Progress on long-standing agreement to improve Maine system remains gradual

Now having passed the 27th anniversary of the signing of a consent decree setting out mandated reforms to Maine’s mental health service system, the state still appears to be moving incrementally toward the desired outcome.  A progress report issued this month by the court-appointed monitor for the agreement stated that “progress is being made, although haltingly at times.”  

Areas that have shown improvement, according to retired Maine Supreme Judicial Court Chief Justice Daniel Wathen as well as advocates interviewed by MHW, include reductions in waiting lists for certain services as well as the provision of needed housing assistance for persons with serious mental illness.  Areas that still require significant attention include gaps in medication management for patients.  

“Sometimes it is a case of two steps forward, one step back,” Mark Joyce, an attorney with Disability Rights Maine, told MHW.  Disability Rights Maine represents the class in the lawsuit that was originally filed after the 1989 deaths of 10 patients at the now-closed Augusta Mental Health Institute.  The terms of the consent decree now apply to operations at the Riverview Psychiatric Center, which replaced the former state psychiatric hospital in 2004, and to services in the state’s community-based mental health system.  

Familiar concerns

The ongoing concerns about Maine’s service system read like a fairly typical list of the kinds of problems that have plagued many state systems across the country: an overreliance on hospitalization, a lack of consumer-driven services, and chronic underfunding.

To the executive director of Maine’s affiliate of the National Alliance on Mental Illness (NAMI), the lack of a master plan to guide the shorter-term actions affecting the system has been an ongoing flaw.  NAMI Maine Executive Director Jenna Mehnert told MHW that while the state’s goal of seeking greater accountability in the system is entirely appropriate, actions under the present mental health administration have amounted to more of an indiscriminate shrinking of the system.  

At the time the consent decree was signed in the summer of 1990, it was estimated that the required actions by the state would be completed by September 1995, according to a summary document on the consent decree from Disability Rights Maine.  More than 20 years and numerous state administrations have passed since then, and progress remains inconsistent.  

An immediate-term problem for the state involves the effects of the federal Centers for Medicare and Medicaid Services’ (CMS’s) 2013 decision to decertify the Riverview Psychiatric Center because of several questionable practices at the hospital.  State officials learned this June that the CMS planned to recall $51 million in federal payments to the state, and the state is appealing that move.  Joyce said state officials have indicated they will use monies set aside in the state’s budget stabilization fund to cover the loss if their appeal is unsuccessful.

Goals and principles of decree

The consent decree’s general goals are to ensure that consumers serve as the driving force in treatment planning and programming; to improve the quality, comprehensiveness and availability of mental health services; and to maximize use of health care and other services outside the mental health system wherever possible.

Basic principles guiding the decree include the redistribution of hospital funds into the community, the need to offer flexible services to address an individual’s changing needs over time and the provision of care in the least restrictive available setting.   

The latest progress report from the overseer of the agreement suggests several signs of improvement.  Covering the period from last December through this July, the progress report points to a significant reduction in waitlists for case management and important support for a rental assistance program designed to facilitate patient reintegration into the community, the Bangor Daily News reported.  

A particular area of remaining concern involves inconsistent access to medication management services across the state, due in part to a shortage of psychiatrists, the report points out.  The situation could have been worsened had state legislators not blocked a recent plan by the Department of Health and Human Services to reduce payment rates for psychiatric services, the court’s overseer suggested.  

Disability Rights Maine’s Joyce said that while the state contracts with private providers for many required services, the lack of available providers does not release the state from its obligations under the court-approved agreement. 

Overall, however, “It does seem that some of the things are improving over what has been done in the past,” Joyce said.  

Gaps in system

NAMI Maine’s Mehnert outlined the history of an eroding funding system that at one time had a broad definition of eligibility under the state’s Medicaid program, as well as discretionary funding for those who didn’t meet Medicaid requirements.  As that system began to contract, access to medications was often the first item clients lost, which in turn led to compromised outcomes and increases in homelessness.

If gaps in the service system are not addressed, Joyce said, the result can be more people ending up in emergency services and in local jails.  He and his colleagues at Disability Rights Maine emphasize the importance of making sure people with mental illness can move through every stage of the service system properly, not getting stuck at any point.  

The Disability Rights Maine summary of progress states, “The hope from the plaintiffs’ counsel perspective is to work with the Court Master and the Department to implement concrete, permanent reforms that will create the comprehensive mental health system that the decree envisions.  Additionally, focus on patients’ rights and treatment at Riverview Psychiatric Center continues to be an ongoing focus for plaintiffs’ counsel.”

Reprinted with Permission

Source: Mental Health Weekly, Volume 27 Number 32, August 14, 2017