January 31, 2014
Representative Tim Murphy
504 Washington Road
Pittsburgh, PA 15228
Dear Congressman Murphy:
I am writing on behalf of the Pennsylvania Association of County Administrators for Mental
Health and Developmental Services (PACA MH/DS) to offer comments on the Helping Families
in Mental Health Crisis Act. PACA MH/DS is an affiliate of the County Commissioners
Association of Pennsylvania. PACA MH/DS represents 48 county-based entities responsible for
administration of mental health and intellectual disability services across all 67 counties, as well
as 21 behavioral HealthChoices oversight entities and 53 supports coordination organizations for
intellectual disability services.
First, thank you for your willingness to introduce legislation that addresses necessary community
mental health services. Your attention and voice are welcome in creating additional awareness of
challenges to the mental health service delivery system at the national level. The Helping
Families in Mental Health Crisis Act identifies substantial areas for consideration in creating a
viable community system. We have not taken a position on the legislation, although our
members have identified several areas of concern. We are interested in talking more with you to
see if our concerns can be addressed.
As you are aware, members of the Pennsylvania General Assembly have introduced legislation
to establish Assisted Outpatient Treatment programs (AOT). PACA MH/DS opposes AOT, as do
a variety of stakeholder groups including some consumers. We have significant concerns about
costs to county government. Our success is limited in working with courts to create outpatient
commitment and specialty courts. Collaboration between the community mental health and the
justice systems is imperative to create an approach to outpatient treatment that can be sustained.
Some counties have had more success than others in developing a working relationship between
the mental health office and the courts. However, the AOT proposals we have seen to date create
a one size fits all, court-focused approach to care which is not effective for treatment of most
individuals with a mental illness. In addition, AOT has not established high fidelity standards nor
has it been noted as an evidenced based practice.
Pennsylvania continues to develop Assertive Community Treatment (ACT), which is an
evidenced based practice. We would strongly suggest that your legislation focus on expanding
access to ACT rather than mandatory AOT. ACT is a team approach available 24 hours per day,
365 days per year. The team of professionals provides case management, ongoing assessments,
psychiatric services, employment and housing assistance, family support and education,
substance abuse services and other services and supports critical to successfully living in the
community. Extensive research and evaluation of ACT over the course of thirty years proves
clinical and cost effectiveness as recognized by the Substance Abuse and Mental Health Services
Administration, the Robert Wood Johnson Foundation and the Commission on Accreditation of
Rehabilitation Facilities.
Pennsylvania struggles to implement some evidenced based practices statewide due to the vast
rural and demographic differences that exist in the state. Evidenced based practices that require
fidelity to the model do not consider the challenges of access due to limits in transportation or
travel time, sufficient numbers of individuals to serve in a geographic area to make the service
economically feasible to sustain a quality provider and the ability to recruit appropriately trained
professionals in all communities. Consideration needs to be given to various options that can
meet needs at the local level that are not evidenced based, but create positive outcomes for
individuals and their communities.
Increasing local awareness and capacity is critical to supporting community members. To that
end, we support the training of public safety officers, police, and emergency workers regarding
mental illness and other disabilities. Training individuals employed in and working with the
public regarding mental illness can be an effective approach to de-escalating a situation and
giving appropriate referrals to services. The evidence based practice of Mental Health First Aid
confirms this.
While there are many positive results from evidence-based practices, the restriction of federal
funding solely to evidence based practices creates concern. A person-centered approach, which
the proposal requires, is intended to be a jointly developed, non-threatening way to plan life and
supports, which may or may not include evidenced based practices. In fact, the person-centered
approach is intended to rely on natural supports, which frequently are insufficient to promote
mental health. Non-evidence based practices and evidenced based practices are both to be
considered in a person-centered approach, but would not be possible under the current proposal
with the evidence based only restriction.
Fortunately, Pennsylvania does have a myriad of practices upon which to build. Mental Health
Advance Directives are effective despite not being evidenced based. They complement the
evidence based practice of a Wellness Recovery Action Plan (WRAP). In addition, Mental
Health Advance Directives empower an individual to share information with identified care
givers and treatment providers. Advance directives reduce adversarial court proceedings while
fulfilling the proposal’s intent to have care givers engaged in the treatment process.
We encourage further discussion on how to align services and approaches that are effective and
appreciate your recognition of gaps. Pennsylvania is a rural state and could benefit from
increased professional capacity, tele-psychiatry, and reforms for individuals who are dually
eligible for Medicare and Medicaid. Technology does need to develop to support services across
systems. In addition, our experience has been that paid advocacy is an independent third party
that identifies individual and systemic gaps. Your proposal would eliminate our current advocacy
structure, which assists in keeping an eye on the viability of the service system as a whole and
for individuals to access necessary services. Pennsylvania’s experience with engaging all
stakeholders from administration, treatment professionals, care givers and recipients has created
a more responsive and transparent system.
Finally, PACA MH/DS is concerned about the fiscal viability of the extensive changes proposed
in a cost neutral manner. Unfortunately, judicial approaches may not realize cost savings for
mental health services, but do decrease costs in other systems over time. Numerous components
identified such as professional capacity, evidence based services, court orders, technology,
mandated training and outreach include historical and new cost drivers in a time where initiatives
are intended to be cost neutral. In addition, Pennsylvania’s recent Human Services Block Grant
includes federal mental health funding and would need to be reviewed in light of any changes.
Your clear interest to create a sustainable mental health system to address individual and public
interest is commendable. PACA MH/DS would like to be part of effective systems change to
create healthy and safe communities. If you are willing to consider some changes to your
proposal, we would welcome the opportunity to talk further with your staff about modifications
to address our concerns. You can contact me directly at 717-232-7554 x 3113 or email
krotz@pacounties.org.
Sincerely,
Kristen Rotz
Executive Director