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• THE GOVERNOR'S TASK FORCE ON THE SERIOUSLY MENTALLY ILL
FINAL REPORT
January 25, 1990
TABLE OF CONTENTS
I. Introduction
11. The SMI Population
111. The System Proposed
IV. Funding
V. Implementation
VI. Conclusion
Page
1
PREFACE
Arizona has always been proud of its quality of life. This intangible
element has lured thousands to our state and has induced those who were born here to
stay. At least one class of citizen, however, does not share in the benefits offered by the
Arizona lifestyle. Arizona has long either neglected or openly discriminated against its
seriously mentally ill population. These Arizonans have been left behind in our pursuit
of the good life under the sun.
In 1989 the Supreme Court of Arizona in AmoM v. Sam, quoting Sen.
Hubert Humphrey, said:
[tlhe moral test of government is how it treats those who are
in the dawn of life, the children; those who are in the
twilight of life, the aged; and those who are in the shadows
of life, the sick, the needy and the handicapped.
The court continued to say that "Arizona has imprisoned its CMI in the shadows of
public apathy" and ordered that the CMI are entitled to adequate care under a
comprehensive and unified system.
It is now time for our state to redress this grievance against a whole class
of Arizonans. The Governor, on May 9, 1989, issued an Executive Order creating the
Governor's Task Force on the Seriously Mentally I11 (SMI). What follows is the Task
Force's recommendation, adopted unanimously on January 25, 1990, for a plan it
believes carries out the Supreme Court's ruling, a plan designed to attack the public
apathy which has for too long plagued the SMI.
s. LA Schw, CChairmmr
Governor's Task Forre - SMI
Introduction
In 1981 a class action was filed on behalf of five indigent, chronically mentally
ill individuals against the Arizona Department of Health Services (ADHS), the Arizona
State Hospital (ASH), and the Maricopa County Board of Supervisors. The charge:
Indigent chronically mentally ill individuals were being denied care in contravention of
Arizona law which provided for a full continuum of care for the "chronically mentally ill"
population of ~rizona.' In 1989 the Supreme Court of Arizona in Arnold v. Sam, upheld
the lower court's decision. Finding that the rights of the class were, indeed, being violated,
the high court decreed that all chronically mentally ill people are entitled to adequate care
under a comprehensive and unified system.
In May 1989, Governor Mofford announced the formation of a Task Force,
charging it with the responsibility to recommend a plan which would comport with the
intent and requirements of the Supreme Court decision. Meetings commenced in late
August of 1989 and have continued nearly every other week to the present. This final
report of the Task Force has been prepared with the assistance of the Department of
Psychiatry of the University of Arizona College of Medicine.'
Members of the Task Force represent a wide variety of interests and
disciplines, including advocates for the mentally ill, consumers and their families, the
Professor and Head of the Department of Psychiatry of the University of Arizona,
government representatives, a member of the judiciary, legislators, a provider of services
to the seriously mentally ill, representatives of the mental health system, and members of
the business community. Interest and participation have been keen throughout the
meetings.
The Task Force plan for a comprehensive system of care is based upon the
following fundamental principles:
All SMI are entitled to be served by a comprehensive system of care that
provides them with a broad range of services;
The system must be easily accessible and non-discriminatory;
The "dollar must follow the consumer" at all levels;
The SMI, their families, guardians, advocates, and clinicians should have
significant control and reasonable options in selecting appropriate care;
The system must be held to a rigorous standard of objective monitoring and
evaluation and must be flexible and able to adapt to new data and ideas as
they evolve;
The system must be centralized, with statutory responsibility vested under a
single authority -- the ADHS; and
1 As is explained below, the Task Force recommends that the term "seriously mentally
ill" be used in place of and synonymously with the term "chronically mentally ill."
'Special thanks go to Ms. Jill Goetz from the College of Medicine and to Ms. Terry
Rider for their assistance in preparing this report.
To guarantee accountability as well as responsibility, a new SMI division
within ADHS should be created to be solely responsible for administering
the new system.
The SMI Population
The chronically mentally ill are described in the Arizona Revised Statutes as
follows:
S O *
3. The 'chronically mentally ill' are persons, who as
a result of a mental disorder as defined in 8 36-501, paragraph
21, exhibit emotional or behavioral functioning which is so
impaired as to interfere substantially with their capacity to
remain in the community without supportive treatment or
services of a long-term or indefinite duration. In these persons
mental disability is severe and persistent, resulting in a
long-term limitation of their functional capacities for primary
activities of daily living such as interpersonal relationships,
homemaking, self-care, employment and recreation.
A.R.S. 9 36-550.
Xc 0 rc
Mental Disorder is defined as follows:
21. 'Mental disorder' means a substantial disorder
of the person's emotional processes, thought, cognition, or
memory. Mental disorder is distinguished from:
(a) Conditions which are primarily those of drug
abuse, alcoholism or mental retardation, unless, in addition to
one or more of these conditions, the person has a mental
disorder.
(b) The declining mental abilities that directly
accompany impending death.
(c) Character and personality disorders characterized
by lifelong and deeply ingrained anti-social behavior patterns,
including sexual behaviors which are abnormal and prohibited
by statute unless the behavior results from a mental disorder.
A.R.S.9 36-501.
In keeping with the modern trend, the Task Force recommends that the term
"seriously mentally ill" be used in place of and synonymously with the term "chronically
mentally ill." The Task Force believes that the current statutory definition should be
maintained and that ADHS must broaden its checklist to determine SMI eligibility to bring
it into compliance with the statutory definition. In addition, commitment laws should be
modified to address the question of competency of the SMI to participate in medical and
health care treatment decisions and the process of adjudication as a CMI (SMI) be
considered as an additional approach to define those persons eligible for treatment and to
assure such treatment within the structure of the proposed system.
Subpopulations
There are subpopulations within the SMI population which have specific
needs and require special attention. The proposed system must be sensitive to cultural and
special needs of all subpopulations and be accessible to all those who are in need of care.
Examples of such special groups are: minorities, the homeless, the SMI living in rural
communities, Native Americans, and those in jails and prisons.
The Homeless SMI
Studies demonstrate that 20% to 40% of Arizona's homeless are seriously
mentally ill. Their illness does not result from their homelessness; rather, their
homelessness ensues from their illness.
The Task Force recommends that, in coordination with public and private
organizations now working in the field, specific programs for the homeless SMI be
established in all areas of the state to bring them into the state system. These special
outreach programs shall identify the SMI and provide them with services -- including food,
clothing and shelter -- in the soup kitchens, parks, and shelters where this proliferating
and most vulnerable segment of the SMI now live.
The Incarcerated SMI
The Task Force recommends:
That the fundamental goal of mental health treatment in jails and prisons
should be to provide the same level of mental health services that are
available in the community and to promote coordination between community
care and the justice system;
That all state agencies endorse the report of the American Psychiatric
Association entitled 'Tsychiatric Services in Jails and Prisons" (March 1989),
and that all correctional facilities, including county jails and facilities, that
house the SMI comply with the standards of the National Commission on
Correctional Health Care. A liaison should be established among the
criminal justice system and mental health professionals to ensure that there
is coordination among the various aspects of the system to assure proper
placement and treatment; and
That statutes be enacted which will give the criminal justice system authority,
when appropriate, to divert the SMI into the mental health system for
treatment and monitoring.
Establishing the Number of SMI
The Task Force charge is to define a system of comprehensive services
responsive to the needs of the SMI and their families. As would be expected, the Task
Force felt that getting an accurate estimate of the number of SMI in Arizona was a
prerequisite to defining such a system and establishing its cost. This proved to be no easy
task: although there have been many studies and estimates, no one can say with assurance
how many SMI live in Arizona.
As of 1989, Peat Marwick, in its state-commissioned report "Preliminary Plan
for Complying with AmoM v. Sam," estimated the number of SMI in Arizona at
approximately 15,000. Maricopa County has said there are 7,500 within its county and, by
extrapolation, 12,500 statewide. The Arizona Center for Law in the Public Interest
estimates the number at about 18,000. Other professional studies estimate the number at
anywhere from 25,000 to 45,000.
The fact is that the number of people in Arizona suffering with serious
mental illness is unknown and will probably not be determinable until a viable system,
accessible to all SMI, is up and running. However, in order to plan, we will assume a
reasonable compromise estimate of at least 15,000 SMI currently within the state,
increasing to 25,000 by the year 1995.
Proposed System
Our primary goal is to create a comprehensive and cost-effective system of
care. To achieve this, the current system -- which the Supreme Court characterized as a
"non-system," inadequate, fragmented, and suffering from neglect -- must be modified
substantially. We recommend that: county SMI responsibility and corresponding
expenditures should be transferred to the state; current county expenditures be contributed
to defray state costs; ADHS be designated as the single statutorily responsible agency for
a statewide system; and a new SMI division within ADHS be established to carry out these
responsibilities to assure suitable attention and authority to carry out this commitment to
the SMI.
The ADHS-SMI Division will enter into agreements with SMI Regional
Authorities throughout the state. These Regional Authorities will, in turn, enter into
agreements with SMI Central Primary Care Organizations, which will become the focal
points of the new system. These organizations will, within their regions, be responsible
for crisis and case management, intake, advocacy, clinical services, and a wide range of
other supportive services.
To meet specific needs, there may be circumstances where the Regional
Authorities' duties may be combined with those of either the Central Primary Care
Organization or the ADHS-SMI Division.
The Central Primary Care Organization will, in turn, contract with service
providers to provide the entire continuum of care mandated by Amold v. Sam. The
Central Primary Care Organization may be a public authority or any other nonprofit agency
capable of performing the services required. We will elaborate on this proposed structure
in the pages to follow.
ARIZONA STATE DHS
SMI - DIVISION
REGIONAL SMI AUTHORITY
L
CENTRAL PRIMARY CARE ORGANIZATION
(Includes Crisis and Case Management,
Intake, Advocacy, Clinical Services, etc.)
b
1 1 1 I
ADHS-SMI Division
The Task Force recommends that the ADHS be designated as the single
statutorily responsible agency for a statewide system of care to the SMI population. To
pinpoint responsibility and accountability, an SMI Division should be established within
ADHS with responsibility to:
Seek out and receive all federal, state, and local funds and allocate such
funds, on a per-capita basis, with special consideration given to rural and
other special areas to accommodate cost differences;
Pursue and obtain Medicaid funding for services for the SMI;
Establish and enforce standards for care, licensing, and certification of
providers of services to the SMI;
Coordinate intergovernmental activities within the state and between the state
and the federal government;
Maintain a comprehensive data bank to track the SMI and determine their
individual needs, as well as the propriety of services provided;
Establish formal public and academic relations with the state university system
to facilitate research, professional training, and public education;
Promote adequate housing by coordinating federal, state, and local housing
programs for the SMI; assist in enforcing the Federal Fair Housing Act;
obtain and administer housing subsidies where possible; certify housing
services and monitor compliance; and coordinate local housing agencies,
mental health service providers, and banking and real estate interests to
encourage the establishment of all forms of appropriate housing for the SMI;
Work with the Attorney General's Office to assure that all local government
authorities in the state recognize the provisions of the Federal Fair Housing
Act banning discrimination against the SMI and to take any action necessary
to assure compliance with the law;
Provide training and educational opportunities for case managers so that
they can assist the SMI of Arizona in receiving all "entitlements" for which
they may be eligible;
Establish a State Advisory Board to the SMI Division, with membership to
include consumers, advocates, and public officials; and
Require independent and objective evaluations of the effectiveness and quality
of the system, which will be integrated and conducted on an objective
statewide basis by an independent organization. Input will be required from
consumers, advocates, family members, and all those involved with the system.
These evaluations, as well as ongoing internal ADHS evaluations, will be
submitted annually to the Governor, the President of the Senate, and the
Speaker of the House.
Regional Authorities
SMI Regional Authorities should be established for as many regions as may
be required to provide a geographically and culturally sensitive system. These authorities
will:
Act as regional administrative arms of the ADHS;
Receive funds from ADHS;
Monitor and audit the utilization of funds;
Monitor quality assurance and peer review activities;
Create liaisons with local law enforcement agencies, jails, and courts;
Serve as a center for patient advocacy;
Facilitate regional evaluation and planning;
Coordinate and facilitate regional fund-raising activities for SMI services; and
Enter into agreements with one or more Central Primary Care Organization
within the region.
The geographical boundary of the region over which a Regional Authority
will have jurisdiction shall consist of one county or more. The number of Regional
Authorities will be based on the geographic distribution of SMI consumers in the state.
Each authority may be a separate nonprofit organization and may be a county or other
governmental body with a board of directors composed of consumers, family members,
advocates, and public members. The management, monitoring, licensing, and administrative
authorities shall be separate and distinct from the service delivery system.
Central Primary Care Organization
The Central Primary Care Organizations (CPCO's) will be focal points for the
system within each region and entry points for consumers to the system. A CPCO will hire
clinical case management teams to work with the SMI, determine their needs, provide or
access appropriate services, and track their progress. Team members will include a
psychiatrist, psychologist, social worker, nurse, psychiatric technician, and others. The
CPCO will provide an alternative to what are now the traditional points of entry into the
system -- hospital emergency rooms, walk-in clinics, and the criminal justice system.
Each team will guarantee that all SMI have access to supportive services,
including, but not be limited to: case management, day treatment, outreach, medications,
and crisis stabilization (see more complete list on the following pages). Case managers will
also be able to arrange travel for the SMI to treatment centers and funding to help them
cover survival expenses. All SMIs, whether they are coming through the jails, courts,
homeless centers, or other institutions, will enter the system at this point.
It is estimated that nearly half of all of Arizona's SMI live at home.
Therefore, the family participation is critical to the treatment plan. SMI individuals, their
families, guardians, and/or advocates, and front-line clinicians will have significant control
and reasonable options to create and/or purchase required services.
Case management teams will have the responsibility for deciding what services
are to be purchased for their clients. Case management teams may either provide directly
or purchase services from any provider. Private or governmental agencies and hospitals
independent of the system's administrative structure will be eligible.
The CPCO will either deliver or purchase from service providers a full range
of services for the SMI, including:
24-hour emergency
services;
hotline services;
short-term crisis beds;
mobile acute crisis
teams;
intake and referral;
diagnosis and evaluation;
crisis intervention;
walk-in services;
psychiatric
hospitalization;
crisis foster care and
respite care;
day support services;
long-term outpatient
psychiatric care;
Service Providers
sheltered workshops;
prevocational and vocational
rehabilitation;
job training and placement;
domestic skills and training;
adult foster care;
volunteer services;
alcohol and drug abuse services;
dependent, semi-independent,
independent, open community,
and congregate care residential
services;
outreach to the homeless; and
outreach to nursing homes.
The CPCO will enter into agreements with service providers to furnish the
continuum of care and services required to serve the SMI. These services may be provided
by any organization or group, including governmental organizations. We further
recommend that regional branches of the ASH be established which will all be an integral
part of this continuum of care.
Funding
The Task Force has concluded that the exclusion of mental illness coverage
from the Arizona Health Care Cost Containment System (AHCCCS) is discriminatory and
that the State of Arizona should immediately commence negotiations with the federal
government to qualify the SMI for coverage under Title XIX of the Social Security Act.
This program should be coordinated by the newly created ADHS-SMI Division.
The Regional Authorities, under the SMI Division direction, will establish
and coordinate local methods of purchasing services. These different methods will include
fees for service and prepaid and capitated financing based on patient needs and program
evolution. Any ADHS prepaid or capitated funds designated for the provision or purchase
of services for the SMI but not expended by a Regional Authority or its service provider
contractors at the end of a contract year may be rolled over into the next contract year but
should continue to be restricted to the purchase or provision of services to the SMI. Such
funds should not revert to ADHS. Each individual clinical case management team will
retain the authority for referral and purchase of services based on individual patient needs.
All purchase of s e ~ caeg reements will be flexible enough to quickly increase or decrease
funding based on actual need and utilization pursuant to established standards of care.
Counties shall contribute to the cost of the system and be capped commensurate at their
current expenditures. The ADHS should administer the program in a way that will ensure
that funding priority is given to the most critical survival needs of the SMI.
As previously pointed out, because we cannot accurately determine the
number of SMI in Arizona, establishing the cost of a comprehensive service system for
them is very difficult: one cannot allocate dollars per client when the number is unknown.
There are as many views of what the cost of a system would be as there are commentators.
The state-commissioned Peat Marwick study estimates the total cost to be $335.9 million.
The estimated statewide cost based upon an extrapolation of the Maricopa County numbers
is $133 million per year. The Arizona Center for Law in the Public Interest predicts about
$292 million per year. All of these numbers include the aggregate state and federal monies
necessary to establish an effective system. Estimates of Medicaid reimbursement of state
expense range from 30 percent to over 60 percent -- further reflecting the wide range of
opinions held on this complex issue.
As with the population statistics, the reality is that we really will not know
what the true costs of the system will be until the system has been created and is in
operation. The lack of good data presents a Catch-22. However, there is a credible
solution to predicting the cost of a viable SMI system. We call it the "Let's be Average"
formulation. In calculating the cost of the SMI system, the formulation depends not on the
number of SMI but rather on the average per-capita expense for the general population of
the various states' SMI programs.
We believe that the best way for Arizona to budget its system is to seek to
become an average funding state. It is to be noted that some of the states with only
average SMI budgets have the best SMI systems of care. While the Task Force does not
suggest that average is acceptable, it recognizes the reality of fiscal constraints and that
attaining a level of funding equal to the national average is a viable and reasonable goal.
We know that Arizona is now spending about $17.00 per Arizonan for adult
mental health care -- the lowest per-capita cost of any of the 50 states. We also know that
the U.S. average per-capita cost was about $46 in 1989. To achieve the reforms required
and become an average funding state over the next five years, the state should budget
about $32 per Arizonan in 1990-91, $37 in 1991-92, $43 in 1992-93, $49 in 1993-94, and $54
in 1994-95.
The 'Zet's be Average" formulation assumes that the budget for the new
system will be phased in over a five-year period. Thus, it will not be necessary to reach the
full budget until the fifth year. The following schedules demonstrate the effect of this
formulation.
REQUIRED EXPENDITURES TO ACHIEVE NATIONAL
AVERAGE PER CAPITA RATE OF SPENDING BY ADHS
PROPOSED PER CAPITA
RATE TO ACHIEVE
ESTIMATED NATIONAL AVERAGE IN
POPULATION3 -X FY94-954 - TOTAL $
PRIOR YEAR $
ADJUSTED FOR TOTAL
INFLATION^ -+ REQUIRED NEW $ = REQUIRED $
POTENTIAL MEDICAID REIMBURSEMENT LEVELS BY RECOVERY PERCENTAGE
TOTAL $
# REQUIRED -30%
'~dju sted annually for growth.
I, 4Using ADHS budget figures of:
Community Services 31,334,400
Administration 1,563,713
AZ State Hospital 28,578,000
# The current estimated expenditure per capita is $16.75. Current national average is accepted
as $46.23. This figure is adjusted annually for inflation, with the expectation that the
average will be $54.08 in FY 94-95.
5Each prior year figure includes an inflationary adjustment for maintenance of effort.
State legislation should also examine requiring insurance companies to
provide equivalent coverage for physical and mental illness. It is clear to the Task
Force that the impact of the insurance industry's failure to address the needs of the SMI
creates a burden on the public system. Both private and federal insurance, including
Medicaid, must be integrated into the system of care.
Implementation
The Task Force recommends that funding for the new system be
appropriated on the basis of a five-year plan, commencing in fiscal year 1990-91, and
then be phased in over the next four years. During the first year, we recommend that
the following actions occur:
Enact legislation so that ADHS becomes the central authority for a
statewide system and consolidate all funding sources;
Create SMI Division within ADHS;
Appropriate funding increases to conform with the plan;
Expand ADHS checklist to include all of Arizona's SMI as defined by law;
Establish and select Regional Authorities;
Establish and select CPCOs;
Establish standards of care and define compliance criteria;
Create data bank;
Immediately apply for federal Medicaid assistance and integrate both
private insurance and Medicaid payments into the system;
Ascertain the needs of all SMI within the state and then prioritize the
delivery of services to those most in need;
Create ADHS housing office;
Initiate plan for ASH regionalization; and
Designate the Task Force as an oversight body to monitor that the system
is implemented.
VI.
Conclusion
The Supreme Court of Arizona in Arnold v. Sam mandated an overhaul of
the current system of care for the SMI. This landmark decision affirmed the
fundamental principle that the SMI people of our state have legal rights to adequate and
accessible treatment for their illness. Acknowledging that Arizona's SMI population has
been denied that right, the state must enact a plan to put this decision into practice.
The Task Force is recommending just such a plan -- one that will bring
dramatic reforms. Putting it into effect will be a daunting challenge, but one that should
result in a system of care for the state's SMI that is unified, cost effective, and fair. By
doing so, we demonstrate that Arizona intends to meet the moral test of government
and free the SMI from the shadows of public apathy.
SLSsrs020290
SLS\O05.Ol5
Governor's Task Force on the Seriously Mentally Ill
Members
Chairman
S. L. Schorr, Attorney, Lewis and Roca, Tucson
Executive Committee
Charles L. Arnold, mental health attorney and named plaintiff in Amold v. Sam, Phoenix
Linda Brock-Nelson, Owner and President of Linda Brock Automotive Plaza, Scottsdale
Carole Carpenter, Maricopa County Board of Supervisors, Phoenix
Sue Davis, member of the Mental Health Association Board, North Valley Alliance for
the Mentally Ill; Chair of the Governor's Advisory Council on Arizona's Mental Health
Services Plan, Scottsdale
Ann English, Chairman, Cochise County Board of Supervisors, Bisbee
Adolph B. "Fito" Trujillo, Gila County Board of Supervisors, Globe
Alan J. Gelenberg, M.D., Professor and Head of the Department of Psychiatry, University
of Arizona Health Sciences Center, Tucson
Imy Gould, member of the Alliance for the Mentally Ill, Sedona
John Kerr, M.D., pediatrician and member of the State Advisory Council on the Chronically
Mentally Ill; Board of Directors, East Valley Behavioral Health Association, Mesa
Claire King, President of Survivors on Our Own, Phoenix
James E. McDougall*, juvenile judge, Juvenile Court Center, Phoenix
John Morrison, Community Care Network, Phoenix
Jose Santiago, M.D., Chairman of the Department of Psychiatry, Kino Community Hospital,
Tucson
Representative Eleanor Schorr, Arizona State House of Representatives, Tucson
Eugene Schupak, M.D., retired physician and former president of a national medical
delivery company, Scottsdale
Steven Scott, Executive Director, Phoenix South Community Mental Health Center, Phoenix
Lawrence Sells, Executive Director, Toyei Industries, Window Rock
Senator Alan J. Stephens, Minority Leader, Arizona State Senate, Phoenix
Senator Robert B. Usdane, President, Arizona State Senate, Phoenix
Representative Nancy Wessel, Arizona State House of Representatives, Phoenix
Ted Williams, Director, Arizona Department of Health Services, Phoenix
Governor's Liaison
M. Joyce Geyser, Deputy Chief of Staff, Phoenix
Advisory Committee
Peter Burns, Director, Executive Budget Office, Phoenix
Boyd Dover, Assistant Director, Arizona Department of Health Services, Phoenix
Susan Gallinger, Director, Department of Insurance, insurance issues, Phoenix
Leonard Kirschner, Director, AHCCCS, Phoenix
Glenn Lippman, M.D., Superintendent, Arizona State Hospital
*Limitation of Endorsement: Because of an ethical limitation, Judge McDougall cannot
endorse the Final Report in regard to any express or implied certification that the matters
contained therein comply with the requirements or mandates of Arnold v. Sam.
