It is clear Gov. Jindal has listened to the stakeholders and decided to follow the evidence by opening two new clinics in New Orleans, maintaining the inpatient bed count in the region and adding new community- and home-based services. Without a veto of the New Orleans Adolescent Hospital, which was underfunded by HB 881, DHH would have been forced to make cuts that would harm New Orleans-area children, adults and families.

In the executive budget, we offered a proposal that would expand evidence-based, community placed services in New Orleans without decreasing the number of inpatient beds available to serve adults and youth.  The Department’s proposal expanded these important community-based services while also saving the state $9.1 million annually. 

The cost of operating the New Orleans Adolescent Hospital (NOAH) annually is $24 million.  We proposed retaining $4 million to dedicate to community-based services, including the opening of at least two additional community mental health sites in Algiers and Mid-City.  Of the remaining $20 million cost to operate the inpatient services at NOAH, the HB 881 NOAH amendment only funded $14.2 million – leaving a shortfall of $5.8 million.  Problematic is the fact that $10.2 million of the $14.2 million restoration would have been required to be moved from Southeast Louisiana Hospital (SELH) in Mandeville, leaving a shortfall at SELH as well.   And, the amendment required $4 million of SSBG funding be moved from the Area A mental health programs, further reducing the dollars available for proven community-based services. 

To deal with these shortfalls, significant cuts would have had to be made to existing services. These cuts could have been implemented in a number of ways, including, among others, the following options or combination of options:

§         Closure of 20 adult beds at NOAH, reducing the total number of beds in the region and thereby reducing access for at least 400 adults.

§         Closure of evidence-based community services such as Forensic Assertive Community Teams, Assertive Community Teams or Child and Adolescent Response Teams, for example, resulting in the loss of capacity for these services for nearly 1,000 children, adults and families.  Currently, the FACT team is serving 83 individuals, the ACT team is serving 74 individuals, the CART team is serving 335 children and 128 families and individuals are receiving supported housing. 

§         Closure of 12 adult beds and 10 youth beds at SELH, reducing the total number of beds in the region and thereby reducing access for 288 adults and 60 youth.

§         A combination of other bed closures or service reductions.

The net result of these, and other, options was the potential for the reduction of as many as 49 adult and child beds in the region or a step backwards in the recent investments made in community-based services, such as FACT, ACT and CART.  This would have had a devastating impact on literally hundreds of people currently seeking, or potentially requiring, services. 

This is clearly unacceptable, as these options missed the goal of reducing cost while optimizing services.  In fact, continuing to fund the inpatient beds at NOAH, at twice the daily cost as other inpatient facilities, makes no financial sense, and would have led to the unnecessary reduction of critical services to the region.  Last year, NOAH served only 70 children as inpatients, while the recent investments in community-based services are helping literally hundreds of children and adults.  NOAH is not a crisis unit for adults, and therefore consolidation of the beds at SELH will have no impact on the crisis system.  The data shows that most referrals for institutional care from the Mental Health Emergency Room Extension at the Interim Hospital are made to DePaul and not to NOAH – demonstrating that other institutions play a far more significant role in the provision of inpatient mental health services.   Quite simply, this amendment subsidized higher cost inpatient services by reducing beds at another institution, or worse, retreating on the major investments made in evidence-based community services. 

Building a Robust Continuum of Care in New Orleans

Last year, a tragedy unfolded in New Orleans that captured the collective concern of all who are frustrated with Louisiana’s lagging mental health system.   A heroic young police officer, Nicola Cotton, was murdered with her own weapon at the hands of Bernel Johnson.  As reported in the press, Mr. Johnson was released from a state mental health institution prior to this horrific act.  In reviewing this case, it was clear the lack of available community-based services—and the lack of a means to compel participation by Mr. Johnson in these services once released from institutional care—had a great deal to do with this terrible outcome.  This event led to swift and aggressive action by Gov. Jindal and the Department, in partnership with the local community.  The Governor issued an emergency Executive Order directing DHH to intervene in the Metropolitan Human Services District, leading to new leadership and massive reforms.  The state sought from the Legislature an emergency appropriation, and invested in millions of dollars in proven community-based services, such as Forensic Assertive Community Teams, Assertive Community Teams and Child and Adolescent Response Teams.  A variety of other therapies were expanded, such as Multi-Systemic Therapy, Functional Family Therapy and other programs.  And, the Governor proposed several pieces of legislation intended to begin a transformation of the mental health system in New Orleans and statewide.  Among the legislation was a bill referred to as “Nicola’s Law.”  This law permits DHH to seek Involuntary Outpatient Treatment for people who need these preventive services, but whom refuse to—or cannot—participate or comply, as was the case with Mr. Johnson.  If an individual is proven to need the services in order to protect themselves or the public, they would be compelled to comply or face the potential for being involuntarily placed in inpatient care by a judge. 

These actions were taken because it was clear that once released from the state inpatient institution, there were few community-based services available to Mr. Johnson, and no means by which the patient could be directed to participate, even if they were available.  There was no Forensic Assertive Community Team or, for that matter, no other coordinated way of ensuring the patient received the services that may have helped avoid this tragedy.  Today, because of our actions, with the support of the Legislature, these venues are now available, and hundreds of people are benefiting.  We cannot afford to go backwards.

According to the Surgeon General’s Mental Health report, which was co-authored by the National Institutes of Health and the U.S. Substance Abuse and Mental Health Services Administration, the national trend in mental health is to reduce dependence on inpatient services and move toward effective evidence-based community services.  One such service is Assertive Community Treatment (ACT), which has proven to reduce inpatient hospital days by at least 58 percent, jail days by 83 percent and homelessness by 37 percent, according to studies by Dartmouth Medical School, Indiana University and Purdue University.  Additionally, National Mental Health Association studies show that at least 40 percent of the hospital placements of children are not appropriate and the children would be better-served by community-based services.

Virtually all states are moving toward a community-based model of care, and are reducing and reorganizing state psychiatric inpatient units.  This is evidenced by simply evaluating the changes in state expenditures.  Data shows that in 1981, states spent roughly 63 percent of their mental health budgets on hospital beds and 33 percent on community-based mental health services.  By 1993, those same expenditures were equal. By 2004, about 69 percent of state mental health budgets were spent on community-based services and 29 percent were spent on inpatient hospital beds—a complete reversal of more than 20 years ago.  Today, Louisiana spends 57 percent on inpatient hospital beds and 43 percent on outpatient, community-based mental health services – clearly demonstrating we are lagging the nation in needed improvements.  This is both wasteful of resources and demonstrates an improper balance of service provisions.  Plainly, as demonstrated by our proposal, the state could save $9.1 million without reducing bed capacity while increasing access to community-based services.  This happens when we make better use of limited resources, and spend the money where it will work the hardest—in the community closest to our families and neighborhoods.

In 2005, DHH, in partnership with other state agencies, began developing a plan for specific changes to Louisiana’s System of mental health care delivery.  Last year, through HCR 184, the Legislature created the Mental Health Care Improvement Task Force to study the ongoing mental health crisis in Louisiana and the progress made on the 2005 plan.  The Task Force—including representatives from DHH, LSU, Louisiana Mental Health Planning Council, Mental Health America of Louisiana, Louisiana State Medical Society, Louisiana Psychiatric Medical Association and the AFL-CIO—recognized the significant advances made in last year’s implementation of the new community-based programs and called for continued coordination in the system.   Indeed, if the mental health funding available is misdirected and used to support inefficient hospital services, the very advances we have made in improving the system will be lost.  Specifically, the task force recommended:

“…the following evidence-based practices as the initial focus for statewide training and implementation: Cognitive Behavioral Therapy, Dialectical Behavioral Therapy, Assertive Community Treatment, Forensic Assertive Community Treatment, Multi-Systemic Therapy, Functional Family Therapy, Illness Management and Recovery, Family Psychoeducation, Medication Management Approaches in Psychiatry, Supported Employment, and Co-Occurring Disorders.”

After Hurricane Katrina, several community access points were closed, and families were required to commute to NOAH in order to receive these otherwise community-based services.  We proposed reopening outpatient access points on New Orleans’ east and west banks—thereby bringing these services closer to the communities that lost them after Katrina.  Set to open in August, these clinics will offer the ACT, FACT, CART and Supportive Housing programs, as well as other new programs, in easily accessible locations near public transportation. These clinics will offer screening and assessment, psychiatry and medication management, collateral counseling with parents, life skills treatment for youth and substance abuse prevention and treatment services. DHH will continue to offer services from the Mobile Mental Health van (NOAH’s Ark) that travels throughout the three parish area and especially serves families in low lying areas of St. Bernard and Plaquemines parishes.  DHH will staff all sites with psychiatrists and psychologists from the LSU and Tulane Departments of Child Psychiatry, which will train the mental health workforce of the future.

Of note, we will fully staff three new community- and home-based Medicaid-billable teams:

§         Two Multi-Systemic Treatment (MST) teams, which will treat 120 children, adolescents and their families; and

§         One (FFT) Functional Family Therapy team.

MST therapy, one of the services targeted for expansion, is an intensive service that treats severe behavioral problems and decreases out-of-home care by 64 percent, according to juvenile justice and mental health experts.  FFT, an evidence-based family systems approach, also lessens out-of-home placement and reduces recidivism by up to 60 percent.

In addition to the commitment to continue the services referenced above, as well as the expanded services, the following ongoing services will be continued through this transformation initiative:

§         Access Unit to triage all the calls and coordinate with the Child and Adolescent Crisis Response Team (CART), which responds to prevent or quickly de-escalate crisis situations and serves 300 people each year.

§         Six Community-based Crisis Respite beds for diversion from hospital and out-of-home placements and serves nearly 300 clients per year.

§         Two Louisiana Spirit Specialty Access Teams with 20 staff members will be available to schools and communities for children and families still struggling from storm-related trauma.

§         Five Louisiana Spirit General Outreach Teams comprising 50 staff members will be providing ongoing storm recovery counseling 24/7 to adults and children in the communities of Orleans, Plaquemines, St. Bernard and Jefferson parishes.

§         DHH’s LA-YES’s System of Care Initiative, which provides intensive case management to 150 youth involved in the juvenile justice or child welfare systems each year.

§         Early Childhood Supports and Services program, which treats children ages 0-5 and is a future Mental Health Rehabilitation (MHR) provider. This program is the state-wide training site for all infant mental health providers through an MOU with the Tulane Department of Psychiatry’s Infant Mental Health Division.

§         Coordination with MHSD’s Child and Adolescent Division for utilization of wrap-around funds to pay for unmet needs such as transportation, uniforms, cash subsidies, recreational programming.

DHH is moving forward to carry out this plan on behalf of the children, adults and families of the Greater New Orleans area. I remain committed to transforming our health care delivery system to one that is responsive to the needs of people rather than the needs of government.

Alan Levine

DHH Secretary

Louisiana Gov. Veto Signs Appropriations, Some NGOs, Requests Vetoed

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