(January 2000)
On November 30, 1999, the Chapter interviewed James L. Stone, the Commissioner of the New York State Office of Mental Health. Commissioner Stone is a social worker and received an MSW from Syracuse University. Governor Pataki appointed him as Commissioner in 1995. Prior to that, James Stone has a long and distinguished employment history as Director and Chief of Service at a number of upstate mental health facilities.
The Chapter interviewed the Commissioner in order to learn more about the State's plan for mental health services and to find out about the role envisioned for social workers in the mental health agencies. The plan is underscored by the recent passage of Kendra's Law and Governor Pataki's proposal to increase mental health funding by $125 million.
What are the major challenges facing mental health service delivery?
Overall, the greatest challenge facing the mental health system is to restructure and move away from traditional funding and programming to managed care. Instead of paying a set amount for an inpatient stay or clinic treatment, we need to assign dollars for what an individual gets based on his or her specific needs.
I also want to focus more on working with localities. We need better partnerships with local governments. Localities should tell the State what their needs are instead of everything being directed from Albany.
We need to focus on accountability and oversight. For example, do we have mechanisms in place that assess that our agency providers are providing best practices? We need more effective ways of monitoring treatment. We need to move toward outcome measurements.
A major challenge is the implementation of the Special Needs Plan. The Special Needs Plan is our mental health managed care program. We currently have 6 Requests for Proposals out and will be awarding contracts in the spring.
Another major challenge is to implement Kendra's Law. We need to collaborate with the localities to identify people appropriate for service under Kendra's Law. In New York City, we will work with the Department of Mental Health to identify high need persons appropriate for service under Kendra's Law. The big gap that is missing in the treatment of the seriously mentally ill is case management. The horror stories we hear about are a consequence of a lack of case management. The patients in the news lately, they feel unwanted, that nobody cares about them. A case manager acts as a mentor, as a sounding board. These are classic social work principals and this is why social workers have so much to offer.
Everyone identified as high need will get case management services but some people may need additional services as well. It is difficult to speak generally because there will be variation from person to person, depending on his or her needs.
What kind of training or certification qualifies an individual to be a case manager?
Usually an MSW or a RN.
These initiatives take time. What kind of time frame do you have in mind?
It's very complex. It varies greatly from place to place. In New York City, it's much easier for a person with problems to disappear. In some of the more rural areas, this work has already begun.
As Commissioner, what have been your top goals and accomplishments?
As a consequence of all the terrific research that's been done, we have made great gains. We are enhancing case management. We also are developing a treatment model for working with co-occurring disorders, that is the dually diagnosed substance abuser and mentally ill person. We need to work more collaboratively with OASAS (Office of Alcohol and Substance Abuse Services). Too often, a mentally ill substance abuser gets turned away from a drug treatment program because they are mentally ill and the mental health agency won't treat them until they get sober! We have to stop bouncing these patients back and forth.
Prevention and early intervention is key. If a person is going to be schizophrenic at age 20, that's the way it is and we can't change that. However, if we could intervene earlier and also work with the family, we could alleviate a lot of later problems. Research shows that early intervention with schizophrenia can make a significant difference both for the schizophrenic and their family, as well.
Employment is another top goal. The mentally ill have the highest rate of unemployment of any disabled group. We need to look at that.
We also need to do a better job of dealing with stigma. Mental illness is the last place where you can insult a group with impunity. For example, a recent headline in a major newspaper used the word "crazy". We need to educate the media that kind of language is not appropriate. I am very proud of our state hospitals. Our rating by the Joint Commission Accrediting Health Care Organizations (JCAHO) of our hospitals is 95% - the highest in the country. We have made terrific accomplishments and I give the staff of those facilities all the credit.
I am also proud of Kendra's Law, which will improve accountability as well as treatment.
What programs are priorities for the mental health funding proposed by Governor Pataki?
There are three general categories:
High Need Adults. The governor has proposed $80 million for services for this population. Case management slots will increase from 15,000 to 25,000 slots. Supportive housing beds will increase from 6,000 to 8,600. These increases will be mostly in New York City. It's very hard to live in New York City on the fixed income of SSI because the rents are so high there. In New York City, a mentally ill person on SSI can't afford a decent home, so we have to subsidize that.
The Discharge Preparation Program: This program will have transitional beds for psychiatric inpatients that have been hospitalized for a very long time. The idea is to ease them into community living through a transitional living program, which would average a few months for each person. It's a big shock when you've been in a hospital for a very long time, to suddenly come out. Right now we have one 48-bed program on the grounds of Manhattan Psychiatric Center. The program will be expanded to 4 other hospitals with a total of 240 beds.
Child Mental Health: We intend to more than double case management slots for children from 2,000 to 4,500. We also want to increase our ability to treat high need children in the community rather than as inpatients. We have surrogate families who are highly trained and care for children in their homes. We plan to expand this program from 365 to 490. We also intend to increase our waiver slots to 600. This refers to our ability to waive requirements or federal funding for inpatient care and apply those dollars to community based care so that children can live in a service provider's home rather than in a hospital.
What role should social workers have in community mental health?
Social workers are uniquely trained to work with systems. This is our greatest strength. Many people went into social work school to become clinical therapists and I think this is where the profession began to go wrong. I know that we are capable of being good clinicians. I have a private practice and I am a social worker too. But we are special in our understanding of how systems work and that is a critical skill necessary at this point. That is why this is a golden age for social work.