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hoods which rank among the top 20 poverty areas, areas which, almost by definition, lack services. With little overall planning and technical assistance from city and State formerly available, well-established institutions were able to develop applications and have them approved. Innovative, community-based and local agencies faced an almost impossible task of competing with the academic or hospital giants, without any assistance from local or Federal Governments.

We must turn this around so that we fulfill our responsibilities. Evaluation, when carried out, has been limited. Criteria have been related primarily to reductions in numbers of admissions and length of stay in State hospitals.

When we move to the issue of catchment area we see another problem. In New York City we adopted the upper limit of 200,000 persons. Yet, in a large urban area this is too low a figure for services that ought to be provided on a larger base, for example, mental retardation and rehabilitation services. Even some children's services might be provided to a larger population.

Yet the process of getting waivers from Federal standards was restrictive, lengthy, and discouraging. Similar problems in implementation have existed at every level between city and State, between city and Federal governments. Nevertheless, I think that we may hope that with our pushing together that that kind of barrier may be broken down.

Now I want to comment specifically as our recommendations.

Here I am confining my remarks to the needs of a densely populated urban area.

Indeed, one aspect of the original legislation which may be subject to refinement is that of offering one model for rural areas, urbanizing intermediate-sized areas, and for the highly urban areas-communities with distinctive characteristics and needs.

The first is that we move away from the concept of a static physical plant to a dynamic network of services that would be comprehensive, coordinated and truly interdisciplinary. Because the medical model of sickness was used, skills of other disciplines and capabilities of related kinds of service providers were not utilized.

Today we can look toward a network of services planned for each community within the city which can be more easily altered as new needs arise, or old ones attain or lose priority.

In regard to a potential overall planning structure and process, there should be required a statement of community needs and gaps of services as a part of a specific plan of how a local area would meet these needs rather than in the past where, almost on their own, organizations developed programs in helter-skelter fashion. In short, I am saying that the community mental health services should be part of an annual and total planning process that is revised, kept up to date and priorities kept current.

In other words, planning and development of community mental health service programs should be integrated in planning for all human services of that particular community.

I believe the five essential services as defined are too rigid and recommend that this specific requirement should be done away with in favor of a more flexible approach to the needed services needed in that area.

We should require, further, that a plan show how State and local services will be integrated, and how coordination of all services within an area will take place.

We must encourage development of integrated case management, so that the family rather than the individual becomes the focus.

Programs for geriatrics, alcoholism, drug user abuse, court-involved individuals, and children and adolescents should be part of the basic package of services.

Under this dynamic model of a package of services which can change to reflect new ideas, needs, the growth or diminishing of old problems, the Federal funding stimulus will yield results if applied to these areas: 1. Innovative methods of community-based care. When cutbacks go into effect, innovative programs of this type often feel the effects first. 2. Services for those in transition from State hospitals or other forms of institutional care-courts, detention programs, shelters, prisons— such as rehabilitation, half-way houses, home care, community residences.

3. There is a need for social skills training for those long institutionalized who need to know how to relate to the outside world.

4. Services integrated with general medical, social and other human services. This would help with achieving integrated case management and with seeing the person in the context of family and community.

5. Expanded mental health information services. Local offices should be opened or expanded, as the system of care can rarely be better than the information which rationalizes its creation and growth.

Evaluation is also essential. We need this to assess effectiveness, and to update services in relation to needs.

6. Innovative centrally run programs. Mental health services available for employees, prison mental health, citywide education, for the public, continuing education for mental health professionals, and research programs should be developed. Retarded, recovered and other handicapped persons should be employed by government as well as business and local agencies. Consultation with police, probation, social services day care, schools and other agencies should take place.

7. Flexible locational capabilities in order to provide funds for renovating and rehabilitating suitable existing structures the arrangement of which can be changed to fit changed needs.

8. Training and manpower. New types of services demand new training and new kinds of manpower, both professional and paraprofessionals-in short, true new careers. For professionals, training should be community- as well as medical-school based. Professionals need new training in new settings to provide new types of services.

I would then say that if we can take this kind of approach together we can begin to move on to adapting some of the innovative ideas or program services into a system which will be more responsive to human needs.

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STATEMENT OF JUNE JACKSON CHRISTMAS, M.D., COMMISSIONER OF MENTAL HEALTH AND MENTAL RETARDATION SERVICES, NEW YORK CITY

"EFFECTIVENESS OF COMMUNITY MENTAL HEALTH CENTERS IN NEW YORK CITY: MODELS FOR FUTURE DEVELOPMENT OF SERVICE"

I. Opening remarks: Overview of Federal, State, and city relationships

I wish to thank you for the opportunity to testify before you today on the experiences which New York City has had with Community Mental Health Centers, and to share with you the new thoughts and models which our experience has generated.

First, I would like to comment on recent legislative and administrative developments in Washington which affect mental health services. In the next sections, I will outline our experience with Community Mental Health Centers and indicate what we would see as vital future development of services with comprehensiveness and continuity.

Finally, I will briefly discuss State-city relationships and refer to the goals, objectives and changing concepts of the community mental health service which we hold in New York City and show how they relate to our proposals for new funding for community mental health services.

This has been a difficult period for mental health. Most mental health services were ultimately ruled in eligible for Title IV-A and Title XVI monies. Mental health patients have been inequitably treated in drafts of National Health Insurance legislation.

As the agency was initially organized, mental health was neither accorded a traditional full committee status in the New York City Comprehensive Health Planning Agency nor was the more advanced step taken to include a mental health viewpoint as integral to its constituents committees (an omission which recent collaboration has begun to undo). Visibility of mental health suffered a substantial setback in the reorganization which brought the National Institute of Mental Health into a relationship to the National Institute of Health which, along with budget cutbacks, will surely reduce the effectiveness of NIMH. Without special earmarked funds, benefits to mental health from revenue sharing will be minimal. Finally, the future of the Community Mental Health Center concept was endangered by Administration opposition to further funding. Continued professional training for psychiatrists through residencies and fellowships as well as for other mental health professional and paraprofessionals is even more tenuous since this was not included in the extension act which Congress recently passed.

II. Impact of community mental health centers legislation on mental health needs of New York City

Community Mental Health Centers utilizing Federal funding are operating in only six out of forty-nine catchment areas in New York City. 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 in Community Mental Health Centers in 1972-73 is $20 million. Thus Public Law 88-164 today funds less than 50% of total CMHC funding, less than one-twentieth (1/20) of the overall city budget. Federal CMHC funding impacts on only six catchment areas out of fifty.

The Federal share of construction monies, where these were utilized, has always been small. For example, a recently approval construction application lists $2 million of Federal money for a $14 million construction project for a CMHC. The mental retardation provisions of Public Law 88-164 were never used; funding in retardation has come through other legislation pertaining to the disabled. Funding for alcoholism, which is administered by this Department, has come through Public Law 91-616, and amounts to $750,000 out of a city alcoholism budget which this year totals $10 million.

What has Federal money accomplished? Have we approached the goals of community involvement and participation in decision making, 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 the public health model to a designated population? Have we moved appreciably toward meeting needs? The 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 in-patient 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 healthhave now been accepted as almost usual rather than exceptional, not only in FMHC'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. Few programs go beyond the advisory board model to sponsorship by community corporations, by councils of community-based programs linking networks of service, accountable to and controlled by the local community. We have yet to grapple with the issue of arousing and maintaining interest of consumers, many of whom are struggling for economic necessities, in what has been for too long a field they sought only when seriously troubled, whose relevance to the social factors in their lives was often neither apparent nor real.

On the negative side, further, a too narrow insistence on a medical model which insufficiently involved other human services and focused too intensively on treatment to the exclusion of rehabilitation and prevention led to a persistence of traditional approaches in far too many instances. Thus, people were excluded in CMHC's as they had been in psychiatric services in the past-because they were poor, or of racial minorities, or alcoholics or addicts, or children, or chronically ill.

Federal and State regulations combined stress the role of the general hospital, and the large teaching hospitals, with their municipal or voluntary affiliates, have grown in power and clout.

The prevalent interpretation of the concept of the community mental health center-as exemplified in the rush to buildings and plans and mini-Departments of Psychiatry-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 ones.

Education, health, the law, the world of work, were systems unrelated to the mental health non-system.

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 neighborhoods which rank among the top 20 poverty areas (areas which, almost by definition, lack services). With little overall planning and technical assistance from City and State formerly available, well-established institutions were able to develop applications and have them approved. We must turn this around so that we fulfill our responsibilities.

Evaluation, when carried out, has been limited. Criteria have been related primarily to reductions in numbers of admissions and lengths of stay in State 'hospitals.

The Federal regulations specify a catchment area of 200.000. In New York City this means that expensive services would have to be duplicated for a small population and that differences in population required by differing service needs require waivers. There is a lack of funds for planning, information gathering and monitoring, as well as technical assistance. Problems in implementation arise at every interface between governmental jurisdictions, and between agencies

unaccustomed to a city department formerly more concerned with being a conduit of reimbursements than a program planner. Alcoholism, drug addiction and mental retardation have been afterthoughts and children have been neglected, a situation made more confusing by inadequate special grants. Yet the spirit of community mental health may persist and be successful.

III. View and recommendations on future community mental health
services legislation

Here, I am confining my remarks to the needs of a densely populated urban area. Indeed, one aspect of the original legislation which may be subject to refinement is that of offering one model for rural areas, urbanizing intermediatesized areas, and for the highly urban areas. At least three approaches should be spelled out in new legislation, for the three types of areas described.

The prevalent interpretation of the concept of the Community Mental Health Center today is a narrow one. A static physical plant is envisioned, rather than a dynamic network of services that would be comprehensive. Because the medical model of sickness was used, skills of other disciplines and capabilities of related kinds of service providers were not utilized.

Today we are looking towards a network of services planned for each community within the City which can be altered as new needs arise, or old ones attain or lose priority.

Thus, the goals of continuity, comprehensiveness and community involvement are excellent ones. However, the funding patterns and the forms and content of services should be made more flexible, and new priorities funded, to achieve these goals.

Specific recommendations are-A. Over-all Planning Structure.-1. Require a statement of community needs, and gaps of services, as a plan of how the local area would meet these needs. This could be revised annually, to allow it to remain up-to-date; priorities could be kept current.

2. Eliminate the specific five essential services.

3. Require that a plan show how State and local services will be integrated, and how coordination of all services within an area will take place.

4. Encourage development of integrated case management, so that the family rather than the individual becomes the focus.

5. Planning for geriatrics, alcoholism, drug users, court-involved individuals and children and adolescents should be part of the basic package of services. Services B. What to fund.-Under this dynamic model of a package of services which can change to reflect new ideas, needs, the growth or diminishing of old problems, the Federal funding stimulus will yield results if applied to these areas:

1. Innovative methods of community-based care. When cutbacks go into effect, innovative programs of this type often feel the effects first.

2. Services for those in transition from State hospitals or other forms of institutional care-courts, prisons-such as rehabilitation, half-way houses, home care.

3. Social skills training for those long institutionalized who need to know how to relate to the outside world.

4. Services integrated with general medical, social and other human services. This would help with achieving integrated case management and with seeing the person in the context of family and community.

5. Expanded mental health information services. Local offices should be opened or expanded, as the system of care can rarely be better than the information which rationalizes its creation and growth. Evaluative data is also essential. This provision would greatly contribute to continuity of care.

6. Innovative centrally run programs. Mental health services available for employees, prison mental health, city-wide education, for the public, continuing education for mental health professionals, and research programs. Consultation with police.

7. Flexible locational capabilities. Provide funds for renovating and rehabilitating suitable existing structures, the arrangement of which can be changed to fit changed needs.

8. Training and manpower. New types of services demand new training and new kinds of manpower, both professional and paraprofessional. For professionals, training should be community as well as medical-school-based. Professionals need new training in new settings to provide new types of services.

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