Gold Award: A Comprehensive Treatment Program Helps Persons With Severe Mental Illness Integrate Into the Community
The staff of MHA Village have long known what is still only slowly becoming obvious to many public policy makers and even some mental health professionals: that one of the best approaches to helping persons with mental illness successfully integrate into the community is to address their psychological and social needs as well as their psychiatric needs—and that this approach can be less expensive than treatment that focuses only on acute care. Too often hospitalization alone provides "drug and run" treatment, where patients are medicated into stability and then released, with no continuing support in controlling their symptoms, much less their lives. Too often it is only a short hop to the streets or to jail. Yet it is estimated that only 10 percent of seriously mentally ill persons receive psychosocial rehabilitation.
In 1989 the California Mental Health Association held a statewide competition for the design and implementation of a model that would change the way mental health care was organized and financed. The MHA Village of the Mental Health Association of Los Angeles County (MHALA) was one of three models selected. It began operation in April 1990 as a three-year pilot project funded by the California Department of Mental Health and intended to break the cycle between streets and jails for persons with mental illness. The program would test an innovative delivery system built on an integrated service approach with capitated funding.
Today MHA Village is a permanent program, funded through a capitated contract with the Los Angeles County Department of Mental Health and serving 276 members, or clients. Located in a three-story building in the business district of Long Beach, California, the Village is a unique nonresidential rehabilitation and treatment center whose primary objective is to provide services that allow persons with mental illness not only to stay out of jail and off the streets but to live full lives, independently and within the community.
The Village's dual mission is to "support and teach adults with psychiatric disabilities to recognize their strengths and power to successfully live, learn, socialize, and work in the community" and to "stimulate and promote systemwide changes so that these individuals may achieve these goals."
The MHA Village was selected in the category of large academically or institutionally sponsored programs. The winner of the award for small community-based programs is described in a separate article on page 1433. The awards were presented on October 25 during the opening session of the Institute on Psychiatric Services in Philadelphia.
An individualized integrated approach
A person who enters treatment at the Village has a serious mental illness, often with other problems, such as addiction, homelessness, and a history of incarceration, and without the personal and financial resources to live independently. The Village's innovative "designed care" program blends a range of mental health approaches, such as psychiatric care, psychosocial rehabilitation, assertive case management, and consumer empowerment, with its own enhancements, such as a quality-of-life focus and a "high risk- high support" philosophy. In an effort to strengthen personal abilities while lessening disabilities, services are tailored to meet each member's distinct employment, housing, health, recreation, financial, and psychiatric needs—and choices.
Personal empowermentthrough a team effort
With a foundation of support provided by Village staff, members are encouraged to take responsibility for their own lives—for establishing goals, developing personal relationships, and handling the tasks of daily living, whether it be moving into a new apartment, asking for a date, or opening a bank account. Responsibility carries risks, but also rewards. Failures, like successes, are regarded as learning opportunities.
A fundamental tenet of treatment is that each member take an active role and even guide the staff in deciding what the member needs and which services can best meet those needs. Answering as simple a question as "What would make you happy?" can help a member focus on options and solutions. A "menu approach" to services and a personal service plan allow members, with input from staff—and family, if appropriate—to design and follow a rehabilitation strategy that works for them.
Every member belongs to a service team and has a personal service coordinator. The coordinator helps the member identify and pursue his or her own goals and design a plan that encourages the member to live and work progressively more independently. The coordinator is part of the service team, which is made up of a full-time psychiatrist, a licensed clinical social worker, a psychiatric nurse, and four psychosocial specialists. The Village has three such service teams, and they are complemented by resource specialists in employment, recreation, money management, and substance abuse.
A member may meet with staff three times a day or once a month, depending on need. Staff are instantly available in case of crises, and on-call assistance is available 24 hours a day. Services are provided in the specific setting where a member needs assistance—on the job, in the home, at school, even at a recreational event.
When members need a higher level of support or assistance but do not require hospitalization, they may receive the services of a "life coach," who is a Village member trained and paid to provide companionship, support, and specific skills training. Although members who receive life coaching obviously benefit from the service, the coaches get tremendous satisfaction out of seeing themselves as care givers rather than perpetual care receivers.
Employment as acornerstone of treatment
Gainful employment is a cornerstone of the Village's psychosocial rehabilitation orientation. Work increases a member's sense of responsibility, self-respect, and independence. The Village itself serves as a training ground, with clerical and maintenance positions and three unique program businesses that provide paid, time-limited jobs to 35 to 40 members at any given time. When a member has acquired the necessary skills—and self-confidence—Village Job Developers help locate and secure employment in the community.
Some members also hold regular permanent jobs at the Village, in community integration, case management, outreach, and data entry.
The psychiatric aspect
Despite the importance placed on psychosocial treatment, the Village does not lose sight of the fact that its members, by definition, have a serious mental illness. Psychiatric care is a critical feature of the collaborative model, and each member works with a designated staff psychiatrist. Psychotropic drugs and medical procedures are used when appropriate, but their use is based on the individual's particular needs rather than on a predefined protocol.
Physicians engage in an ongoing dialogue with their patients. For example, physician and patient together assess the benefits and risks of taking a particular medication, as well as the consequences of not taking it. When patients feel that they are being heard and that they have some decision-making power, they are more likely to adhere to a recommended course of treatment. If a member needs to be hospitalized, the Village psychiatrist is the admitting, treating, and discharging physician. This approach maximizes continuity of care while minimizing disruption in the member's life.
Proof of success
Proof of the Village's success was evident early on. During its three-year pilot phase, an independent evaluation by Lewin-VHI, Inc., found that fewer than 20 percent of its members required hospital treatment. By the third year, 65 percent were living independently, and only 2.4 percent were in institutional care. Sixty-eight percent of the members were engaged in work or education.
An in-house study tracked the progress of 190 members during the 1997 calendar year and found that during this period homelessness was reduced by 78 percent and conservatorship by 46 percent. Independent living increased by 57 percent and employment by 76 percent.
Proof of the economic benefits of the integrated, member-oriented approach is in the numbers: yearly funding for a high utilizer of traditional services in the state of California is estimated to be $18,799, compared with the Village's costs of $16,190 for a high utilizer and $4,950 for a low utilizer. At any given time, only four Village members (approximately 1.5 percent) are expected to be hospitalized.
The Village has a strong commitment to continued self-evaluation. Service outcomes are carefully monitored and studied, and medical quality assurance is maintained through a medical quality team, which meets bimonthly and comprises psychiatrists, psychiatric technicians, and psychiatric nurses.
A model for others
The Village actively assists other mental health organizations in replicating its approach. "Immersion training" is conducted on-site. Consultation services and training in key Village components, such as integrated services, capitated funding, and outcomes-based evaluations, have been provided to mental health professionals and administrators in more than ten California counties as well as in Maryland, Colorado, Iowa, Arizona, New York, Alaska, and, internationally, Japan, New Zealand, and the Netherlands. True to its principle of individualized service, the Village makes its training user friendly by tailoring a curriculum to an organization's specific needs and helping it adapt what it has learned to local cultural, linguistic, and systemic issues. The goal is to be "an inspiration to help others form their own visions."
The Village has been designated as an "exemplary practice" for the Substance Abuse and Mental Health Services Administration's consensus building project, which provides funds to programs seeking innovative practices to replicate. The Village is one of six models in the National Mental Health Association's Partners in CARE (Community Access to Recovery and Empowerment), a project to improve systems of care for people with schizophrenia.
The challenges of funding
When the Village became a permanent program in 1996, funding was shifted from the state to the county level, leaving the Village faced with what it terms "many obstacles and opportunities." The state had provided a single funding source for $2.1 million and a capitated rate of about $18,700 per member. Losing this type of funding made the model difficult to replicate because the capitation rate was too high and the single stream of funding too rare. Furthermore, membership was expanded from 113 to 276 clients. The only new funding to finance this expansion was the roughly $800,000 to be generated from federal financial participation.
The Village met these financial challenges by first developing a two-tiered funding system that offered a capitation rate of $16,190 for 138 high utilizers and a rate of $4,950 for 138 low utilizers. By blending the two rates, the Village began offering its full scope of services to both groups for an average capitation rate of $10,570. Second, it prepared all its program staff to bill portions of their time to Medicaid so that the required federal financial participation could be generated. As a result, the program has more than doubled its service capacity and improved its economy of scale. Now the Village is a financial model that is cost-effective and can be realistically replicated.
As the single point of responsibility for its members, the Village receives a set amount of funds for each member and provides or purchases all the mental health services the member needs. Thus staff are able to work around bureaucratic obstacles to appropriate intervention. With funds available at the staff's discretion, patients do not need to wait for approval for necessary medications. Services that may be vital to a member's day-to-day progress but are not traditionally funded, such as transportation to a job interview, can be provided.
By emphasizing coordination and intensive case management, the Village has reduced the amount of funding spent on costly hospital care, allowing it to shift resources to less expensive services that focus on improving members' quality of life, such as employment, housing support, and help in building a network of support in the community. In 1998, for example, the program spent 14 percent of its budget on 24-hour care; the average for the state's public system was 55 percent.
In November 1999 the Village was chosen to be a pilot program under California Assembly Bill (A.B.) 34, which provides $10 million for a state demonstration project aimed at expanding community-based comprehensive systems of care for severely mentally ill persons who are homeless, recently released from jail, or at serious risk of incarceration or homelessness unless they receive appropriate treatment.
The future
In a new effort under A.B. 34, the Village is looking at how to tailor its services specifically to people with mental illness who are at the greatest concurrent risk of homelessness and incarceration. It is also designing a "transitional age youth" program for adults age 18 to 24 years using the same holistic emphasis.
For more information, contact Martha Long, Director, MHA Village, 456 Elm Avenue, Long Beach, California 90802; phone, 562-437-6717; fax, 562-437-5072; e-mail, [email protected]. Visit the Village's Web site at www.village-isa.org.
