Grading the States 2006: New Hampshire - Narrative
A front runner in the 1990 State Ratings and previous NAMI state reports, NH demonstrates how much funding can be cut in 16 years, and how impermanent even exemplary service systems can be. As New Hampshire is embarking on a series of new and potentially creative initiatives, this is a crucial time for persons living with major mental illnesses and their families. However, the history of how much has changed in the Granite State should be reviewed before looking ahead. Here are some examples of how the former national system exemplar has suffered in the ensuing years under many different leaders faced with the need to balance the budget:
- The Division of Mental Health has been down-graded from a division in Health to a bureau within Community Based and Long Term Care. Access to the leadership has become increasingly more difficult.
- Evidence-based practices (EBPs) - developed locally by Dartmouth's Psychiatric Research Center's experts - are lagging in implementation here when compared to most other states. This important program, developed by a college in New Hampshire, is taking its business elsewhere.
- The state hospital has been under increasing pressure to handle forensic clients.
- Discharges from the hospital are routinely delayed due to lack of community alternatives and housing resources.
- A bill before the legislature to add $1million to the 10 stressed Community Mental Health Centers was turned down last year, and faces stiff opposition this year.
While all is not lost, this stunning series of data points is a beginning to understanding where the system needs to go.
The mental health planners in New Hampshire are looking ahead, and have a multi-year plan to extend evidence-based practices across the state through a SAMHSA grant and changes in Medicaid funding structures. This is both realistic, because that is where the federal match for state return is, and also risky - the federal partner in this dance may or may not follow the music. The trade-off in trying for federal match money is the uncertainty that the resources will be there, as the budget deficit in Washington is not indefinitely sustainable.
New Hampshire does learn from its mistakes. In 1984 the state had decided to limit Medicaid prescriptions to three per month, which drove up hospital and emergency costs seventeenfold. This is an instance of the common error of addressing one silo - medication expenses - while ignoring another. New Hampshire now has a "soft PA" (Prior Authorization) procedure: if the doctor orders a prescription for the consumer, she gets it. This follows a consumer protection best practice regarding prior authorization for expensive and necessary medications. Many states still limit the number of medicines artificially, and this is a poor way to make medical decisions. The Granite State has a better model, rooted in experience.
The first supported employment programs were developed in New Hampshire. The multi-year expansion of EBPs is well worth watching, but is endangered by the cut in the Dartmouth contract. While New Hampshire appears static, most other states are moving ahead to expand supported employment programs and employment levels, many with consultation, training, and financial assistance from the Johnson & Johnson-Dartmouth Community Mental Health Program. Though imperfect, these models deserve special attention; there is room to expand them, and this part of the multi-year expansion of EBPs is worth watching. One of the challenges they face at this early stage of development is the organization of the departments within the mental health system; currently, the substance abuse authority is in a different department.
The consumer and family movement is alive and well here - the culture celebrated in NAMI's 1990 Report has many elements that continue to this day. Peer Support Agencies provide real help and mentoring. New Hampshire is also creatively addressing physical health risks in the population with an NIMH grant to use disease management techniques for diabetes, high blood pressure, and elevated cholesterol - an illness and management extension which may be a national model for addressing cardiovascular risk in the population.
New Hampshire hospital is a modern, physically pleasing hospital but is under tremendous system pressure - more admits, shorter stays, and more forensic patients - and maintains supportive and collaborative relationships with consumer and family members who monitor the quality of care. It is viewed as enlightened, even as by several reports the service has become more medical and less rehabilitative due to the pressures it faces. This is a very good component of the system, despite the changes around it.
More troubling spots are the state of the Community Mental Health Centers and the shortages of the housing that are needed to accompany the essential rehabilitative, clinical, and outreach services. Legislator Senator Peter Burling is quoted in the Manchester Union Leader of January 11, 2006, saying that, "We've been short changing the very agencies we rely on so we won't have to use government to perform the same services." The article quotes several agencies who testified they are cutting back services and creating waitlists.
The problem with attempts to save money by clipping CMHCs and the Dartmouth contract, of course, is that the state pays dearly when it has to place people with major mental illnesses in correctional settings and when it gives up Dartmouth's grant-writing capacity. There is no way to ignore the need to develop services that prevent the use of expensive and inappropriate correctional settings as care facilities of last resort.
New Hampshire's mental health system is not what it used to be - and this is no one person's fault. The key question, however, is what it will become as it commits to such heavy reliance on Medicaid matching services. There are a good many smart people in the Granite State in leadership positions. Will they get the resources they need for a safety net if Medicaid falters? What new resources will support the community safety net? These answers will likely determine how, in the end, the state spends its money - on services or corrections.
For New Hampshire, recovery is possible, and it can gain back what it has lost and move forward to a family- and consumer-driven system. But it will require an investment in adequate funding treatment and support systems. Cutting in the name of efficiency is no longer tolerable.
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