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Rosenberg: The next revolution in behavioral health

March 5, 2012
by Dennis Grantham, Editor-in-Chief
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National Council looks to the future of care, kicks off 42nd Conference and Expo in Chicago

With a look back to the 1950s and a look forward to the next decade, Linda Rosenberg, MSW, President and CEO of the National Council, is set to launch the Council’s 42nd annual National Conference on Mental Health and Addictions in Chicago.

With a membership approaching 2,000 organizations, the National Council continues to enjoy growth despite tough times for community mental health organizations in many states, where burgeoning deficits continue to lead legislators toward continuing or expanding often huge funding cuts. These cuts began following the 2008 recession and took on new urgency with the end of the “enhanced FMAP” funds that helped to soften the recessionary blow before concluding in June 2011.

While Rosenberg sees great change over the horizon—she believes that the 2012 election will give the field a brief respite from major federal legislative changes until after the next presidential inaugural.

“No matter who wins, change will continue,” she says, noting that “whether you’re with those who would increase taxes on the wealthy or those who would cut spending,” presidential and Congressional action on Social Security, Medicare and Medicaid is likely to unfold quickly in 2013.

In the interim the action is within the states – health homes; accountable care organizations; essential benefits and exchanges; and Medicaid managed care – are all in play and the National Council tackles all aspects of payment and service redesign in Chicago.

The next revolution in behavioral healthcare

For those interested in improving interventions and services, there is advice and help aplenty at the conference, whose theme is built around what Rosenberg refers to as “the third revolution” in behavioral health care policy.

“The first revolution in care occurred with the creation of state hospitals in the 1950s, which were intended to be a humane alternative to centuries-old practices that chained mentally ill and addicted people to workhouses and jails.”

And, according to Rosenberg, “while the state hospitals were revolutionary in that time, we learned that long-term institutional living at best results in dependence and at worst abuse. Ultimately, large state hospitals came to be understood as warehouses.”

Today, behavioral health is living through the end of the second policy revolution, the era of deinstitutionalization, which began with Social Security and Medicare that created access to disability supports, the promise of living outside of state hospitals, and the vision of community-based mental health services under 1963’s Community Mental Health Act.

“Deinstitutionalization was good policy, but like many policies, funding was inadequate and implementation was poorly executed. There were tragic unintended consequences,” says Rosenberg. “We found that our communities were terribly short of places for deinstitutionalized people to live and that there simply wasn’t enough support available, the result was life on the streets.”

Despite the difficulties, community living has been for most an improvement. Rosenberg sees it as a difficult journey with slow progress. This isn’t so much different from the evolution that we’ve seen for people who have cancer,” she asserts. “Decades ago, people whispered about “the big C”; cancer was something that separated them from others.

Now, however, it’s not uncommon to have a friend or colleague who’s receiving chemotherapy before they come to work in the morning, or who has a follow-up check with the doctor at lunchtime. We’ve really become much more comfortable interacting with people who are coping with a serious or chronic diagnosis.”

“This,” she says, “is where we are headed for people with disabilities including individuals with mental illnesses and addictions — the third revolution is to walk the talk of ADA and Olmstead. The integration of mental health, addiction and primary care is just one aspect of a larger policy shift towards inclusion, to a time when we accept people with mental health or addictions diagnoses as our neighbors and our colleagues, a time when we see their treatment and their progress toward recovery as something that is just part of their lives and ours.”

A coming together of behavioral and family services

As care continues to evolve in response to changing perceptions, funding, and politics, Rosenberg sees a similar evolution in how behavioral health and human services relate to each other. “There’s a coming together of services that are centered on the family, to families in crisis, since these families often have not just one need, but a series of related needs,” she explains.

These may range from services for a child with special physical or emotional needs, or to families who must deal with the special needs of a child while dealing with their own mental health or substance use problems.

“What’s bringing these services more closely together philosophically is the need and the opportunity to deliver services with and through a single point of accountability.”

It’s an idea that appeals to consumers, who often prefer the ability to obtain multiple services in one location. But the combination makes sense in other ways as well. “On the funding side, what’s bringing service providers together are changes in the means of reimbursement—a shift toward outcomes based incentives and population based capitation.”

In addition, she maintains that there are issues of size and scale. “It is increasingly difficult for small behavioral health organizations to meet the demands of multiple purchasers and keep up with the emerging treatment evidence.