mental healthcare system could ride his coattails to higher achievement, provided it doesn't collapse under the strain of expanding too much, too fast. In practical terms, it remains uncertain what the currently proposed reforms will mean for the average person living with schizophrenia.
Commissioner Elizabeth Childs of the state Department of Mental Health, a clinical psychiatrist, is one of the state's best hopes for skillful navigation of the changes that lie ahead. Under current plans, Medicaid behavioral health services, delivered by a for-profit provider, are being integrated within the Department of Mental Health (DMH), while the entire endeavor may be restructured - potentially eliminating a behavioral "carve out" that links payments to clinical incentives, and involves consumers and families at every turn.
For all these system changes, the devil is in the details. Changes in administrative and financial structure need to be coordinated with changes in the state hospitals, as well as the urgent need for community-based services. There will be a lot of moving parts, and confusion may befall people who depend on the services. Addiction and substance abuse are getting needed attention - but non-Medicaid substance abuse services are located in a different agency - inconsistent with a unified behavioral health plan. It may be like being at Fenway Park: people will need a scorecard to follow what's happening.
The state can be commended for moving to raze two old state hospitals and build a new facility. The investment is long overdue (Worcester State was founded in 1833). Westboro State Hospital has no air conditioning, which in the summer creates a risk of hyperthermia and death for any patient taking anti-psychotic medications.
Even now, access to inpatient care is a problem. One doctor reports that it is easier to get into Harvard than to get admission to an inpatient state bed. Also,emergency rooms feel the pressure of acute bed shortages in many areas. State hospital bed closures coupled with multiple system changes and lack of community services can lead to catastrophe. North Carolina is one example that might be studied closely for comparison as Massachusetts contemplates massive system changes.
The Massachusetts Mental Health Center in Boston desperately needs to be rebuilt. The state's current plan will give Brigham and Women's Hospital a 99-year lease to the state-owned land in exchange for rebuilding the mental health center on a portion of the land. It is a creative transaction that can serve as a national model - a public-private collaboration that uses a physical asset to continue to benefit consumers; i.e., essentially, a mental healthcare "trust."
Massachusetts is commended for model regulations on the use of restraints and seclusion, which take effect in 2006. The state's reorganization of human services has promoted some excellent interagency work - such as the collaboration between DMH and the Department of Social Services (DSS) to help mothers with serious mental illnesses whose children have been removed from their homes for protective custody.
Massachusetts has a good, comprehensive inpatient services plan. It also has many good residential, supported hosing, employment, and clubhouse services - but very long waiting lists for case management and housing. To its credit, DMH is open about the shortages.
In 2002, the Massachusetts DMH developed and implemented a Cultural Competence Action Plan (CCAP) to focus the Department's mission on providing culturally competent care to consumers in the public mental health system. Goals of the plan include increased partnerships with multicultural communities, enhanced leadership to reduce health disparities, integration of cultural competence principles in the DMH workforce, and use of DMH data to study and better serve DMH clients of multicultural backgrounds. Massachusetts once led the nation in studying causes of mortality - the ultimate health disparity statistic - in the past and needs to regain its leadership, especially as multiple service changes are on the horizon.
Overall, what seems to be lacking is political will by the governor and legislature to spend what it takes to eliminate shortages, and to make financial investments to improve the crumbling facilities.
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