New Plan’s Holistic Approach to Mental Illness in Los Angeles

LOS ANGELES — When Gov. Jerry Brown (D) eliminated the state Department of Mental Health earlier this year, some mental health advocates who championed Proposition 63 in 2004 — the Mental Health Services Act — wondered if promises would be kept to improve delivery of mental health services and treatment.

“Since most planning and responsibility moved down to the counties, several efforts in the state have tried to bridge the space between where we are now and where we were a year ago,” said James Preis, executive director of the not-for-profit Mental Health Advocacy Services in Los Angeles.

Among those efforts is the Los Angeles County Department of Mental Health’s Innovations demonstration program, funded through Prop. 63’s 1% tax on Californians with incomes higher than $1 million a year.

Proponents and clients say Innovations offers a fresh approach to caring for the county’s uninsured, homeless and under-represented ethnic populations. It takes a holistic approach in addressing the deadly “tri-morbidity” trifecta — co-occurring medical problems, mental illness and addiction.

“Innovations is most unusual because an allotment of money is being used to push the mental health system forward where it hasn’t gone before,” said Roderick Shaner, medical director of L.A. County’s Department of Mental Health — known as LAC-DMH. The program aims to identify new practices for learning, while increasing its array of creative and effective approaches to delivering needed services.

“It’s easy to say you should integrate and collaborate, but it’s not the easiest thing to get done,” said Preis. “The devil’s in the details — figuring out how to deliver those services.”

“Been there, done that” programs aren’t welcome, mental health officials said. They said new programs must bring innovation into the mental health system.

“We even have the freedom to fail, as it were,” said Shaner. “Ultimately, we must provide a full accounting of what happened, even if it wasn’t successful. Then we must ensure that California and the nation are aware of what we did.”

Whole Program, Whole Patient

The department and its stakeholders initially reviewed 105 models and ultimately chose four, intent on increasing quality of services, improving consumers’ outcomes, promoting community collaboration and removing system fragmentation and barriers.

The stakeholder process started in 2009. Program implementation kicked off in February; services were offered starting in April and are currently funded through the end of fiscal year 2014.

“It can take a long time to get from idea to implementation,” said Maria Funk, LAC-DMH’s mental health clinical district chief. As implementation loomed, the county was also preparing for health care reform.

Innovations appears to align with health care’s general transformational push toward collaborative and integrated care, which promotes a team approach that maximizes resources, controls costs and considers the “whole patient.”

“People realized we must provide integrative care to provide good care,” Funk said. “It’s especially true for the homeless, who have many health care issues, are more vulnerable to problems and for whom care is fragmented. This isn’t just a collaboration between a mental health provider and health care provider — it includes a team doing real outreach.”

Shaner said his department welcomes opportunities to deliver better access to physical health services for all its mental health clients. “We have not been as successful at that,” he said. “We also can’t pretend that cures and effective treatment for mental illness consist of a clinic visit during which a primary care physician just prescribes medication.”

Innovations Come in Four Models

The latest component of the Mental Health Services Act to be implemented, Innovations is based on four models.

1. Integrated clinic model: Clients come to a community-based site, such as a primary care clinic or mental health clinic to receive services.
2. Integrated mobile health team model: Services come to clients. In a “housing-first” approach, LAC-DMH also works with housing developers and obtains federal housing subsidies and other resources.
3. Community-designed integrated service management model: It promotes collaboration and partnerships with a focus on cultural sensitivity, and helps clients with information, transportation, motivation, encouragement and more.
4. Peer-run model: This is run by people who’ve experienced mental health issues and is set to kick off soon.

Under the mobile health team model, for example, five teams contract with L.A. County. Teams include a prime contractor funded by MHSA and a federally qualified health center. Team members follow an organizational chart and a set of policies and procedures, and meet in the morning to decide the day’s work agenda, just like in a hospital, said Funk. One team serves Hollywood and Long Beach, one serves both Venice and Santa Monica, while two teams serve Skid Row and South Los Angeles.

“It’s challenging for them. People who work with different agencies have to work together, as if they worked for one agency,” Funk said.

As is typical of integrated models, these multidisciplinary teams may include psychiatrists, psychologists, social workers, medical doctors, nurses and nurse practitioners, clergy and trained mental health consumers. Team members utilize a vulnerability index, a survey tool for identifying and prioritizing the street homeless population for housing, according to the fragility of their health.

“Some clients have already moved from homelessness to a permanent place to live — affordable housing — under Section 8,” Funk said. Fifty clients are destined for the Skid Row Housing Trust’s New Genesis development downtown, with more clients scheduled in 2013 for Step Up on Second in Santa Monica.

The process may begin with a team member offering someone a blanket or a sandwich — even a nuzzle from a service dog. Once engaged and ultimately once housed, clients receive medical, mental and substance misuse services, said Funk.

“Combining supportive services with housing is really critical. You can’t have one without the other,” she said.

A Promising Start

“We can deliver services all day long, but if clients return to their Skid Row ‘homes,’ their chances greatly diminish,” said Lezlie Murch, senior vice president at Exodus Recovery, a behavioral health care management company. Exodus, partnered with Christian Health Centers, is a prime contractor for L.A.’s downtown area.

Before Innovations, Exodus had no ability to provide comprehensive health services to clients who had co-occurring health issues, said Murch. “We would refer them out to a clinic, then they might take a long bus ride and sometimes couldn’t get in after standing in line, even though we tried to provide linkage. This is the first time any of us have had an opportunity to integrate physical health with mental health service delivery. That’s why it’s so successful,” Murch said.

Still, it’s early in the game. “We’re all learning how this works, and there’s a major evaluation component to it,” said Funk.

“Innovations is about creating a learning laboratory,” said Debbie Innes-Gomberg, the county department’s district chief of MHSA implementation and outcomes. “This project could influence so much of what we do in the future. We may be able to extend learning longer if we need more time.”

Extension and funding may be predicated upon how well care was integrated, whether it provided appropriate service levels, its quality, level of community improvement, stakeholder satisfaction and cost.

“We don’t want to repeat mistakes of the past, so we put a premium on cultural sensitivity, recovery, access and reducing stigma,” said Shaner. “Innovations may make a small contribution to how we might best do just that. Things learned in a ‘carved-out system’ for mental health can be helpful for all people’s health systems.”

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