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There is one thing that I feel very stongly: The emphasis of the recent changes within the last several years, which made it even more possible for community mental health programs to begin in areas which were poorest in resources, should be continued and strengthened.
Any governmental program should be designed not simply to reinforce strengths but also to move capacities where there is now too much weakness for strengths to develop.
That is federalism at its best. We might make even stronger efforts to support programs in impoverished areas.
I would like, if you would permit me, the privilege of reflecting further on that important question. It is too important to give a quick
Mr. SYMINGTON. You may prepare a memorandum on that and we will make it a part of the record.
[The following letter and attachment were received for the record:]
NEW YORK STATE DEPARTMENT OF MENTAL HYGIENE,
Hon. JAMES F. HASTINGS,
Congress of the United States,
DEAR CONGRESSMAN HASTINGS: Dr. Miller tells me that at a meeting with you you asked him to prepare some recommendations for possible changes in the Community Mental Health Centers legislation. Following up on your request Dr. Miller called a meeting of eight people closely involved in mental health center planning and development in this State.
I enclose a summary of points made at the meeting which I hope will be of help to you in your further deliberations.
ANTHONY SPELLMAN, M.D.,
JULY 9, 1973.
MEETING OF JULY 3 ON COMMUNITY MENTAL HEALTH CENTERS
The following is a condensed version of notes taken by Dr. Spellman and my self during the July 3rd meeting on Community Mental Health Centers. I have found it useful to group the various ideas expressed by the participants in the following manner:
1. General. There seemed to be general agreement that there should be a longer commitment by the federal government for funding of community mental health centers. Particular concern was expressed for the future of centers funded at the poverty level and a suggestion was offered to reduce the federal funding level for these centers by not more than 10% per year in order to allow them adequate time to develop alternative sources of revenue.
There was also a recommendation that the federal government provide support for the entire program rather than for staffing costs only.
2. There was concurrence on the need for continuing federal support of those program areas which are unlikely to attract support from 3rd party funding mechanisms, such as consultation and education, training, community organization activities, etc. (see also Congressman Roy's bill).
3. Start-up costs of new centers should continue to be supported by the Federal Government, regardless of other reimbursement mechanisms that may be developed.
4. There was less concern than expected about the gross discrepancies in funding levels of different catchment areas. However, there was agreement that a high level of funding does not necessarily mean a high quality program. The problem requires further study and perhaps new legislation could require NIMH to conduct such a study and develop guidelines to determine the range within which operational costs should be kept.
B. COMMUNITY MENTAL HEALTH CENTER CONCEPTS
1. Catchment areas.-The catchment area concept was considered to be basically sound but in need of revivision of its operational definition to remove some of the rigidity which has crept in. No specific recommendation was made by the group; however, after the meeting, I saw Congressman Roy's bill which contains a new definition deserving of careful study.
2. Essential services should be continued as a basic requirement, possibly with the addition of pre-care and aftercare. The majority seemed to feel that, particularly in poverty areas, there should be more flexibility for phase-in-not requiring 3 of 5 services immediately-including inpatient-and allowing more than 18 months for phase-in.
3. System building.-Much discussion focused on a stronger legislative mandate to total systems of care:
Formal integration of all health components in each area—the Federal government would contract for a total service system.
Tightening up of agreements with state hospitals-need for centers to increase their sense of responsibility for the severely or chronically ill. (We probably have a fairly good handle on this in New York by insisting that the written agreement preclude transfer to a state hospital on the basis of length of inpatient stay alone. Perhaps this should be built into federal regulations, if not the law.) The name of the Act might be changed to "Mental Health Services Systems Act".
A comprehensive mental health plan should be mandated in lieu of the present State Plan for construction of community mental health centers.
4. Community control.-New legislation ought to mandate real community control. A great deal of thought will be required to identify clearly what is meant by this term. At a minimum it should mean control by a representative community group which addresses itself to the total needs of the community rather than control by a group such as a hospital board with more parochial interests relating to a particular agency.
C. POLICING AND EVALUATION
1. The federal government needs effective power to police centers or should provide the various states with the means of policing them. The legislative mandate to do so must be reinforced by appropriate line item appropriation.
2. There is need for much better evaluation of programs both internal and external with the ability of federal (and state) governments to make changes in program direction as needed rather than merely monitoring compliance with the original application. The grantee himself should be required to make appropriate changes in his program in response to changing needs of the community served or to new discoveries and techniques in the professional field.
3. The contract between the federal government and the center should be in relation to specific program objectives. This would make possible a meaningful system of accountability.
4. There should be a graduated response to non-compliance. The limited alternatives open to DHEW Regional Office staff often prevent effective action to force centers into a state of compliance. Total suspension of funds is an unpalatable alternative because it means that people in need will have to go without services. A more appropriate response would be a partial withholding of funds until the deficiency has been corrected.
Mr. HASTINGS. I would like to acknowledge your leadership in the State of New York. Having served in the State legislature from 1962 to 1968 while you were actively developing the system of mental health centers in the State of New York, I was very much aware of your contribution.
I have a couple of questions, but time won't allow us to discuss these as fully as we should. Hopefully at a subsequent period we can. Our figures indicate that of the persons served by community mental health centers throughout the country, 64 percent are below $5,000 income level, which would seem to indicate that the larger share does go to the impoverished in this country.
At the same time figures seem to indicate that medicaid and medicare only proved 6 percent of the total fund paid into CMHC.
First, with that number people at the poverty level served, why isn't the medicaid a more significant factor in relation to the source of funding?
Is there some rational reasoning for this which you could tell the committee?
Dr. MILLER. I regret I can't. I don't believe that would be our experience in New York.
Mr. HASTINGS. I would repeat, of course, these are nationwide figures.
Dr. MILLER. It would be hard for me to answer.
Mr. HASTINGS. Could you provide the New York State figures reflecting what is our experience in the city of New York?
Dr. MILLER. Yes, I can do that.
[The information requested was not available to the committee at the time of printing.]
Mr. HASTINGS. Since medicare is only a small part of the 6 percent which includes both medicare and medicaid, does this reflect that community mental health centers are not serving enough elderly people?
Dr. MILLER. That would be a reasonable assumption. It has been a nationwide experience, I think that other than at certain public residential, or State hospital programs, the elderly have long been grossly underserved.
Mr. HASTINGS. Do you thing we should put some emphasis on these areas in future legislation?
Dr. MILLER. I think that would be salutary.
Mr. HASTINGS. In the rural areas of this State, of which my district is a part, and of the country, is the 75,000 minimum population figure for a catchment area a limiting factor to the viability of community mental health centers in rural areas?
Dr. MILLER. I think it probably has been, but it need not have been. It was said even in the early days of the program that if there was any reasonable evidence which showed that these limits were inappropriate, they should be closely looked at and reconsidered. In some instances they have been; but perhaps in too many instances, they may not have been.
I think it was important when the bill was passed and I still think it is important, that these programs seemed to be the kind that were simply not going to be able to select populations for their convenience. In doing so, some rural areas on one end of the scale and some highly organized metropolitan areas on the other may have felt the inappropriate pinch of a regulation.
I don't know whether lowering it from 75 to 50 would solve the problem, because there would then be some at 45 that would be appropriate. I think it is important to stress the fact that a valid application that differed from those limits should be considered on its merits. Mr. HASTINGS. If the Secretary of HEW had the flexibility of improving an area of less than 75,000
Dr. MILLER. I think that would be helpful.
Mr. HASTINGS. I have many, many other questions and I hope that we will have a further opportunity to discuss these questions with you when we have further hearings in Washington.
Dr. MILLER. Thank you very much, and I will send you a memorandum on those other questions.
Mr. SYMINGTON. Thank you very much.
At this time we will be pleased to hear from Commissioner June Christmas of the New York City Department of Mental Health.
STATEMENT OF DR. JUNE J. CHRISTMAS, COMMISSIONER, DEPARTMENT OF MENTAL HEALTH AND MENTAL RETARDATION SERVICES, NEW YORK CITY
Dr. CHRISTMAS. Mr. Symington and Mr. Hastings, I wish to thank the committee for the opportunity to speak before you today. I will request that my prepared statement, from which I shall present some remarks, be placed in the record. Primarily, I would like to share with you the experience we have had in New York City with community mental health centers, specifically those federally funded and let you know our recommendations for community mental health services in the future.
New York City Community Mental Health Centers, utilizing Federal funding, are operating in only 6 out of 49 catchment areas. Two other centers not receiving Federal funds follow the Federal guidelines.
The total budget for mental health, mental retardation and alcoholism services in New York City, exclusive of the State system, is $170 million. Total Federal input is $26 million, of which only $8 million is in community mental health centers. The bulk of Federal aid comes through medicaid, and amounts to $18 million. Total Federal, State, and city money for community mental health centers in 1972-73 is $20 million. Thus Public Law 88-164 today funds less than 50 percent of total CMHC funding, less than one-twentieth of the overall city budget. Even in construction the amount of Federal input has been small; yet the effect of Federal legislation has been immense.
If we look at what this has accomplished, I think we may begin to raise questions as to where we should be going in the future.
What has Federal money accomplished? Have we approached the goals of community involvement and participation in decisionmaking of comprehensiveness and continuity of care, of diminishing the role of the State hospital? Are services traditional or innovative? Have the principles of community mental health been extended, along a public health model, to a designated population? Have we moved appreciably toward meeting needs? I would say that experiences in New York, while not typical, even of large cities, because of a relative abundance of services for some, illustrate a few of the results experienced nationwide in urban areas.
Certainly there have been successes. Two CMHC's located in the Borough of the Bronx have made it possible to offer services to a deprived population with high indices of need in all areas, a population that virtually lacked locally based mental health services prior to CMHC's.
One of these has worked cooperatively with the State hospital toward an integrated approach to care. On Staten Island, the Borough of Richmond, a CMHC is making possible inpatient care on the island
for the first time and will develop links with local ambulatory care programs. In the Borough of Brooklyn, a CMHC has been a national model for community involvement.
New concepts have been introduced through CMHC legislation requiring community involvement and consultation and education. They have been developed extensively in innovative programs. Even in more traditional centers, initial hesitant steps toward community involvement and community advisory boards and consultation, outreach, and education services-both new to mental health-have now been accepted as almost usual rather than exceptional, not only in CMHC's, but in other programs as well. True, the role of the community remains to be defined; the partnership is still an unsteady one, but the advances have been made in the direction of greater accountability and greater responsiveness.
But, too often, consumer and citizen involvement has been perfunctory tokenism. We are suggesting that we move in a direction toward sponsorship by community corporations, by councils of community-based programs linking networks of services, accountable to and controlled by the local community. This is one direction in which funding and program planning should move.
We realize that we have in jeopardy the one program in New York City, in Washington Heights, which is so structured, and we trust that the imminent situation of near disaster will not really come to pass. We see this as a new direction in which community and providers can work together to provide a different kind of care.
Narrow insistence on a medical model, insufficiently involved with other human services, focused almost exclusively on treatment to the exclusion of rehabilitation and prevention. This approach led to a persistence of traditional approaches in far too many instances. People were excluded in CMHC's as they had been in psychiatric services in the past, because they were too poor, or of racial minorities, or alcoholics, or addicts, or children, or chronically ill, or retarded, or elderly. We think it is of paramount importance that all mentally disabled be included in services.
The prevalent interpretation of the concept of the community mental health center as a structure-as exemplified in the rush to plans and buildings and minidepartments of psychiatry-this narrow concept must be open to question. Somewhere in the past as we all joined the bandwagon, the idea of a comprehensive network of services of all relevant human services within a defined area-was put aside in favor of the massive applications wending their way to Washington for the far-off program. Now we find ourselves bound to buildings designed to house large numbers of inpatients when the needs of today indicate far more ambulatory care; we are locked into structures which limit our ability to respond to changing program needs.
There has been little innovation in the content of services nor have linkages been developed. The five essential services are the traditional
Education, health, the law, the world of work, are vital systems which are not related to the mental health nonsystem.
In the worst cases, services offered have often borne only a tangential relationship to the needs of an area. In New York City, for example, only three of the six federally funded centers are located in neighbor