Grading the States 2006: Pennsylvania - Narrative
Pennsylvania is a study in contradictions.
It has a complex mental healthcare system, serving a diverse and in many places aging population. Philadelphia, Pittsburgh, and Harrisburg are key centers, but to a significant degree, the state is county-driven, mountainous, and rural. The Pennsylvania Office of Mental Health and Substance Abuse Services (OMHSA) itself describes the state as having a "highly decentralized mental health system" in which "governance is an often confusing mix of town, city, country, and state jurisdictions." These factors also make it hard to generalize about the quality of care in the state - because so many decisions happen locally.
At times, Pennsylvania rises admirably to the vision of being the "Keystone State," exerting national influence. The state has been a pioneer in reducing the use of restraints and seclusions. Pennsylvania also is active in building capacity for treatment of co-occurring mental illness and substance abuse, winning a Co-Occurring State Incentive Grant(COSIG) and training 1,000 certified professionals in the field.
An OMHSA policy document on transformation and recovery, "A Call for Change," was developed with statewide consumer and family participation, consistent with the state's longstanding support of community support programs (CSPs).
Major changes are in progress, but lack an understandable blueprint for stakeholders. Hospital closings are a case in point. Harrisburg State Hospital was recently "closed," although 50 individuals remain within the facility under the care of another provider while other arrangements for their services can be arranged. Another closure is rumored to be coming; this seems certain, although it is uncertain which of the remaining state hospitals will be next. When the stakes are this high, people deserve a written long-term plan for their reference. As the number of state long-term psychiatric beds decreases, consumers and family members need to know well in advance the arrangement for community services or transfers to other facilities.
Every mental health system requires carefully balanced levels of care. That includes state hospitals for longer-term inpatient care, but consists primarily of crisis centers and short-term acute inpatient and intermediate care facilities in communities, as well as outpatient community services like Assertive Community Treatment (ACT), supported housing, and independent living options.
Where community services are not available or are not sufficient to meet the need, the entire system backs up. Advocates report that waiting lists are growing and access to services is reduced. Consumers languish in hospitals beds at one level because there is a lack of available community services - or they are sometimes discharged without appropriate provisions for community care.
One way to balance the equation: have the real estate that remains after a hospital is closed remain "in trust" for people with serious mental illnesses. Proceeds from its sale, lease, or public-private redevelopment can be reinvested in the mental healthcare system.
As Pennsylvania moves into another round of hospital capacity reduction, it has an opportunity to become another keystone state in this regard. Land trusts are an opportunity for innovation.
It's also important for consumers and families to know how closures fit with proposed changes in the Medicaid system, and from a broad, statewide perspective, access to adequate care in rural areas. The state has a well-regarded Community Hospital Integration Program Project (CHIPP) to help support people in community settings after they make the transition.
Pennsylvania has made noteworthy strides in evidence-based practices (EBPs). The state has 20 ACT teams, and more in development. Although advocates report that most fail to meet national standards, approximately 10 are seeking fidelity to the EBP model. They are mainly in the Philadelphia metropolitan area. A few teams are devoted to transitional age populations - a novel application.
Pennsylvania has implemented a "PennMAPS" physician-prescribing decision making tool. Working off of the TMAP model from Texas, PennMAPS gives psychiatrists guidance on which medications to use and on improving quality of care and cost-effectiveness. It has structured and improved decision making in state facilities, but not taken root in communities, which rely on more informal provider and consumer education.
The state also is providing important support to the Pennsylvania Psychiatrist Leadership Council in order to help increase the recruitment and retention of psychiatrists for public sector and community practice.
Access to effective medication is a major concern. Under Medicaid, the state limits the number of medications a person can take each month - in spite of the fact that individuals with serious mental illnesses often have co-occurring medical conditions and side effects. Co-payments have been increased. The important issue of access to medications for people with serious mental illness is an area that advocates will continue to watch closely.
The state has an eye on improving mental healthcare within the correctional system, and there is growing interest in jail diversion programs. Allegheny County Forensic Services won the Innovations in Government Award for its state inmate re-entry program. The state is beginning to address the need to activate Medicaid benefits immediately after correctional stays. The initiative should be fast-tracked. Treatment is a key to preventing recidivism.
Going forward, Pennsylvania's transformations will require committed leadership, steady state investment, clarity of purpose - and most of all, balance. The Pennsylvania Web site was rated the worst in NAMI's Consumer and Family Test Drive. This presents a simple challenge for this prosperous state to remedy that embarrassing shortcoming. The state would do well to study North Carolina's experience to understand the risks of imbalance. Pennsylvania is a much larger and more diverse and complex state. If mistakes are made, the consequences will be proportionately greater.
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