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The Office of Behavioral Health hosted six community forums across the state in September 2017 to discuss behavioral health successes, needs and opportunities with individuals with lived experience, families, service providers, behavioral health workers, local human services, community partners and more. The forums facilitated an open dialogue about available services, ideas for next steps, and stigma reduction.
Below are common themes from attendees about what is going well and areas to improve, as well as answers to attendees’ frequently asked questions. Each of the forums, held in Pueblo, Durango, Fort Collins, Grand Junction, Frisco, and Northglenn, drew crowds of around 50 people or more.
Across all six communities, OBH heard about programs and strategies that had improved regional behavioral health. Comprehensive wraparound services, engaging peers in treatment and recovery, collaboration and cross-sector partnerships, integrated and co-located care, and employment services in almost every community were identified as areas that are going so well that communities would like to have more.
ACT teams work within community mental health centers and include social workers, nurses, psychiatrists, substance use treatment providers and case managers. These teams bring comprehensive services to individuals in the community and have been effective in helping individuals access full wraparound services, including mental health services, substance use disorder services, primary health care, dental care, housing and employment assistance, and other services that help individuals maintain community living.
Although ACT services are especially useful for high-acuity individuals, attendees routinely said that both workforce issues and the distances ACT teams need to travel in rural and frontier areas to provide community-based services create a lack of availability of ACT services throughout Colorado. Currently there are ACT teams in all 17 community mental health centers (CMHC). The ACT teams are located in the population hubs of the CMHC regions, which include: Littleton (AllHealth Network); Colorado Springs (AspenPointe); Aurora (Aurora Mental Health Center); La Plata County (Axis Health System); Sterling, Fort Morgan (Centennial Mental Health Center); Montrose (Center for Mental Health); Adams County (Community Reach Center); Pueblo (Health Solutions); Jefferson County (Jefferson Center for Mental Health); Denver (Mental Health Center of Denver); Boulder County (Mental Health Partners); Grand Junction (Mind Springs Health); Greeley (North Range Behavioral Health); Alamosa (San Luis Valley Behavioral Health Group); Canon City (Solvista Health); La Junta (Southeast Health Group); and, Fort Collins (SummitStone Health Partners).
Services provided by peers, both in the community and facility-based treatment, have been beneficial for individuals and families. Peers are able to connect with individuals due to common experiences and can give families clear guidance on what they can expect in navigating the behavioral health system. Community mental health centers, substance use treatment and recovery providers, and crisis services across the state are hiring peers to help engage people in services, provide support through treatment and recovery, and set person-centered policies for behavioral health organizations.
Communities are working together to better meet the needs of individuals and families across multiple public and private sectors. Partnerships include mental health providers, substance use disorder providers, primary care facilities, resource centers, schools, early childhood providers, law enforcement, community foundations, advocates, and employers. Recent partnerships with law enforcement including training police and sheriffs, hiring care coordinators, and funding through Senate Bill 17-207 were identified specifically as partnerships that are improving community health. Although community partnerships are growing, full integration of services across providers in different systems is still a work in progress due to stigma, cost and payment uncertainty, and workforce shortages.
Integration of behavioral health and primary care is happening, and communities identified this as an area of success that could be expanded for adults and children. Some communities wanted to see more mental health services in primary care offices, especially in areas that have primary care offices but not behavioral health offices. Other communities were excited for the growth in primary care services being offered in community mental health and substance use settings, especially for individuals who are severely mentally ill and spend more time with their behavioral health provider. For crisis services, communities identified the need for co-located withdrawal management (detox), crisis stabilization and treatment services.
Twelve of the 17 Community Mental Health Centers currently use the IPS model of supported employment. IPS is an evidence-based practice that helps people with mental illness find and keep employment. For individuals with behavioral health disorders, discrimination in hiring and firing is illegal, yet gaps in employment, criminal justice involvement, and stigma all contribute to challenges in employment. IPS works with employers to reduce stigma and connect them with a workforce individuals in recovery.
Each community identified some region-specific challenges and talked through potential solutions. Most communities identified a need for more access to specific services like substance use and prevention or population-specific services for pregnant women, adolescents, high-acuity individuals and individuals with criminal justice involvement. Some systemic problems, such as stigma, workforce and transportation, and reimbursement for integrated or complex programs were discussed on a local, state, and national level.
Overall communities wanted more walk-in or same-day access to services. When an individual is at the point of reaching out for services, whether for mental health or substance use concerns, community partners and clients would like to see more options available to quickly get connected to services. For public and private insurance, communities want to see expanded networks and increased access to behavioral health providers. Providers shared the challenges of becoming an approved provider for both private insurance and Medicaid. Additionally, other treatment services need to be expanded, such as medication-assisted treatment (MAT), to meet the expanding needs of individuals and communities due to the opioid crisis.
In addition to the availability of services, communities noted the need for programs and services that were assertive in engaging individuals in services. This includes community-based services rather than office-dependent, outreach to individuals who are ambivalent to engage in services and more flexibility around appointment times.
Many communities would like to see more withdrawal management (detox) and residential or inpatient substance use disorder services, which are located generally on the Front Range or in more urban areas. Same-day access to these services and partnerships with law enforcement were identified as crucial for these to work. House Bill 17-1351 requires the Department of Health Care Policy and Financing to complete a report by November 2017 on the feasibility of providing residential and inpatient substance use disorder treatment as part of the Medicaid program.
Communities shared that finding substance use services that specialized in pregnant women and adolescents is particularly difficult. Causes identified were workforce limitations, lack of funding, and lack of knowledge of existing resources. While school-based health services have been successful in providing mental health services for youth, they do not include substance use services or serve high-acuity youth. Mother’s Connection is a state-funded resource for mothers and expectant mothers struggling with addiction with the goal of maintaining family unity. This program addresses the unique health needs of women through partnership with a network of local, state and federal organizations and departments and provides funding for residential treatment.
The cost of services was consistently identified as a challenge for clients and providers. Specifically, multiple payer sources, limited funding and a complex system led to confusion on how to access or be reimbursed for services. Payment reform, integration of services, increased state funding, investment in prevention and early intervention, and technology were all listed as potential strategies to improve the behavioral health system and reduce cost and complexity.
In urban, rural and resort communities, high costs of living (especially housing) and smaller populations in communities lead to limited workforce availability, making home-based and community-based services, which are very effective, difficult to provide. Providers, advocates, coordinators and persons with lived experience all spoke about the difficulties of traveling to appointments, especially those not in their communities. Telehealth was one solution that was helping address this issue. Communities and providers with established “grow our own workforce” plans through partnerships with schools in their regions were very hopeful this could improve availability of behavioral health services and retention of the existing services.
Integrated care was also seen as an option to alleviate some of the transportation and workforce strain on individuals, families and providers. Having school-based health centers and primary care offices provide behavioral health services expands behavioral health services into communities that may have previously struggled to access or maintain services in their communities.
Although it was generally acknowledged that communities are making progress on reducing the stigma about mental health and substance use disorders, stigma-related barriers to accessing services remain, especially in smaller communities. Culturally and trauma-informed care needs to be incorporated in all service delivery modalities. Stigma also continues to play a role in individuals accessing employment and housing. Although it is illegal to discriminate based on a behavioral health disorder, often individuals do not feel that they can disclose their behavioral health issues, for fear that their employment or housing will be in jeopardy or they will be treated differently.
Every community identified investment in comprehensive primary prevention programs in communities and schools would help reduce the need for higher-cost emergency and treatment services and provide long-term cost savings through creating healthier communities. This could also reduce criminal justice and law enforcement costs by decreasing in the number of individuals in jails related to an untreated behavioral health disorder. Partnerships with schools, early childhood services, local human services and primary care were all listed as essential existing or potential strategies to improve prevention and early intervention screening, referrals and coordination of services.
The challenges with availability of affordable housing were noted across the state. This includes supported housing programs as well as housing that is both affordable and where landlords are willing to lease to individuals with histories of mental health and/or substance use disorders. In particular, individuals with felony offenses have difficulty accessing the housing needed to sustain their health and recovery.
Colorado has two key programs that are designed to promote integration. The State Innovation Model (SIM) and Accountable Care Collaborative Phase II (ACC 2.0) will expand behavioral health services into primary care settings and support bi-directional models of care for primary care services in behavioral health settings.
The Colorado Health Institute has analyzed the next phase of Medicaid’s Accountable Care Collaborative (ACC 2.0) in Colorado. Their breakdown is called “The Route to the RAEs”.
Additional questions regarding Colorado’s Medicaid Benefit were consistently brought up during the 2017 Community Forums. Information related to Colorado’s Medicaid Programs can be found on the Colorado Department of Health Care Policy and Financing’s website.
View photos taken at the various behavioral health community forums
Please contact Stacy Anderson at firstname.lastname@example.org if you are interested in hosting a forum in your community in 2018.