Commission to Study Mental and Behavioral Health in Maryland
[Music] thank you everyone for being here I’m Boyd Rutherford and I’m pleased to welcome everyone to this greater Washington regional meeting of our Commission to study mental and behavioral health in Maryland I want to thank our host Montgomery College for having us this evening providing the space for us to do this and to talk about this critically important issue as I’ve said before the the subject of this commission that we’ll be discussing and continuing to discuss over the next several months and actual years it’s not always an easy topic to discuss but this represents something that we I should say an opportunity for us to make a real difference in people’s lives and to truly change and reform the way we deliver services to some of our most vulnerable citizens it’s if I like to say it’s far past due that we take a serious look at how we deliver mental health services as I say when I say how we deliver I also include the the federal system as well not just our our state and it’s something that I feel very strongly about and an issue that is close to my heart over the last four or five years four and a half years since the governor and I have been in office we’ve been working to address the state’s opioid issue and I’d say I came to understand many of you probably already knew understand the relationship between the disease of addiction and mental illness previously I looked at these conditions are separate and distinct and I’ve learned and as you all many of you already know that substance use disorder and mental illness are often co-occurring and for some people it may have been a situation where people were self-medicating where they had undiagnosed mental illness and so we want to make sure that we you know address these issues because they do not just affect the individual who is suffering but also the families and their communities as well as well as their friends I should say too so we want to take a fresh and serious look at how the state and and the country for that matter bring care to individuals and families and to that end the administration committed created this commission and the governor asked me to chair it it was through an executive order earlier this year and our goal is to identify ways to improve the services that affect many Marylanders that are suffering from mental illness and co-occurring conditions and we’re doing that by engaging families advocates petitioners and those on the front lines of this issue and we’re holding meetings like this across the state to hear from you the community and to take that feedback that we receive and provide recommendations to the governor at the end of the year we did produce an interim report it is it is on my website as well as others and we will disclose where they are I don’t remember where they are off the top but I’ll let you know but on on my website you can find the interim report that we put out and we’ll talk a little bit about that but I want to say that our our work won’t end with the year-end report we’re going to continue this commission and continue working through the length of our administration so at this time and actually before I move on I I saw that the county executive walked in thank you for being here in a few minutes I’ll give you an opportunity to speak but I want to let the Commission introduce themselves and we can start to my right good afternoon I’m Kerry Guthrie Chow president and CEO of cornerstone Montgomery of behavioral health nonprofit here in Montgomery County good afternoon i’m pat mehta chef ski I’m a family advocate and I am also a registered nurse hello my name is dr. Lisa Burgess I am the acting deputy secretary of a Behavioral Health Administration in Maryland addy a member of the Senate representing these Stern Shore and I’m also an advanced practice psych nurse on behalf of the state police superintendent I’m major Roland Butler of the Field Operations Bureau good afternoon my name is Debra Nelson section chief for school safety and climate at the Maryland State Department of Education and specialist for Psychological Services and I’m representing dr. Karen salmon who’s a state superintendent of schools yeah I’m Dennis Rader chief operating officer and Medicaid director for the Maryland Department of Health and in charge of them microphones tonight I’m Barbara Allen and I am the executive director of James place I also serve as a co-chair of the Behavioral Health Advisory Council for the state hello I’m Sarina ecwid with Nami pence George’s County good afternoon I read mer from the Maryland insurance administration Steve Schuh with the opioid operational command center I’m dr. Randall Darrow I’m the director of mental health for public safety in Corrections bernini am an associate medical director to Kaiser Permanente and I’m a child and adolescent psychiatrist my specialty now as I mentioned before the Commission was established by an executive order we have 21 total members six public members and we are tasked with the responsibility to make recommendations to the governor advise em on how to improve the continuum continuum of mental health care in the state to also make sure that we consider the findings of the Maryland Behavioral Health Advisory Council in their strategic plan on 24/7 crisis walk-in and mobile crisis team services I mentioned that we’re conducting the regional meetings and then we’ll be producing reports including the interim report that I mentioned that we do a little discussion now and one of the questions about the interim report and maybe I think before I get to the interim report I think we need to approve the minutes from the last meeting I sometimes get ahead of myself so I have to remember to look at the agenda did everyone have a chance to review the minutes from the last meeting okay any comments all in favor we submitted the interim report several weeks ago and a lot of the gil-find is an update of the different subcommittees that have been created crisis services families and children finance and funding and Public Safety and judicial system and so it was as these Commission the work forces or the work groups were we’re starting they provide an update of what they have done and the meetings that they have had the work groups are chaired by individuals on the Commission but made up of individuals both on the Commission as well as other interested parties and so I would you know direct people to the report a couple of things that we did mention in terms of what we want to see explored further is the question of reciprocity particularly with professional counselors and therapists right now we do not have a true reciprocity and so it creates a challenge for some of our providers both on the substance use side as well as the mental health side in attracting professionals that may be licensed in another state but are interested in working in in Maryland as we all know we’re we’re a relatively small state and you can get depending on traffic of course to another jurisdiction in an hour and in some cases less than that much less than that depending on traffic of course so that is something we want to explore and I’ll bring up and I don’t think I had a chance to mention but when I was in Delaware recently I found out about the consortium called sight path pack and it’s similar to the nursing consortium senator with they’ve started with six states they’re still working through the regulations but they have their they’ve agreed to have a reciprocity arrangement with psychologists and it’s something worth looking into Delaware is currently a member the other states are not our surrounding states are other Delaware of course for those who are on the Eastern Shore or northern part of our state it’s something that’s worth taking a close look at and seeing if that is something that makes sense from Maryland as well another area that we we said we would explore further is the definition for emergency facility for as defined for individuals in crisis right now in our health regulations the definition or at least the interpretation has been an emergency facility is an emergency room emergency department and so when you have an individual who may be in crisis they have to be evaluated have a physical evaluation and and it’s stated that they would go to an emergency facility well if you have a stabilization Center that may have a nurse practitioner or a physician there they can do that assessment and not have to tie up the emergency room because that’s another place where you could possibly lose that individual or just the the challenges associated with our emergency department so we’re looking at how to you know streamline that process and then a third area is the area of parity parity between behavioral and physical health we’ve received a lot of comments with regard to whether all of our insurance carriers are abiding by the mental health and addiction Equity Act which assures parity between behavioral and physical health and so it’s looking at that area as as well now I’ll turn to the committee because we had a discussion with regard to terminology and utilizing that you know making sure we are consistent and everyone understands the the terms when we talk about mental health versus mental illness or substance use disorder or behavioral health in general and I think Steve you had a chart which he wanted to and I hope I’m not going to do all the talking Ronnie – we will get to public comments in a few minutes and we’ll start with the county executive yes No please go I’m sorry various terms are rather fluid and sometimes overlapping they can change at a high rate of speed and our office the opioid command center put together this this chart which unfortunately we don’t have one on the slides but we will make it available on the website but it’s it’ll be easy for you to follow as we talk through it prepared this chart to facilitate the discussion among the members of the Commission and reflects what we believe is is the most prevailing current usage the broadest category is human health and human health consists of both physical health and behavioral health starting with physical health a person’s physical health status is neither inherently positive nor negative we should all attend to our health we’re either physically healthy or we are physically impaired or physically ill similarly with behavioral health there are in current usage mental health dimensions to behavioral health and then a substance use dimension to behavioral health most people today we believe understand the term behavioral health to include both traditional mental health as well as substance use issues on this on the mental health side just as with physical health a person can be mentally healthy or they can be mentally ill with respect to substance use status there are people who use substances but are non problematic and there are people who use substances in a very problematic way but not all of them have subs use disorder there are many people who are problem drinkers were problems substance users who do not reach the clinical threshold of having a substance use disorder so within the world of problematic substance users our two populations non su D and su D or substance use disorder so this is not intended to impose a definitional regimen on anyone this is just food for thought because I would imagine everybody in the room has a slightly different take on on these various terms so thank you lieutenant governor any comments you know I don’t claim to be an expert so we have some experts here right mint mint or was mint oil miss sure I would like to speak up on this because I’ve dealt with them for years and I guess my distinction is that and I know this gets fuzzy for the purposes of our discussion we separate su DS substance use disorder and mental illness behavioral health was a term that brought both of those categories together I think because people didn’t really want to look at the term brain disease it’s early brain disease which then falls under physical health and that makes it really complicated but for working definitions I think we’ve always sorted out what serious and persistent mental illness and then you have chronic and habitual addiction and then but it gets fuzzy because everybody talks about we’re treating mental health but if we’re really preventing mental illness and promoting mental health then I think clarification of those terms would be helpful because it makes a difference from my perspective a clinical perspective of the activities that are we engage in to address those it’s a great start to the conversation and certainly having I’m sure many of us not all of us have either had to start a document or had to edit a document and it’s far easier to edit a document it’s a started document so I you know so one of things that came to my mind as as you started talking about this is you know health is a ever evolving conversation on one end on the other end some people say that the more things change the more they remain the same I think we had that conversation before we started this this meeting formally so I would say again this is a great start to the conversation and it gives a framework to start talking about the the other areas that are subsumed under the broad spaces on on the document and and so I do want to commend you for starting that so for example I would say the document allows me I drew on I mean it was it’s just so it’s just really just lays to one being able to look at the interconnection between physical health and behavioral health so I do my little triangle between human health physical health and behavioral health because as you you said a mr.xu not even frequently real how both and and I also do my little triangle it’s not little but between mental health and substance use disorder so senator said not infrequently you have them than both and and and so one things I did appreciate appreciate about the the interim report is that it did highlight the fact that right now this is where we are right now these are the terminologies because we know that things do change I know that one of the issues that that’s that we discuss in the literature is really if it a brain disease versus behavior and and and having to have that tough discussion because then that really in a clinical realm that lends to treatment right so again I just want to thank you so much for starting this document and allowing us to [Music] [Music] substantial percentage of the members have what we call is a dual diagnosis which is a mental health term that is commonly used wherein there is a huge overlap almost by 30 to 50 percent of the patients tend to have comorbid diagnoses of both mental health and substance abuse I would just add a bi-directional arrow I mean I realize we are not here to be an academic exercise to define our goal is to primarily come up with some broad categories and try to put them into buckets I think this is a terrific start but a layperson this is very easy to understand [Music] [Music] we had one of our Commission meetings there was talk about just that the holistic approach to to help and the idea that the primary care physician would be looking at more than just your you know what it’s just physical to look at the I guess it was a better term than what I’m trying to come up with I said all holistic but I think it was the complete care does someone remember the individual talking about that you’re all looking at me like my hair’s on fire and I don’t I don’t have any hair okay I agree with the conversation as well the only thing that I would like to put forth before the Commission for consideration is that there are certain social determinants that really play into which of these categories you fall into at any single point in time and from day to day can actually shift so that you fall into another category if that makes sense and so I’m not sure how to capture that I’m not really good at flowcharts but just that well thank you well we’ll work on this to continue to make sure that we are using the terminology appropriately and that we all understand and that those who are reading and you know following along that they understand the you know the the terminology that we’re using and the interrelationships between these these areas now in the turn go to the subcommittee’s for their updates and we can start with crisis services crisis services that it’s had several meetings and has explored a range of issues pertaining to the crisis response system including behavioral health issues emergency medical systems issues our next meeting is tomorrow we’re very eager to have public participation that event will take place in Frederick at the following address twelve East Church Street in Frederick at 9:30 a.m. and we would be delighted to have anyone here join us and and and participate in in the public session we’ll be hearing a presentation from Baltimore City and their crisis response system thank you one of the things that came up in the one of the previous meetings with crisis services was the issue of transportation and so that may be something that we have to at least think about in terms of how people can get to if we have crisis services like the 24/7 crisis facility how to give people to and from and in some cases it may be you know working with law enforcement or working with the emergency response and that’s what we we need that that was the whole point of having the suggestion with regard to the definition for emergency facility that it doesn’t have to just be an emergency room emergency department but so that the the EMT can take a person to a facility to us that can help them in that situation or law enforcement can take them to that that facility as well or their family and so okay so youth and families Adam secretary you said you would the subcommittee met on June 26 and they revisited the three focus areas which is k-12 education caregivers and families and mental health coordinators but at the same time the discussion shifted to other areas that the group thought that it also deserved attention such as the need to increase awareness and access to support and services for individuals from the birth to five age range who may be experiencing a behavior health concern or who may be witnessing their family member who has behavior health concern so that’s something that the group wanted to also take on another area that was discussed was the mental health coordinator designee designated for each school system the group wanted to look into how has it been working what does the workgroup look like and how can he be improved since it’s something that is so closely related to the focus areas another population that the group wanted to focus on was the transitional age group aged 18 to 26 they thought it was important to also focus on that on that group and then a representative from the Department of Juvenile Services also brought up the important topic of youth in the justice system whether they’re improving on probation in the system or have a record they need more services for this group and they thought that it was very important to have that discussion as well so I keep adding another topic also was suicide prevention very important in the impact that social media has on in this on this area and the data is not even an even distribution but in each age band suicides have rights and and and we need to look at that I’m bullying very important as well so the discussion will continue I follow of meaning what will take place and we’ll take a deeper dive on the focus areas and the new designated topics very important areas when you mentioned the transitional eighteen to twenty six from some of the material I forget often a young person doesn’t start showing signs of severe mental illness such as schizophrenia or bipolar until they’re in their early 20s and and that goes hand in hand with the other area you said with how do you handle how do you help an adult family member because that 21 22 year-old and the eyes of the law is considered an adult and and they feel that they’re okay you know when you talk to them this they know you’re the problem not on I’m not the problem you’re the problem and so they feel they’re okay but everyone knows that there’s a challenge and so how do you handle that the federal cure Act was supposed to address that but I haven’t found where the regulations have been promulgated that that provide that service that allows for breaking through that HIPPA barrier that the family members can get help and be able to be consulted on what is going on with with a physician or provider of you know with regards to their adult family members so that I’m glad that you know you’re looking into that and and as well as caregivers Dennis finance yes sir lieutenant governor al I think Yael you’re gonna start why don’t you go ahead and then I went first last time and I was been working hard sorry coach Eric all right thanks Dennis lieutenant governor members of the Commission the financing and funding subcommittee has met twice since the last full commission meeting we met on June 17th and July 15th during that time the insurance administration has received and began analyzing the second annual network adequacy reports that we have received from commercial carriers doing business in Maryland we have reported to the subcommittee on our first impressions of the reports it appears that there’s a general trend in improvement in the behavioral health networks however many of the reports were inadequate and did not provide the basic information required by the regulations additionally most carriers reported non-compliance with the wait time standards the next steps for the MIAA is to include followup with the carriers to obtain the missing information and to do an analysis of their methodology to make sure that the the information contained is accurate during the two subcommittee meetings the MIAA requested and received feedback on issues that behavioral health facilities are experiencing during the credentialing process with commercial carriers as a result of that feedback we’re gonna host a separate call specifically for the credentialing issues for behavioral health individual providers and facilities and that will occur on August 8th the call information and agenda are on the Commission website and anybody naturally is welcome to participate our next subcommittee meeting will be on August 12th and Dennis with that I’ll go back to you Thank You al lieutenant governor as we reported the last time and we’ve continued to work diligently over the last month bringing up a focus on what we’re calling system of care in terms of get the the MCO s and the behavioral health community coming together with folks who have an interest in parity to discuss how to get better service and outcomes managed care organizations thank you for reminding me too many acronyms thank you but the managed care organizations we just approved the new administrative services organization you led that at the Board of Public Works last week and there are a lot of new services that are going to be brought to bear in the administrative services organization contract with and we’ll have a new company called Optim who will be providing that service that links into this group and in the finance group we’re focusing on one of the four issues that were in the preliminary issues list and that is to assess and to develop quality outcome principles and there’s a sense that by focusing on quality we can improve cost over time and so that’s sort of the thought process we’re just getting that cranked up we’re getting input and so we’re using these finance committee calls to to get organized around that and we’re bringing that information back to the system of care process just today we had our first major work group meeting where we brought the workgroup together we’ve had and with therefore discussion groups that are supporting the workgroup and there’s been at least one meeting of the behavioral health community and the managed care organizations and the Maryland Hospital Association is also convening meetings so we have a all-hands-on-deck effort here this group will be meeting for four years and our target is to finish our work in coordination with the General Assembly that Senate Finance Committee and the house government Operations Committee is and Senator Kelly herself is going to sit on the steering committee that secretary Neill is chairing and we what we met with delegate pena Melnick last week and she’s they’re going to provide somebody for this journey so we have a lot going on and we’re taking on a very large issue but if you think about it Medicaid spends on somatic care for managed care about 5.4 billion dollars and in the behavioral health side we have the total public behavioral health system with my partner that’d be secretary Burgess is two billion dollars the Medicaid component of that that’s managed by the ASO is about 1.4 billion so we’re talking about five point eight billion dollars in resources so we’ll continue to report back here but this is providing us a very nice venue for discussing these quality principles sir well that’s you raised a good point where she will be sharing that with Al as they look at how to apply that our focus right now is on the public behavioral health system before we get to the public comments I just want to give senator Hester an opportunity to introduce yourself thank you for coming in if you want to I kind of introduced you but I didn’t thank you so much to tenant governor um senator katie Hester I represent Howard and Carroll counties and as my distinct honor to be I’ve been appointed to join your committee so thank you so much I look forward to it okay thank you and I jumped ahead of dr. narrow there so okay thank you very much we had our meeting earlier this month and we had several participants attending which I think was excellent what we decided to do was to put the focus on the first area that was noted in the in the charge to the group which was the looking at policies of first responders related to identification of individuals that behavioral health episodes so we had a lively discussion for a few hours and the real focus we had there was to come up with some recommendations and the first recommendation was to develop or actually not developed to utilize what’s called the sequential intercept model as a means to develop an actual mapping of available resources across the state of individuals with behavioral health issues it’s a nationally-known type process that’s there the other thing we thought would be advantageous would be to provide standardized training for related to behavioral health related to individuals in criminal justice personnel which would be law enforcement Corrections Juvenile Services and the courts because in terms of my agency with Public Safety and corrections our ProAm privation agents you know although they have a degree of training associated with the mental health services sometimes when offenders come to them for supervision they’re not really quite sure if they have a mental health issue where might them what where might they refer them to how do you interact with them so we thought that was an appropriate aspect of training that should be recommended we also thought it was important to identify civic partners that currently exist in the community which actually come out of utilizing the sequential intercept model and the other part that we think is important to justify the continuation of this of course would be to develop a data collection system to demonstrate both the effectiveness and the decision-making related to the model you know your discussion is actually interesting so we have a public meeting and it says sorry I mean I felt perfectly comfortable sitting there I was interned I thought I thought it was really actually helpful framing the work you’re doing I want to thank you for doing this and I think this is a very important Commission I’ll say I wish you had the abilities of the Kirwan Commission because Kirwan is dealing with two sides of this problem which is a what are the programs we need to move our children forward and how we can pay for it and the part that we need to confront because I think we all know pretty much what we need to do I think you all map out a reasonable way forward and then the question is going to be how do we pay for the reasonable way forward and I would suggest that dealing with mental and behavioral health issues is as important as dealing with education issues we’re dealing with education issues because we’ve lose these students in the beginning we losing people on the other end to behavioral and mental health issues and both of the result of us not being able to take full advantage of the human resources that are available in our communities when we lose people who can’t do productive things we lose the opportunity to take advantage of the skills and the intelligence they could bring the things and we don’t do it so I I hope that in the long run we really get to tackle the financial challenges that it takes to really fund some of the things that we all know we could be able we could and should be able to do I’ll just do a little bit of some of the fun things I’ve been dealing with because I’ve seen I’ve seen this issue front and center this week multiple times in over recent weeks I’ve talked with groups of high school students who talked about levels of depression and stress that I’ve never seen and most people have never seen I was regaled with stories of students who had breakdowns in school were taken out of school by ambulances and got to spend days in the hospital getting mental health support and I went to school in Montgomery County and that was not the kind of stories that people told about what was going on inside the high schools and these kids to a person went around the room and talked about stress and the impact on their lives in school and that’s I think important that you know we you know we know we don’t have the counselors or psychologists in the schools that we need to have in the schools I was meeting with the community in Montgomery County the other day and they were talking about the growing number of homeless and the problems they’re presenting in the community and more prominent behaviors more behaviors that were disturbing and talking about the impacts on the businesses and the residents that they were trying to attract there but what I took as encouraging is they did not want me to arrest people a lot of times and in other days that would have been the conversation can you put these people away and instead they said you’ve got to find a way to treat these people they need help and we need the resources to be able to help them and we need programs to be able to help them I operate one of the largest mental health facilities probably in the state of the largest going to our state but injuries but are as you know one third of the people in our jail present’ with mental health issues they really don’t belong in jail and if they got the treatment if we were able to support them and all health issues they wouldn’t be in jail and their resources that we spend to put people in jail is enormous and you got to wonder if we took those same resources and put them in mental health what would we get the same thing is true with homelessness if when I arrest somebody for not complying with the not appearing in court and they get a bench warrant when I’m going to spend to put someone into jail overnight or for two or three days it’s probably equal to what I could have put them in a good hotel in Montgomery County for a month and they’re going to go back and back and through this we need more support for police crisis teams we talk a lot about you know more and more police go out in the field they encounter people who present mental health issues they don’t have the resources to deal with them we don’t have enough crisis teams to get there or get there in time because what we have has to be in the right place and the right time to arrive there before an officer winds up doing something they would probably rather not do and these are real life-and-death decisions to get made simply because in some cases we weren’t able to get the right resources to that place at the right time so these are all real things that we deal with and the last thing I’ll talk about is you know knowing people in the mental healthcare deal with people folks who present both disabilities but also mental health issues and some of them receive services but if they’re out allocation for services runs out because they spent what the agency can spend in dollars on getting a person beat in front of a psychiatrist or whatever the help they get they will go for a period of time until the next cycle begins for their funding and I’ve heard people say that what they hope is that they get arrested before they do something they’re hurt themselves or somebody else because they go through a period where their mental health declines and it’s not being treated and and so what you hope for is they wind up in jail that’s not what any of us want and not what is not what they want so I’m here just you know I’m I see the human face of this all the time I know from your resumes and what you’ve done you all see the human face of it so I want to encourage you you know to work on developing plans that more effectively help us address these issues in the community and to the extent you can you know we need to get our legislators to summon up the courage to provide the funding this is this is a bipartisan problem you know I can’t point to any administration that fully address these issues is just simply we’ve not faced up the stuff it’s time for us to face up to it you figure out what’s what’s it going to take in resources in order to do the right thing for these people because ultimately it’s gonna be the right thing for our community so thank you for giving me a few minutes and I really do appreciate the work you’re doing all right thank you very much and I just want to say that you know in the slightly differ with the the current Commission is that we are looking at the detail in terms of what’s the best way to go forward before the you know throwing money there are places where we do need additional resources but there’s also this has been as you said well passive that you know and the folks here know it better than I do that starting in probably the mid to late 60s where we D institutionalized the institutions were not great because we were warehousing people and there were all kinds of abuses but we didn’t have the warm handoff of where the individuals would go they were supposed to go into community organizations community health services and they didn’t always go there or there weren’t enough or they didn’t have the resources to take them and then you know if you remember the 70s are and now the homeless situation and individuals and that the only place was to the jails one thing that the administration is doing with regard to the Baltimore City Jail the only jail that’s run by a state agency or a state is with the new jail that building instead of a new just purely lockup that 40 to 50 percent of the beds will be for mental and substance use disorder because the person may commit something that is a crime but their real issue is treatment and and you know they’re only in the jail for about six months on general on on average and so if you don’t address that issue they they return but one of the problems and like you said with the individual who was saying that they would want to go to jail before something they do something is the standard for commitment is that they have to be a danger to themselves or an imminent danger to themselves or others and so this individual knows that right now I’m danger but I can be but there’s no way to give them so we’re looking at how do you address that individual as well how do you address the the individual who can’t really care for themselves so it’s it’s you know coming up with the plan and then the resources to implement those plans but thank you very much and you definitely see it you’re facing in the front line do we have other elected officials that I don’t you know or here okay then I’ll go to the list that I have and the list doesn’t mean that you can’t speak these are just people who signed you up to to speak off the Ginsberg you have been following the county executive that’s a tough act hello my name is Arthur Ginsburg I am the president and CEO of CRI CRI is a non-profit behavioral health provider in Anne Arundel Baltimore and Montgomery counties a majority of the patients we serve are publicly funded Medicaid patients I am here today to encourage this commission to tackle comprehensive reform making the investment needed to build a strong accessible behavioral health system that Maryland needs the certified community behavioral health clinic ccbhc model embodies the structure and investments needed in Maryland ccbhcs ensure that access to treatment is available at times and places convenient for those served prompt to intake and engagement and services post discharge follow-up access regardless of ability to pay and place of residence crisis management services available 24 hours per day with a ccbhc level investment in creating a stronger more transparently accountable system Maryland’s community behavioral health providers will be in a position to reduce hospital admissions reduced readmissions and reduce emergency department utilization I urge this commission to include comprehensive solutions like ccbhcs in your recommendations thank you for your time before you sit down [Music] how does one normally get how do you get patients how do they come into the door right now crie is not a ccbhc providers right okay so I wouldn’t be able to answer that question sorry because I asked that because it goes back to the definition that we were talking about with emergency facilities that if someone if if a emergency personnel first responder the ambulatory service they bring a person to one of those facilities right now of the way whether they typically won’t bring them to those with select because of the definition to take them to an emergency room and so we’re trying to address it so they could possibly go to another facility but what the model requires is that people can walk in the door heat treated and seen especially in emergencies right same day and the emergency they should be treated they should be seen so it’s a 24-hour now there’s not never urgency or you know regular patrol for almost there’s a different time limit but even that it’s supposed to be fairly quick there should not be a delay in service since I can hear about now that takes six weeks to see a psychiatrist there’s different models that allows for that structure perhaps scheduling just happen and then there’s different things when you’re talking about a police I know in Oklahoma one of the ccbhc is there they have unranked with the police where every police car has a tablet and if they come across someone who they you know believe in to a health issue they link immediately to a provider of me of the tablet do an assessment and they would take them to wherever that service would be so the diversion happens almost straight not even in the for anything else so there’s a lot of you there’s models all over the country there’s eight states that are doing the CC majors models and all of the different ways of putting these requirements together and measuring out there are expectations between Congress the Senate in particular to expand thank thank you very much how much is the funding for the Maryland two facilities over two year purity [Music] thanks for bringing that up and and one of the things that dr. Burgess and I have talked about and maybe this could be discussed at some point in the crisis services as I’ve read the the information because we’ve met with some folks about this is a the thing that’s most attractive about it is it’s a 24/7 service and we don’t have that and a lot across the state so it raises a question in my mind as we’ve got the administrative services organization which is Oregon you know has organized all the providers in in across the state is does that see see see HPC model then organized the providers around the state into networks the interesting to hear more about that down the down road thank you good evening I’m the executive director of the community behavioral health Association of Maryland thank you for having this commission and creating the opportunity to have this wonderful discussion tonight I think like many other folks in the audience and on the Commission it’s it’s refreshing and inspiring I think to hear the level of knowledge from this body and level of interest in tackling these issues cbh represents community-based mental health and substance use providers across the state of Maryland on their behalf we work to promote access to behavioral health services and improve the quality of services I meant earlier today with one of our members in Frederick and they’re not able to be here today but I just wanted to share a little bit of my conversation with you and then I could pick up a little bit on some of your ccbhc questions sir so I met earlier this afternoon with behavioral health partners of Frederick they’re one of the largest outpatient mental health clinics in Maryland they serve 5,000 patients every year in Frederick and the surrounding areas they have a partnership with Frederick Memorial to provide rapid admission to folks being discharged from the hospital there with behavioral health needs so I asked the CEO when I asked all my members what keeps you up at night and I can tell you that the CEOs of community behavioral health systems are staying up at night thinking about the same things all across the state and what keeps them up and what he what he’s told me today was that he can’t meet the demand for mental health and substance use services in Frederick and every day you know putting people coming in on waitlist dry to maintain caseloads he said you know what they’re the barriers that they encounter you hear everyday about we read it all about what’s happening with the opioid epidemic the other thing that they’re seeing I think is what what Marc Elrich brought up I mean this rising epidemic that folks on the frontlines are reporting in youth and young adults I mean just a spiking increase in the need for behavioral health services he identified three barriers that keep that organization from meeting the needs of their community the first one and I think Commissioner read where this gets to the imperative of your work is you know he gets referrals from the hospital regardless of payer our hospitals are on an all payer system our community behavioral health system is not on an all payer system we struggle to get in the door with the commercial carriers credentialing rates far below the cost of care and and just coverage in terms of the benefit array with the commercial carriers very different from from how Medicaid operates and and do I think a real challenge to meeting needs in that community the second one is that on the Medicaid side our we haven’t really operationalized integration in a concrete way their license as an outpatient mental health clinic they’re serving people people are coming to them with substance use needs and their struggles like we have to get a separate license to deliver integrated care you know there are a lot of barriers around that I think our continuing focus on making sure that our regulatory and licensing process it supports the clinical product that we want and need just continues to need to be a focus is that just with Medicaid or is that just our general licensing that the health department and well that’s a great question sir under the the 1063 licensing I think is where our folks get licensed and that’s where you license as a sort of separate buckets I know the behavioral health administration I think has been working on a co-occurring licensing category but I don’t know where where that work is yeah well it just so happens I’m also the great chief medical officer Medicaid so you’re right it’s it’s a it’s a challenge we are working on it as mr. Schrader had pointed out earlier we are taking advantage of being both under the Mental Department of Health and and and this is one of the reasons why we’re so involved in this commission and we’re very grateful for it but you’re right you know I’m go to be hack and I and I might my task is to be involved and all of our stakeholders and partners so that we can keep you updated as we work on on this issue we know that this this this topic of behavioral health integration is hugely important it’s also important that we be the model for that so I hear what you’re saying and we all working I think you’ve been pointing out that we’re doing that and then the third barrier he raised and all these are things that we all know and we’re all working on so I appreciate your attention to all of them and the third one is the perpetual the work force they cannot find and recruit psychiatrists and therapists for the level that they need and the reimbursement rates in a highly competitive under resource field don’t allow them to do that and that turnover you hire therapist a therapist Li’s that’s a waitlist right and a vacancy in behavioral health is a waitlist that’s a kid being referred to you that you’re putting on a waitlist instead of providing treatment to so we all know that these are barriers we’re all working on them but what I want to echo my colleague Arthur Ginsburg’s remarks that there are comprehensive solutions they require funding it’s the certified community behavioral health clinic model as a model that says what is what is the service delivery system that you want and need for mental health services do you need it in the police cars do you need it in the schools and provides a mechanism and a model and a medic state plan to deliver it so that’s out there it’s available if we have the political will to do it and I urge you to consider that so with that thank you very much yes yes I think there’s a there’s an insufficient number of providers at least according to the the federal look at it so so there’s a core problem there but then when you have an insufficient number then and you have an underfunded community behavioral health system we were kind of last in line for getting who’s available without sufficient funding resources yeah yeah I was going to say we’ve also heard that you know and that’s why we talked about the reciprocity in some of these areas that you know that if you’re in the northern part of the state there people in Pennsylvania or Delaware that that may be interested or they relocate because they’re you know a military spouse or whatever the case may be and they come to the area but they can’t practice here yeah or they’re some period of time before they can practice and so the provider can’t afford to pay them if they can’t see clients so if that’s one of the things that we’re you know trying to address as well to see if you know we can have be able to at least make it easier to attract talent yeah thank you one of the things that we see there’s a big workforce development issue as well that they some of them don’t have the competencies and be able to treat people with cars so I think that workforce development is another issue I think you’re yeah thank you yeah thank you we’ve been my office has been traveling around the state visiting with local jurisdictions to assess various behavioral health particularly opioid related programs and almost every single jurisdiction has brought this up very serious issue and and it applies to all manner of behavioral health professionals not just psychiatrists or even psychologists and there are a number of things that have been suggested to us that don’t require money but would probably help one of them is accelerating the hiring cycle times that it takes local jurisdictions an incredibly long time to hire somebody and by the time they get through their hiring protocol the other part the person’s taking a job because they can’t wait three or four months for a job another is academic requirements that in some cases are getting in the way of of promotions and are making career tracks less attractive and I don’t know the ins and outs of that but there are a certain number of credit requirements that we require for a person to move up even if they’ve got 20 or 30 years of experience that makes going back to school about the last thing they want to do and really isn’t necessary so maybe we should look at that another is simplifying the credentialing process do we even need a credentialing process when we have Jayco and carve and other credentialing organizations or maybe ours could be much simpler as a supplement to their and finally honoring other state certification programs if if a person’s competent – that’s the reciprocity issue right and one of the ideas that came up actually this very day lieutenant governor was maybe creating a compact of adjacent states where the adjacent states we all agree on a standard protocol and and a common certification well that was one of the things that you know we were suggesting at least look at the adjacent States and our interim report too and I mentioned that compact that the Delaware is part of at least with psychologists that you know look at what we can do to have this cheering reciprocity so that those who may come here you know from other states are willing to be here but they can work if I may respond those those are all great ideas and really creative non funding based solutions and I think they’re all good ideas but increasing the the workforce overall is part of the solution but like Commissioner Redner said it still doesn’t get to that you know compared to hospitals or education systems where our folks tend to have lower salary scales and a little bit more of a you know at feel like at least what my members reporting at the back of the line in terms of getting these folks but they’re equally creative ways of getting to that also outside of the funding I think in Florida they’ve conditioned their state loan repayment programs on graduates going into community-based practices to qualify for the loan repayment because I with absent that folks tend to tend to find the highest paying job so there are there ways a to lift the overall workforce but then also to sort of say our priority is helping to address it in the community setting as well no that’s a good idea particularly in our rural thank you all right Thank You Marty Birnbaum hi my name is Marty Birnbaum and I’m a licensed clinical social worker I’m from pathways substance abuse treatment program in Anne Arundel County so I did come here to make some requests ask some questions but I would also like to respond to some of the excellent comments that you all have made and thank you all for your work and for taking this on so the first comment I want to make is and I applaud mr. Shue’s group’s efforts to really kind of highlight we really got to get our terminology be talking on the same page that’s a great place to start and everyone has the same kind of confusions about the terms so what a wonderful place to start and what I want to point out about that is that whether you once once your mental health issue or your substance abuse issue has progressed to the point of problem and you become diagnosed you’re diagnosed out of the same Diagnostic and Statistical Manual this is the same DSM whether it’s substance abuse or mental health and so what happens after that is it splits and so to me that’s kind of a false dichotomy is you know that it splits from there and I’m going to address that what I wanted to a request I wanted to make but I wanted to point that out to to your discussion to your discussion about the workforce there are also other things for example with substance use we have done a lot of work I’m sure most people here have heard of peer counselors and the peers but the peers are not licensed by any board in Maryland so that’s an issue they have a board it’s sort of a voluntary board they do excellent work and we’ve got peers all over the place doing stuff so if if there was some licensing you know credentialing entity for peers right there would increase our workforce at least as far as substance abuse but probably something similar could be done for mental health so that’s just a thought and then my last kind of response I have many many things that I’m thinking of – what you’ve said but save them for another day but you know I appreciated you bringing up deinstitutionalization because then probably people do know that there was really no act which created the institutionalization the act was something like the Community Mental Health Services Act and this is we’re talking 50 years ago and it was supposed to create a network of care where you didn’t have to be warehoused you would be treated in your own community and there there were some efforts made but I think that failure 50 years ago has kind of led us to where we are so I hope you all are going to meet for a while and be tackling this because it’s it’s it is a big problem I can’t think of anything more worthy that you could be working on than this problem what I came here to say was that looking at the system as you are you really have an opportunity in looking at the mental health system and the substance use system to look at the co-occurring disorders I mean now is the time to develop such a system and if you’ve been working in the field or dealing with this for any length of time I mean really most most people do understand that it’s an overlapping problem and so you know back in the day you looked at primary or you figured out do you go here first and then oh you go there first and and we’re still there and we really can do better than that we have separate regulations we have separate financing we have separate oversight we have you know we have a behavioral health system over two silos and but the people have the same issue so the silos are not helpful so if everyone if you all just you know went back to your departments and said hey every unit look at how you substance abuse unit do you have any barriers to someone delivering both the services and vice-versa I mean we could probably come up with a lot of things and I think the bonus is I think it would be cost effective to treat both issues at the same time so that was one point my second point is medical necessity so everyone’s heard about the issue of medical necessity if you’re dealing with parity and yes Virginia it is still a problem you will have heard the sort of the emphasis on the acuity nature so what that means is that if you are a person that I’m talking about substance abuse now if you’re a person who abuses benzodiazepines or you abuse alcohol then withdrawal is a very very serious issue why because there’s a risk of seizure but if you are abusing opiates there is no seizure risk you don’t meet medical necessity in and of itself so since there’s no seizure risk what our people who are trying to help someone access their insurance or their Medicaid their private insurance or their Medicaid and pathways serves individuals with both we get asked about DTS we get asked about seizures we get asked about blackouts and none of those apply to someone who’s taking prescription pills not one of those things applies so we suggest that something that’s relevant to opioid use disorders such as a history of overdoses be asked when you’re assessing someone for an opioid use disorder there’s really no reason why someone who has had eight overdoses does not meet medical necessity criteria when any one of those overdoses could cause them to die and the very last thing that I wanted to say and we’re talking about work force and I think this impacts a lot of issue I brought a paper and I’d be glad to give it to anyone who would be willing to take it from me is that we worked really really hard on that keep the door open Act which got rolled into the hope Act and there were fee increases for providers built into that and so just in particular substance use programs and July first the new rates came out and so none of the level three programs are included in that rate increase again this is the third year in a row so I mean even from there you can see this chart and all that yellow on the chart is are the fees that were not increased but in the hope Act that says that they were to be increased and so that means detox rehab same fees as when they when those programs were first started so I don’t think that was the intent of the Act and I just wanted to point that out thank you thank you thank you very much Laura willing hello my name is dr. Laura Willing I’m a child and adolescent psychiatrist at Children’s National Health System in Washington DC I want to thank you all for tackling this huge complex of vitally important issue I’m encouraged by the depth and breadth of the discussion that I’ve heard here already I wanted to take this opportunity to give you a little bit of information about the scope of what we’re seeing in our health system and then give some ideas of what I think might be helpful children’s no National Health System provides inpatient emergency and outpatient services in DC and in Maryland we have two regional outpatient centers providing mental health care in Maryland and Rockville and in Laurel from our emergency room in Washington DC we see we see about two thousand three hundred and forty-one psychiatric evaluations a year this is just for children we also I’m sure you guys are also aware of the emergency room boarding crisis so when there are not enough inpatient beds and these are for children that I’m talking about we have anywhere from zero to eighty eight children of boarding in the emergency room waiting for a bed each month for fiscal year 2019 it was 492 total borders that’s people just children just sitting in the emergency room waiting in the inpatient unit we have a child psychiatry unit inpatient and Adolescent Psychiatry inpatient unit we had 463 children admitted to our child psychiatry unit over the past fiscal year and 586 admitted to the adolescent psychiatry unit about 30 to 35 percent of those patients are from Maryland they live in Maryland and they’re coming into DC for care in the outpatient setting we see approximately 900 outpatients for new patient evaluations in our outpatient setting in DC 45% of those are from Maryland there’s a lot of kids coming to see for treatment and our waitlist is two to six months two months for just a general psychiatry evaluation six months and some of our more specialty programs in Rockville the way this is two months and we see about 184 patients new patient evaluations a year part of what is stunning this this problem the waitlist the boarding crisis is the shortage of mental health providers including child mentalism psychiatrists there’s a national shortage of psychiatrists there is an even more severe national shortage of child and adolescent psychiatrist at Children’s we’ve had several open positions for several years for child psychiatrists as as many people have already brought up today I think mental health parity is part of the solution to this problem I will refer you all I’m sure many of you’ve already read the 2017 report by the actuarial firm Milliman it really outlines that there is severe Network inadequacy in many of our health plans our patients cannot find care there’s a reason that they’re coming to the emergency room to get care when they send a wait list to see psychiatrists and therapists at other places there’s a reason that people are driving from Anne Arundel County to DC to see me and waiting on my way list for six months there’s not enough psychiatrists or therapists or other providers in the state of Maryland or anywhere in the country this is not a unique to Maryland problem we need adequate networks and we need parity and reimbursement also to help improve those networks we also need more resources for children needing psychiatric care in the state of Maryland this is a whole continuum of resources so we need more inpatient care we need more outpatient care we need more partial hospitalization programs we need more intensive outpatient programs we need more residential programs we need more evidence-based therapy we need multi-systemic therapy we need dialectical behavioral therapy we have lots of people working hard gathering data and getting evidence that these therapies work and I see a patient and I say ha I’ve you know identified the problem and I have this evidence-based therapy that data shows will be helpful for you but there is none available we’re frankly in a tri-state area so I think if we can work on improving our whole spectrum of care that will help reduce pressure on just using the emergency room for crisis services and if we work on mental health parity starting with transparency I’m encouraged by the initial interim report that you already have if we can work on improving transparency and then the next step would be work on parody enforcement for these health plans thank you why is it you know and this is just not locally but nationally that we have a shortage of psychiatrists doctor youth child psychiatrist do we know why is it that the people are not going into the field [Music] okay [Music] Oh my understanding to some of it is that most at least in psychiatry it’s a retiree and there aren’t enough people and let me add something to this is probably some topic that we probably don’t talk enough about but certainly this is a forum for it so it has something to stigma to um and and those of us who are in the clinical realm we know this those of us who went to medical school we know this so you know and so it’s it’s someone put an ounce not just United States problem this is a universal issue I wish I knew another word then stigma but I don’t so you know is how how we value this this field that we’re in and and you know and can we increase that value you know I know that people question why I went into the field and so I’m understanding it’s even within the field of behavioral health or stigma from those who have substance use disorders those have mental health issues so you know and and and and one would wonder does it start with with the curriculum with education and and I would even go as far as to say does it start in our and our schools before we get to college and and and in our media so that this is a systemic issue and so that’s one the second thing is when you deal with with psychiatry you’re not just doing you know with a person that comes into your to your office and they leave and and even more so as a child psychiatrist right so you don’t what the family I’m doing the schools I’m sometimes dealing with the law enforcement I’m I love what I do I am at a psychiatrist also but when you think about what you you you know so yes you know what I’m talking about right and right and and so and so I think that all of those issues are I think we can start addressing some of them but it really requires us to do have this frank conversation sometimes we don’t want to talk about the fact that this is a field that’s not really respected and and on the other hand on the other hand I will say that colleagues who who have had experience very much respect what we do so so I know I feel like I’m talking both sides but I think that’s the nature of what we do is complicated it’s not just one or the other but I do think that this commission lasting more than a year or so will advance that ability for us to continue to have this in our public domain that’s a very good point I mean because we know that you know mental illness is a major stigma associated with it years and years of media you know from horror movies when I was a kid that you know made it something that was scary and and so and then you know the jokes and other things that have gone on that have made a major stigma when you even talk about the area people don’t want to talk about they don’t want to come forward if they have a problem or they have a family member with a problem we’ve talked about stigma with soap with substance use disorder but it’s much more so when it comes to mental illness and mental health and so thank you and that brings up a point too in terms of adolescent care and I was going to ask I’m not sure if Dennis or dr. Burgess or in communications the new hospital that’s going in Prince George’s County I have one person to talk to me about a concern about not having psychiatric room for adolescents they they have they’re putting in a psychiatric unit but nothing for adolescents so that they don’t have to go down to Washington for service for the young people so I don’t know if either one of you are in contact with its University of Maryland system I guess where the hospital University of Maryland Medical is I mean I might add having been in the system for a while we used to have child and adolescent units I know in the Eastern Shore we did and I know we used to have those in the Baltimore ER we have nothing right now on the Eastern Shore we had our last residential treatment center closed about three years ago and so there are just no services and and yes and for children and we’re just talking about substance use and abuse and mental illness I’m not even talking about some other ought to some other issues we just have no beds and that’s a major issue I hear about from constituents all the time I just go back to something that County Executive was talking about in terms of visiting a high school and what a lot of these kids that are you know suffering from ranging in I guess depression from early minor minor depression mild depression to something that is clinical and and I’m gonna sound like cranky old man right now and which I am but it is social media is part of the driving force that you and I didn’t have when we were in high school and so I mean I I look at my son’s social media now he’s 30 plus years old but you look at it and I know him but looking at it on the outside he’s living the best life in the world because on social media you show all your fun stuff you show when you on vacation you show you know eating some food at some restaurant but you don’t see when you know things aren’t going so well because they don’t put it on social media so if if you are you know a kid and you’re you know maybe anti not quite as social you may be socially awkward or you’re not out there talking to people and you look on social media and it seems like everybody’s having a good time but me you know and it can then further you know isolate you and so but I’m being a cranky old man and I won’t get into the videogames and all that – but yeah I used to be you know your parents they could go outside and play let me introduce you to some people go go play oh it’s yeah in my day speaking of not an old man I saw councilman rice come in did you want to address the the group it’s hiding in the back and on your comments the county executive so we play tag team lieutenant governor let me just say thank you as chair of the Education Committee for Montgomery County but also as the chair of the Education Committee for the Maryland association of counties let me just stress what you talked about in terms of the importance when it comes to our young people and ensuring that their mental health is paramount it really is one of the things where was just reported about chronic absenteeism when it comes to Montgomery County Public Schools one of your largest the largest public school system in the state of Maryland and quite honestly as I can tell you in being able to spend a lot of time with a lot of our councillors as well as our school resource officers inside our schools a large portion of that is mental health days our children are actually taking days off to where they’re completely exhausted from the trials and tribulations that we didn’t experience I mean as I heard you talk to the county executive it’s so true the same thing exists even in my generation it’s a little bit later than yours but still is the exact same thing to where we don’t it’s just small just it’s just a small window but it really is one of those where we have to start to understand that these are the kinds of things to where parents are actually even calling in and saying I need to have a mental health day for my child to get them away from the stresses and the challenges of what we see in just as you said and you commented about social media I just want to highlight that and have us really lect on the fact that if you’re the person who has parents who are struggling to be able to afford the cellphone for you so that you can keep up with the Joneses and then you here and you see on Instagram all the great things that your other friends are doing and how your life is not the same all it’s doing is highlighting for them the difference is in terms of where they are and different and these are the things that we’re hearing from our kids as you talk to them and say this is even more so talking about how these kids lives are so much better than mine and my life is horrible and my life isn’t good because those kids are going on vacations and going on trips and Here I am stuck and can’t do whatever and so you’re right social media plays a key part not in terms of just internalizing and making a front in terms of how my life is great and it’s really not and I really don’t feel great about myself but it also makes other people feel less positive about themselves so just wanted to share that with you something that we’re seeing in our schools and where and when it comes to the mental health of our children it’s really something that we need to continue to prioritize which really comes down to ensuring that we have additional counselors and resources inside our schools so thank you thank you and Oregon recently you know implemented mental health days I guess I had a slight difference when I was reading about what Oregon did and just said that they should just be included with sick days and and not you know have to classify that it is a mental health day you know and just fit into that and again not being the education expert but you know one of the things that maybe our school systems I was going to talk to dr. Salmons about it is that why not have mental health days at school we’re kind of all your classes you you talk about mental health I mean and it can be an even relaxation exercise I know they have to get through criteria you know the the curriculum and they have to do the tests and stuff like but there’s time that even in a math class that you can say we’re just going to do third-grade math today in high school or for the first hour here’s a seat just like what you had in the third grade you know or if second grade it’s just one plus one you know and just something to let kids relax a little bit after they laughs for a while but get them to relax and then you go back into you know this but you can do that in your history class you can do things in your science classes and talk about I think is that brain disease you know just things that can maybe lower the anxiety that some kids have you know because and we need to bring their parents in because many of them put the stress on the kids gotta get into the good school you got to do this great thing about our countries you can go to any school and you can reach the highest you don’t have to go to a college to reach the highest levels and many of our entrepreneurs and the richest people in the in the country dropped out of college thank you lieutenant governor and it’s really interesting I do character counts in our schools in Dorchester County and one of the interesting observations I’ve made we’ve had at school that was designated needing extra mental health professionals and over the school year one of the things I watched was teachers in the beginning of the day with kids that were fifth graders and they’re getting ready now to transition into the next level but these were very needy kids and every day she would get all of the students together indian-style in his circle and they’d talk about what they brought to school that day and then they wrap it up at the end of the day and I thought that was remarkable because it was a great way to let the kids either vent or chill out if you will said that then they could go ahead and be focused in their learning so I think there are a number of very creative interventions that are going on to address the anxiety level of the kids in our classroom and certainly some of those good examples are being shared but you’re right those are the kind of interventions that I think make a difference with a student’s ability to focus and learn yeah and I just wanted to agree one of the other things we see is a lot of schools using things called mindfulness activities mindful moments mindful rooms that help kids become centered and focused a little bit usually with the support of an adult who’s there with them to kind of guide them and kind of help them to reflect we also see a lot of schools implementing restorative practices and using circles as a way to build relationships and to enhance connection between students and staff in schools but it’s something we do need much more of but you know we have seen some really promising practices with that I didn’t have anyone else signed up but if anyone wants to speak good evening dr. Raymond Crowell I’m the director for the Department of Health and Human Services here in Montgomery County thank you all for taking the time to do this and I won’t be briefed as the hour is getting late that no folks do have other things they want to do a couple of things on social media just to say this to you I think social media is a reality of our system it is not going anywhere it’s not going away and as Tobias it is neutral it’s what it’s the content and how we use it as an example we have a young man in Montgomery County who invented an app called take the pledge that is targeted to high school youth and I didn’t fight you to just go to Google that take the pledge it’s about five things that you do for yourself every day and here’s a suggestion for every day and and think that you can do to the to the comments I’ve heard here this evening Kirwan and k12 K through 12 is an interest of mine that has been a lifelong interest of mine I think that that or Kate what K through 12 has been interest and I think to the extent that we can coordinate and integrate the work of behavioral health in across the state with what’s happening with care so they align and integrate in a way that helps us to do our work collectively for our children would be helpful school isn’t just about depression it’s about anxieties about stress it’s about fear is about needing a mental health break and and sometimes you have to take one before you really need one and our kids sometimes don’t get a chance to do that so those issues are important on the issue of transitional issues I think we have and tied to school we have a process of youth becoming disconnected from us and disconnected from everything that’s important as they age out in a mental health I think that’s true they turn 18 they don’t have anything to do with us but that process starts with disengagement in schools before we get to disconnection so recognizing that we have to go upfront and go upstream and and think about how we support and and and and support providers to do things that help us to get kids to re-engage and stay connected to kids rather than letting them start to disengage and pull out what I hear system of care I think about promotion of an integrated system that starts with promotion of wellness prevention treatment and recovery I worry that when I hear systems of care here I don’t quite understand what it means necessarily but it’s it could be primary care and behavioral health but we got to get behavioral health squared away integrated I think as we as we go down this path you heard a couple of times about staffing tonight we have in workforce we have a real shortage of psychiatry nurse practitioners social workers numbers are going down the cost of education you know it’s just skyrocketed for folks and when you look at the math around what I’m gonna get paid as a social worker or a nurse practitioner or a psychiatrist and public service versus private practice the math is compelling to pull you out of the system or to get you to go some to into another field so we’ve got declining declining interest in this and I think that at some level we need a pipeline process whether it’s loan forgiveness or incentives to encourage high school associate kids in the sauce in Community College to try to move in this pipeline and figure out how we support them I think that is something that that we can do locally some things locally without having some state support and some state engagement in that process would be very helpful I think the the the last thing I he’s been talked about so I won’t dwell on parody except to say that one of the challenges we have with with ACA in the exchanges is that we have folks in the exchanges who have insurance coverage that is catastrophic coverage who cannot could go full year and never meet their deductible but who have little health and substance abuse issues those folks end up being a burden back in the public system because they show up in the emergency departments they show up in our in our public clinics and we end up having to figure out how we cover the cost or say no to them and then the last one back to staffing is that we have a diversity issue in in in pipeline as well we’ve got an incredibly and increasingly diverse county and state and country and the folks that are able to afford to go to school who have capacity to go to school are not that don’t represent the diversity of the country and and in the state right now so we need some some attention to that issue if you all think about what you’re doing and and how we go forward and in the in the state so thank you know Brian’s leaving right we’re ready to talk good evening lieutenant governor members of the Commission my name is Eileen Cahill I’m with Holy Cross Health in Silver Spring Maryland and I was not intending to talk today but I just heard some things I would like to elaborate on workforce clearly as an issue and also is the disconnect between psychiatrists and therapists because often patients go to you know both but the two aren’t talking to each other and that’s that’s a really key component of integrated care you know that overall sense of somebody’s seeing all the facets of their care Shannon said integrated care that was the word I was looking for earlier when I was talking about holistic so okay continue I know I just because I really do workforce issues so I would also say you need to look at bed capacity in the state inpatient beds for adolescents but also for adults and I would also say I think the been a big advocacy for children and adolescents today which clearly is needs to be done but we also need to talk about seniors and one of the biggest declines of health among seniors is social isolation that leads to depression so we need to think as people are aging in place and aging in their homes when they start to become less mobile how do we integrate them into community so I just raised those points and thank you for your time yeah no that’s a very good point you know depression and particularly when they become less mobile when they stop driving that is a big factor Oh women I was fascinated by your point about it increasing the bed capacity are you talking about within the private hospital system the 48 huh private public I you know I’ve I work I’m not a clinician I do advocacy for Holy Cross but because I work in health care and probably a lot of you know this when you work in health care but it assumes you’re an expert on everything so I get a lot of calls from my lot of calls from my friends and Friends family would that are dealing with mental health issues so they’re always asking me you know so for recommendations and things along those lines and I hear about their journey and a lot of them are going into emergency departments and and someone mentioned I get the lady from Children’s was talking about boarding and in in emergency departments you wait for a bed to open but and then you might get discharged from that facility because they’re at capacity and they’re being sent out of their community and especially true for children I mean a lot of those folks in Montgomery County they might go to the Adventist health care system has an inpatient unit but they’re at capacity so they’re going up to Hagerstown I mean that is just a tremendous tremendous burden on families to want to be there for their child but having to drive two hours so they can see him on a daily base I do think that there’s just just based on anecdotal experience of people I’m hearing about but I’d like to say when they asked me for some suggestions and I stay engaged and connected with them a lot of times they’re leaving Montgomery County because there’s not enough and even then they’re going also down to the district because there’s not enough bed capacity it’s the fragmentation of care on behavioral health both from the mental illness side and the substance abuse side is just it’s heartbreaking it’s not just here in Maryland or Montgomery County we know it’s a national but it is heartbreaking and when you can’t help your family member your friend oh my goodness it breaks your heart all right good evening lieutenant governor and Commission my name is Ken Alford I’m the systems director for behavioral health at University of Maryland Capital Region health covering Bowie Laurel and Prince George’s County we today are very happy to be here to kind of share some of the work that we’re doing with mental health and behavioral health as well as some of the concerns that we have in terms of moving forward in the future our current state at University of Maryland Capital Region at Prince George’s we have a 32 bed inpatient unit that unit is broken down to patients that have what we call high acuity which means that they come in with florid symptoms of psychopathology they’re florally manic schizophrenic and really need acute treatment about half of those patients are actually brought into emergency petition and I think you mentioned that earlier the process where the police will bring them into the emergency room it might be a family member of a parent or even a community friend and has recognized the person may be in distress they activate a forensic response to police come in they bring the person the person is in an emergency petition and they are in our emergency room to be placed to be evaluated and then see if they meet eligibility either for an inpatient service or something less less a lower lower level of care what we’re finding is our emergency rooms are really being overrun we are stressed particularly on the weekends we’ve seen Friday and Sunday we have surges of behavioral health patients literally that are in our emergency room areas where patients are getting treated for car accidents or what other services are in AED our psych patients are right there and then we try to work fast to process evaluate support them and get them the proper treatment but we don’t have the resources and as already mentioned our patients on they’re being looked at other areas in the system in the state and that can take hours usually it takes days a particularly if it’s an adolescent they’ll stay in our emergency room for days until we find beds that are open for them to be safe and then add to that burden if the person has acute suicidal ideation Joint Commission has really increased its standards on how hospitals manage those type of patients so we as a hospital system have to now supply one-to-ones for everyone that comes in with acute suicidal ideation and so the system is really burdened where patients are employee staff that normally would be treating medical patients are now deployed to do one the ones on patients that are expressing suicidal ideation so we we really are in dire need of support and ideas as our system continues to grow we had the closure of Providence Hospital another hospital system recently Takoma Park is then shifting its behavioral health beds downsizing and we’re seeing these involuntarily committed patients show up at Prince George’s Hospital same level resources but more people entering the system and really taking us to stress level so what we are asking or proposing is that we need a maybe like a psych Urgent Care where we can use some of that space to decompress our emergency room for patients that may not need acute involuntary treatment but maybe couldn’t do something a lower level could we use an act team that could really follow the patient in the community not just have the emergency room as the first source of treatment but perhaps following where they are if they’re in the school if they’re at home this team could follow and support their care and also a safe place for our minors our current state is our adolescents sit in this emergency room with adults with other emergencies and again causing trauma for them seeing the other things that’s happening around them so we know that the emergency room is not the best place for patients and acute distress and then finally looking at what happens to our patients when they’re discharged we’re finding that homelessness is a big factor we are stressed to find placement that is a safe discharge so they go home with treatment but then who follows them 10 15 30 days later or they show up back in emergency room five days later with the same level of pathology so thank you Commission thank you for turning over [Music] Shannon it mentioned it and you’re currently piloting tell me what it is again CC CC e BAC it is is a step in that direction in terms of a diversion diverting so that they don’t go into the emergency so we look forward to it because we we definitely can use to help we’re trying to find creative ways to manage our patients so we look forward to that model you know as the new hospital is coming in have you talked to them at all about having adolescent facility within the hospital so the good news is that we have our new CEO dr. right Joseph right he actually is committed to child and adolescent services being provided in the community the current model did not include adolescent and child services however there’s some rework that we have to do because the community need particularly in Prince George’s we need to relook at that new space to see could we do a model that would support children and adolescent services so there is serious conversation being developing our board room to figure out what we do next I see delegate I don’t pronounce your name wrong sorry oh I got the accent in the wrong spot thank you if you want to say something as well maybe after the since she beat you – my name is dawn o Cronin I serve as counsel to the state’s active assailant interdisciplinary work group and I also serve as counsel to the Maryland Center for school safety so the activist and interdisciplinary work group asked me to come and sort of take a look at what you were all doing because one of the mandates of the executive order that created that as a public body required prevention and I co-chair the prevention subcommittee of that workgroup so what we are learning through our work there on the prevention subcommittee is again these problems with the revolving door where law enforcement and some law enforcement units that have crisis intervention teams that are partnered with them and have formalized partnerships still are unable to ensure that those folks don’t end back up out on the street or end up there because there is only so much they can do and many restrictions with how they can in fact interact with those citizens so that is that is one bucket of problem over here on the school side and secretary Padilla sits on the advisory board for the Center for school safety and we work very closely with dr. Nelson the 24 mental health services coordinators that each local school system had to have in place by the start of last school year the Center for school safety is now conducting monthly meetings with them to try and find out what their challenges and issues are and the intent of the group and request was that they also have quarterly in-person meetings where they are able to roundtable and discuss those issues the safe to learn act 2018 also required a 40 hour model school resource officer a school security employee curriculum that all of the SROs and school security employees in the state of Maryland must be trained in prior to September 1st of 2019 and we are in we have about four more weeks left to go of that so I’ve been traveling across the state serving as an instructor in that program but a lot of the issues that you have all discussed in terms of adolescent behavioral development trauma-informed interventions restorative practices are all modules which are included within the instruction that all the SROs and the school security employees are receiving as a part of that 40-hour curriculum so I just wanted to provide a little bit of an update about the things that are going on in the in that context for everyone yep thank you very much we good will good evening lieutenant governor members of the Commission my name is delegate Gabriel a Severo and I wanted to welcome you to my district district 39 I’m an alum of Montgomery College so really glad to see that we’re convening what is a really important conversation in an institution such as this I want to also acknowledge my colleague who’s the council member for this district and used to be a delegate as well Craig rice in the back yeah I’m sure so we still on for drinks right Craig okay great right let me just say I’m here to to listen and to learn I think we have certainly come a long way from what was then the Maryland Department of Health and Mental Hygiene and I think it was important for us to not just change the name but change the way we view and interact and serve those with mental health issues and a big part of that is not seeing them as individuals who are broken or who are in any way unclean as the word Mental Hygiene used to suggests but these are in fact Marylanders who need the the kind of help and support not just from institutions and organizations but from the community I’m reminded of the words of Audrey Lord who said you know without community there’s no liberation and so it’s really important for us to understand that those struggling with mental health issues in fact need our support and not are very you know unsavory gays so with that I’m here to listen I’m here to learn and certainly looking forward to working with this commission and the lieutenant governor and my capacity on the Appropriations Committee because everything that we do and everything that we study comes with price tag at the end of the day and we need to ensure that we’re as it relates to the budget we’re providing for those most vulnerable and those that need it the most amongst us so thank you very much for being here and I look forward to listening in and being a part of the conversation Thanks thank you unfortunately you’ve missed the majority of the program but we will be having additional meetings like this the next one will will be in Western Maryland we haven’t decided exactly where we’re going to be at this point whether Hagerstown or over the first set of mountains in in Cumberland but we are gonna be doing that we also need to get to the Eastern Shore we need to get to the Eastern Shore well we wanted to get to the West before it starts snowing but you could be snowing when we get there but it’ll be lighter snow so then we know the shore is always wonderful so we’ll get there and probably in the northern part of the state Baltimore County or Carroll as well so any other additional people wanted and delegate I’d also refer you to our interim report it just will give some of what we’ve done so far and some additional information thank you thank you for letting me speak I’ll make it real quick I know everybody’s anxious to get home here today my name is Christina calendar my job today is mom of an adult with an addiction mental health issue my child was diagnosed with post-traumatic stress and depression I’m one of those moms I go through the doors of party houses and I drag my child out there’s so many things that we parents see that maybe the private and business or medical sectors may not see that we can introduce to the committee as a problem there are some inconsistencies when we see our child go to you know health care centers I can see as I was listening I kept thinking oh let me tell you a story about that let me tell you a story about that I was hoping today that I could come and maybe talk about it if we could get a parental committee together to be able to present those issues and the things that we see to the committee and maybe have an interim so that we can come up with it with with or solve those issues one of them was I heard somebody talking about the emergency room I was in the emergency room and my child wanted to go to a rehab and we were told sorry we don’t have the bandwidth to help you you’ll have to call tomorrow morning at 9 o’clock when they open to see if you can get a bed but that was not acceptable for me my child wanted to go right there and then I needed her to live and if I let her go I didn’t know what was gonna happen when she walked out that door I’ve into a plasma clinic in Glen Burnie where she was about to sell her blood for $200 to go buy drugs that’s not acceptable I’m a parent who’s seen these things happen and I want to make sure that we can bring it to light and find solutions for that as well well I would ask you there are a couple of areas that we have set up subcommittees one is the youth and families and when we say youth and families we’re not just talking K through 12 kids as was mentioned by the secretary adult family members that it is very difficult to get assistance because she’s considered confident in the eyes of the law if she’s considered confident she can’t sign a contract because you know she may be under the influence but in terms of her medical in terms of her privacy in terms of substance use treatment she’s considered competent and is protected and so we we have to find solutions and like I said that the core Act which was a cure Act excuse me which was federal legislation a couple of years ago was supposed to address part of that but I don’t think that they promulgated the regulation so that you can talk to the providers on that the crisis subcommittee crisis service subcommittee is is looking at and it’s sporadic some counties have 24-hour seven-day-a-week crisis services which would address the situation that your your daughter was in because as you know you know better than I do or as well as everybody here when a person is has substance use disorder and they’re ready for treatment they need it then because if you wait longer they’re getting sick mm-hmm and once they’re sick they’re gonna do anything they can to not be safe and so you know we’re trying to you know see where the gaps are because not every county has the 24 hour crisis services some have them and some have kind of a hybrid of it where it’s not on the weekends which is the big surge that occurs and so we’re trying to address those issues and come up with you know recommendations solutions and where we will need funding to do them and in some cases it’s not just you know new funding which I would say to the delegate it’s making sure the funding that we’re utilizing like how much is being spent in Medicaid and even on the private insurance is going to the right places you know that it’s being spent wisely because there are you know providers and there are other things out there that are not really providing the services that they should or the quality of care and so we have to look at that but I would encourage you to to look at the work groups that we have their public yeah yeah we’re not a closed group the Commission is is set up but we’ve created the work groups because we’re not going to do everything at the Commission level to bring you know recommendations from the work groups which are public and we’re actually putting information on our website that when the meetings are taking place and and suggestions that come out of there so you can participate yes thank you yeah we made it a point to have a commission that had you know as many voices as possible and particularly people who’ve experienced the issues that you’re you’re going through so I know we we all sit up here looking pretty and stuff no I there’s so many things that you learn when you’re when you’re doing the parents side of it I’ve worked in the Medicaid feel for 24 years so I’ve already had the mental health on the clinical side but now I’m having to deal with it with a child and an adult child an adult child and this is a whole new experience so and you know I’ve been called that mom and but that’s okay that’s okay that’s okay thank you no thank you we don’t have anyone else then I want to thank everyone from participating for being here thank the Commission for for being here and participating we will we will be once we get our minutes we’ll post them on our website well we’ll post these the minutes that have been approved on the website the next meeting will approve and it’s from this meeting and they’ll be posted you can also submit comments if others if anyone wants to submit comments regarding things that we should consider you can send them and I think we have the email address up here okay I never look up I’ll say that we have a website I don’t know what the website address isn’t it sitting right over here okay so so thank you and we’ll let folks know with when and and where I can say we’re planning to go of west next time and we’ll that’ll be out on our website and we’ll put information out about it so thank you again [Music]
A commission, which is chaired by Lt. Governor Rutherford, has been tasked with studying mental health in Maryland, including access to mental health services and the link between mental health issues and substance use disorders. The commission includes representatives from each branch of state government, representatives from the state departments of Health, Public Safety and Correctional Services, and Human Services, as well as the Maryland State Police, the Maryland Insurance Administration, the Opioid Operational Command Center, and six members of the public with experience related to mental health.
behavioral health Behavioral Health Services Craig Rice Germantown Campus Lt. Governor Rutherford March Elrich Maryland Maryland Insurance Administration MC MCTV Mental and Behavioral Health Mental Health Montgomery College Montgomery County MD Opiod opiod operational command center public meeting Rutherford
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