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local mental health-mental retardation programs. Additional statutory authority extended that responsibility to alcoholism and drug programs in succeeding legislative sessions. Today, these regional boards constitute a vehicle for cooperative federal, state and local relationships geared toward effective service delivery system. Each authorized regional board was encouraged to initiate a request for a federal grant-in-aid through Public Law 88-164 and the subsequent Public Law 89-105, with "seed" money from the Kentucky Department of Mental Health as matching funds.

To utilize the federal construction funds, 2.5 million of state revenue bond dollars were made available to the regional programs to supplement local funds. The result was 188 new inpatient psychiatric beds funded and 26 new mental retardation facilities. With exception of 30 inpatient children's beds, the remaining facilities have been allocated to communities and private hospitals as a means of providing additional support to the community center programs throughout the state. Each of the 15 regions received some share of the bond and federal funding in one phase or another of the construction program. Staffing grants were received in all of the 22 catchment areas operated by the 15 regional boards. Alcohol and drug grants from state and federal sources, as well as Title I ESEA and Title IV-A and Title XVI and XIX dollars, were available as services were expanded through affiliates.

Fundamental to the success of this comprehensive approach are the following concepts: (1) The program must provide access to multiple services to people in every county of the state. (2) Services must be provided to include prevention, treatment and rehabilitation in the areas of mental illness, mental retardation, alcoholism and drug addiction. (3) Medical and social services must be integrated to assure continuity of care. (4) A complete mix of available financial and clinical resources must be utilized through contract and affiliation agreements rather than total dependence upon direct federal or state grant support. A business-like approach is paramount to the multiple financing route, even though it often complicates the lives of the clinical service deliverers.

Even in this short statement four common misunderstandings of the community center system can be cleared up:

They are that mental health center programs are "simple mental health center-neighborhood psychiatry offices; that state hospitals inevitably are the recipients of the community center dregs that service by physicians alone can cover the need at much less cost; and that mental health center administrative costs are enormous."

First. The community center concept has always involved multiple service, multi-location programs united through cooperative agreements with existing organizations as well as catalytic action to develop new services to fill gaps. Such affiliations with mental retardation, education, counseling and rehabilitation organizations are fundamental to provision of broad support and dimension to the psychiatric clinic, and relieves the overwhelming demand for direct psychiatric treatment through positive interdiction of cumulative illness. Social services are not synonymous with social militancy but are in fact a long recognized and legitimate running mate of community health services.

Second. Where positive integration of community and state hospital services are achieved, nearly always through aggressive state participation in community center development, the state hospital becomes a therapeutic community. Insistence upon community center assistance with discharges and placement of geriatric patients is essential. Shared finances and adoption by the state of such other federal assistance as Title XIX and XVI is of course basic. In Kentucky, we are now concentrating upon raising payment and standards for private nursing, personal and intermediate care homes as an alternate system to huge packages of state dollars to rebuild ancient state custodial facilities. The results of the integrated program are seen in Exhibit I.

Third.-Service costs for private physician coverage alone are no lower than the same services provided by the same staff in a center, and in fact, if the same variety and amount of service were to be provided by the private sector alone, in all probability the cost would be the same. Furthermore, in the multiple service center, non-profit, and non-competitive, physician, psychologist and administrator alike can share resources. Kentucky's experience with administrative costs is indicated in Exhibit II. As any store manager will attest, it costs as much to open the doors for one customer a day as it does for a volume, and that costs go down proportionate to utilization.

Fourth. The Kentucky centers started from scratch, had to build up utilization, amortize start-up costs, sell service and learn to administer a new program. Two nationally known accounting firms have worked five years with the department in evolving a cost accounting system uniform from state department to center to center. Electronic data processing oriented, this system will be in operation completely by mid-summer. It not only will prevent some of the misinformation commonly hurled at such operations, but will speed up accounting and other administrative processes with concomitant increases in efficiency. Its present status is such as to permit us to provide the information with respect to administrative personnel costs in the Kentucky centers.

Finally, one should point out that while community mental health centers in Kentucky have resolved much of the problem of reducing Federal shares, (see Exhibit III) there is still the very real need to continue to supply other states with the initial assistance from the bill, while they obtain the necessary legislation and personnel, and to maintain a reasonable level of continuing support while the necessary personnel, training and service quality improvement takes place.

It is my opinion that few kudos have been granted for the accomplishments throughout this nation of this program, and it is astonishing even to me as a student of human behavior, how readily the critic hurls accusations, no matter how poorly informed he may be, and even more amazing, how readily his charges are accepted, even in the face of facts and evidence of sincere and dedicated progress and effort. I am confident that the members of our Congress will discern the facts and uphold the benefit available to our nation from this program.

ADDENDUM TO TESTIMONY-I

The Commissioner of Mental Health is authorized to make state grants to the regional programs. In return under KRS 210 he has the power to promulgate rules and regulations governing the eligibility of community mental health programs to receive those grants. The Department of Mental Health has filed with the Legislative Research Commission a number of administrative regulations concerning board representation, methods of selecting members, the system of committees, personnel accountability, and various other components of the program. Each year the boards submit to the Kentucky Department of Mental Health a complete Plan and Budget for the next fiscal year, outlining in explicit detail all components of services offered by the comprehensive care centers. No program is eligible for a grant until its Plan and Budget has been approved by the Commissioner of Mental Health.

In addition, the law mandates that the Commissioner shall prescribe standards for qualifications of personnel and quality of professional service. The Department has re-evaluated its monitoring and regulating system. Attached, as an exhibit, are present administrative regulations with the proposed revisions.

The proposed revisions governing Board membership establish not only larger nominating committees and public advertising, but provide that any person who is a legal resident of the geographic region may present a petition with 25 names or more to the board and through this petition becomes a candidate on whom the entire board must vote at its annual election, or when the board replaces vacancies.

New regulations governing personnel regulations are especially significant. At the present time, qualifications, salaries, job titles and names of each person on the center staffs must be submitted with the annual Plan and Budget. The new regulation would, in addition, require that any time after the annual Plan and Budget is approved any change in personnel qualifications, salaries or specifications would be regarded as a revision to the Plan and Budget and must be submitted to the Commissioner for approval prior to implementation.

Another method of control which the Department has recently developed is the computer system. The Department's computer system has gained nation-wide attention and publicity as the first of its kind in the mental health field. providing a wide range of fiscal and personnel information. The Department is at the present time installing video terminals in each of the mental health center's headquarters and in the Central Office of the Department of Mental Health.

These data processing units will serve as devices to transmit personnel and financial information to a central computer operated by the Department of Mental Health and will also have the capacity to serve as a visual inquiry

terminal. These units will provide to the appropriate official of any center in the state, as well as authorized staff members of the Department of Mental Health, immediate access to the financial status of payroll disbursements and of all other types of expenditures in every center in the state. This capacity to retrieve management information will provide a means of monitoring the efficient and effective use of resources and serve as the base for projecting future resource needs in each component of the center program.

Ernst & Ernst, a nationally known accounting firm, has been engaged by the Department to conduct audits annually of all comprehensive mental health centers and to provide, as well, an ongoing management systems study. Included in the exhibits today is the cost allocation plan for the Department of Mental Health recently developed by Ernst & Ernst.

From the inception of the mental health centers the Department of Mental Health directed in its regulations that an adminisrator as well as an executive director must be employed by the centers. This was to provide administrative and financial accountability. Because of this Kentucky has truly developed multiple sources of funding for each center and is not dependent on any one resource. However, there has perhaps been misunderstanding about the administrative expenditures of the centers. The exhibit attached to this testimony will attest to the actual adminisraive overhead in each of the 15 regions. The total expenditures for administrative and clerical personnel range from 8 to 14 per cent with expenditures for clinical personnel ranging from 86 to 91 per cent. Several of the Boards serve multiple catchment areas, such as in the populous Jefferson and surrounding counties.

ADDENDUM TO TESTIMONY-II

The average daily census of the four state psychiatric hospitals dropped 55 per cent from 1966, when the first two community mental health centers opened, to March 1973 after the network was completed. Today there is a total of 1988 patients in residence. The hospital staffs have not decreased, allowing therefore a more realistic patient-staff ratio. The median length of stay for fiscal year 1972 admissions range from 20.5 days to 25.9 days, with the average stays ranging from 34 to 42 days. A table depicting average length of stay by diagnosis covering admissions in the 1972 fiscal year is enclosed.

Admissions, however, have increased as casefinding and screening services of the centers have accelerated. Ready access to the hospital provides short hospitalization opportunities and rapid return to the community and followup services there.

The result of the centers' program has been salutory. Since the advent of the centers, Kentucky has been able to achieve accreditation of all of its state psychiatric hospitals.

The chronic patient load in the hospital has decreased as the centers and the Department have found methods by which to employ the private sector and federal programs to provide care for the chronic brain syndrome and long-term schizophrenic who have comprised as much as 90 per cent of the state hospital population in previous years. Thus, as admissions and readmissions have increased, length of stay in the hospital has dramatically decreased and the complexion of the total hospital population has changed.

The mental health center program has promoted a much rapid acute patient turnover, has forced an increase in the quality of the state hospital staff, and in effect, has helped to bring the state hospital into the mainstream of psychiatric practice. The centers provide a mechanism for pre-screening and post hospitalization follow-up for the chronic patient.

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