Policy recommendations

RECOMMENDATIONS FOR FURTHER EXPLORATION
Summit participants identified a range of additional policy and program recommendations that were not identified in the literature review process, but seem promising and worth further exploration to address mental health disparities in Colorado. These are included in the table below as identified by the four work groups at the Summit, including financing, systems integration, education and delivery system, and research and data.

Recommendations for Further Exploration
Financing

Top Priorities
  1. Look to private financing to develop an event or foundation to raise money for a range of mental health services – prevention, intervention and treatment (e.g. Race for the Cure).
  2. Need to address financing issues for health care for offenders transitioning out of corrections and residing in community corrections who currently are ineligible to apply for and receive Medicaid, Medicare or Colorado Indigent Care Program (CICP) health insurance.
  3. Need to complete a cost-analysis study to look at the implications of health care parity (equal coverage for mental health and behavioral health services with physical services) through public and private financing streams and then support for expanding Colorado parity laws.

Issue #1: Private financing
  1. Summary: Look to private financing to develop an event or foundation to raise money for a range of mental health services – prevention, intervention and treatment (e.g., Race for the Cure).
  2. Description: Summit participants wanted to identify a solution related to private financing. They suggested creating a foundation or other large scale fundraising event (e.g., Race for the Cure) to raise awareness and funding for mental health services – prevention, intervention and treatment.
  3. How to address: This would be addressed external to public financing streams and would need to solicit the support of funders, businesses and others.
  4. Who: Participants identified the need for a celebrity to spearhead the effort and additional partners could include the Colorado Forum, Chambers of Commerce and additional companies, boards and management who are committed to giving back to the community and/or mental health issues.
  5. Resources: Summit participants felt that in order to fund such an initiative, several key funders needed to be approached including foundations, pharmaceutical companies and casinos (businesses with a direct interest in or link to mental health and substance abuse), and other businesses that adhere to Peter Drucker’s organizational management philosophies of giving back to the community, need to be solicited with the concept.
  6. Other: Participants felt that any private organization would need to have a tight, corporate structure with low administrative overhead to be successful.

Issue #2: Financing for health insurance for transitioning offenders
  1. Summary: Need to address financing issues for health care for offenders (individuals convicted of a state felony) transitioning out of corrections and residing in community corrections, who currently are ineligible to apply for and receive Medicaid, Medicare and the Colorado Indigent Care Program (CICP) health insurance. Without such health coverage, offenders who have routine, urgent and emergent health and mental health needs will not be able to receive health care services and may return to correctional facilities where health care is covered by the state.
  2. Description: The overall issue is that offenders: a) sentenced to community corrections (following a felony conviction) by the court; b) transitioning out of prison into community corrections; or c) placed in community corrections by the parole board following a technical parole violation, do not have health care coverage. State or federal funds are not available for this population. A large number of offenders in these programs are unemployed and have significant medical, mental health and substance abuse needs.
    • The Federal Social Security Administration does allow for offenders residing in a community corrections facility to apply for and receive Supplemental Security Income (SSI). However the State of Colorado, Department of Heath Care Policy and Financing has, to date, not allowed offenders in these programs (with or without SSI) to apply for or receive Medicaid, Medicare or CICP. The state, not federal, government establishes its own policies regarding Medicaid, Medicare and CICP eligibility, and extent of health care coverage.
    • The Colorado Department of Corrections (CDOC) provides complete health care services (medical, dental, mental health) for those offenders incarcerated in CDOC prisons. For those offenders who are on parole or in community corrections, the CDOC may subsidize a limited amount of mental health treatment; however these state funds are minimal, specific to the offenders conditions of parole or community corrections placement and do not cover health care costs associated with medical or dental needs. These funds are only identified for specific mental health treatment.
  3. How to address: Some of the possible ways to address the issue identified include:
    • The State of Colorado can apply for a Federal Medicaid Waiver. This waiver, if approved, could create a special provision whereby offenders in community corrections can apply for and receive Medicaid.
    • The Colorado Department of Health Care Policy and Financing could amend its Medicaid and CICP policies to include offenders in community corrections, however this would require budgetary expansions from the state.
    • The state could adjust the statutory definition of offender in community corrections. Currently the statute defines offenders in community corrections as “inmates,” which implies being “incarcerated” (parole has a separate statutory definition). The state’s, specifically the Department of Public Safety (DPS) and CDOC, policies and procedures are defined by this statutory language; however, as has been discussed, inmates in prison receive full health care services; whereas, inmates outside of prison (i.e., community corrections do not have access to public health insurance). DPS and CDOC, as well as other state agencies, may be impacted by such legislative change.
    • The state could fund health care separate from the Department of Health Care Policy and Financing. For example, the state could direct general fund dollars to the CDOC or DPS to manage the medical, dental and mental health care services (including medications) of offenders in community corrections.
  4. Who: Some of the players identified that need to be involved include, but are not limited to: Colorado Departments of Corrections, Public Safety/Division of Criminal Justice, Health Care Policy and Financing and Judicial, Colorado Community Corrections Coalition and County Community Corrections Commissions.
  5. Resources: Possible resources to inform the work include: Criminal Justice Mental Health Consensus Project, coordinated by the Council of State Governments, ReEntry Policy Council, Bazelon Center for Mental Health Law and the Social Security Administration
  6. Next steps: The Legislative Task Force for the Continuing Examination of the Treatment of Persons with Mental Illness who are Involved in the Justice System (Task Force) has created a sub-committee to specifically address this issue, including: evaluating current state policies, other state activities and developing solutions for Colorado.
  7. Other: Need to have data to demonstrate cost impacts of this, decrease emergency room (ER), recidivism, etc. For example, New York State has a Medication Grant program which covers the cost of medications (i.e., medical and psychiatric medications) for individuals released from jail or prison while they wait for their Medicaid eligibility determination.

#3: Cost Analysis and Parity Expansion
  1. Summary: Need to complete a cost-analysis study to look at the implications of health care parity (i.e., equal coverage for mental health and behavioral health services with physical services) through public and private financing streams and then support for expanding Colorado parity laws.
  2. Description: Summit participants supported the idea of completing a cost-analysis study to look at the implications of health care parity (i.e., equal coverage for mental health and behavioral health services with physical health services) through public and private financing streams. Data could then be used to demonstrate and support the expansion of Colorado parity laws to increase access to health insurance and coverage for mental health and substance abuse services.
  3. How to address: Cost analysis by neutral entity, then would have to address legislatively.
  4. Other: Need to have data to demonstrate cost impacts particularly to the business community on the savings of parity.

Other Areas Identified for Further Exploration
  1. Create a formula to ensure the ratio of dollars spent on human services is appropriate compared to other services (e.g., transportation, criminal justice, etc.)
  2. Address Taxpayers Bill of Rights (TABOR) long term
  3. Get a community stakeholder group to work on identifying where money goes in mental health (i.e., drugs vs. therapy)
  4. Streamline existing insurance process so more providers will accept public and private insurance
  5. Recycle medications and work with private entities to achieve
  6. Small-scale pilots to fund programs in culturally-traditional or alternative services to demonstrate their effectiveness
  7. Continuously collect and enhance data to measure outcomes and successes of different practices – mainstream and culturally-traditional – to then drive funding decisions
  8. Mental health special districts
  9. State contracting with minority and cultural agencies and providers

Systems Integration

Top Priorities
  1. Create legislation to fund alternative or culturally-traditional therapies and to expand the definition of health care to include holistic health care services that integrate mind, body and spirit into services listed as billable services under public and private insurance. This would be a holistic package that is culturally sensitive to families, consumers and communities.
  2. Develop integrated financing to address mental health disparities through collaborative process that includes: assess regulatory/statutory barriers; address these barriers and others; provide incentives for communities to collaborative; and reward communities for using culturally-specific services and best practices.

Issue #1: Fund culturally-traditional and alternative therapies and expand definition of health
  1. Summary: Create legislation to fund alternative or culturally-traditional therapies and to expand the definition of health care to include holistic services.
  2. Description: Create legislation to fund alternative or culturally-traditional therapies and to expand the definition of health care to include holistic health care services that integrate mind, body and spirit into services listed as billable services under public and private insurance. This would be a holistic package that is culturally sensitive to families, consumers and communities.
  3. How to address: Through legislation – in order to accomplish this task, a consistent message needs to be developed that is used to educate policy makers as well as marketing to the general public to influence policy makers.
  4. Who: In order to accomplish this task, a consistent message needs to be developed that is used to educate policy makers as well as marketing to the general public to influence policy makers. The groups that need to be involved are: legislators, consumers, families, business community, health care community, and local communities, including the rural areas of the state. This group would also need to work with the business community to address any of their concerns.
  5. Other: Incorporate traditional healers into mental health system, funding for alternative therapy

Issue #2: Develop integrated financing
  1. Summary: Develop integrated financing to address mental health disparities through collaborative process
  2. Description: Develop integrated financing to address mental health disparities through collaborative process that includes: assess regulatory/statutory barriers; address these barriers and others; provide incentives for communities to collaborative; and reward communities for using culturally-specific services and best practices
  3. How to address: regulatory, statutory, incentives
  4. Who: Department of Human Services, Health Care Policy and Financing, Center for Medicaid and Medicare Services, faith-based providers, consumers, local mental health boards, private nonprofits, legislature and all branches of government.

Other Areas Identified for Further Exploration
  1. Address funding silos
  2. Develop agreed upon referral systems between different areas of service delivery
  3. System of care – eight domains of life
  4. Rural and mountain communities
  5. Education and training of workforce
  6. Cultural issues and diverse workforce
  7. More funding for family advocates, patients navigators and case managers – follow up for services
  8. Do not forget communities – involve them in collaborative projects (e.g., faith-based)
  9. Linkage between mental health and health (symptoms of mental health) and substance abuse
  10. Families need all systems
  11. Individualized services – more family voice
  12. Every agency brings a consumer to the table
  13. Diverse groups of lawmakers, leadership
  14. Smooth transition
  15. Stigma and education – school-based deals with stigma
  16. Integration of body, mind and spirit
  17. State fund community projects where organizations are working together
  18. Too many community projects – more administrators use for services
  19. One stop shopping
  20. Transition to community and lack of resources
  21. Comprehensive universal health care ensuring mental health is covered adequately
  22. Increase funding for mental health services
  23. Finance integration/blended funding
  24. Regional SAMHSA (Substance Abuse Mental Health Services Administration) office
  25. Client-centered services
  26. Community council that is culturally diverse planning for mental health
  27. Mental health consumer directed choice in treatment
  28. Mental health needs to be in community and community based – emphasis on community- based behavioral health services
  29. Treatment teams need to be multi-disciplinary
  30. Regulatory agencies need to be integrated.

Education and Direct Service Delivery

Top Priorities
  1. Reintroduce enhanced Senate Bill 06-111 – Cultural Competency for Health Related Professionals.
  2. Identify methods for integrating traditional healers within the Western service delivery system.
  3. Establish state and county level Cultural Advisory Councils to develop local policies for the delivery of culturally-appropriate mental health services.

Issue #1: Reintroduce enhanced Senate Bill 06-111
  1. Summary: Reintroduce Senate Bill 06-111 – Cultural Competency for Health Related Professionals.
  2. Description: Senate Bill 06-111 mandated cultural competency educational programs for all health related degrees. The Bill directs the Department of Public Health and Environment to establish and direct a task force to study and make recommendations on specific course curricula.
  3. How to address: Senate Bill 06-111 was vetoed by Governor Owens at the request of the community who were concerned about unintentional consequences. The workgroup recommends reviewing the concerns, revising the bill and resubmitting to the state legislature.
  4. Who: Colorado Consumer Health Initiative, Colorado Department of Public Health and Environment and universities.
  5. Resources: Writers, reviewers, implementers, advocates, curriculum examples and state models.
  6. Next steps: Ask Colorado Consumer Health Initiative to lead the effort.
  7. Other: Create a working diversity plan with demonstrable competencies and include in continuing education for current staff. Current staff are poorly trained.

Issue #2: Integrate traditional healers within the Western service delivery system.
  1. Summary: The Mental Health Planning and Advisory Council for this project, in addition to research, identifies that traditional healer utilization is important to diverse communities.
  2. Description: Traditional healer services are broad and unique to specific cultures. Links to services outside of the mental health field often occur in crisis and collaborations have proven successful. Culturally-traditional service providers rarely receive compensation for their services and it is necessary to educate the mainstream mental health system and their providers on the benefits of working together.
  3. How to address: Through education of providers and through research of other state models that reimburse for culturally-traditional services.
  4. Who: Colorado mental health centers and culturally-traditional service providers.
  5. Resources: Funds to reimburse for culturally-traditional services, funds to offer cultural competency training, and funds for language translation.
  6. Next steps: Establish working contracts between county-level mental health centers and culturally- traditional service providers.
  7. Other: Identify how culturally-traditional services and/or culturally-competent practices are currently implemented within the mental health system.

Issue #3: Establish state- and county-level Cultural Advisory Councils
  1. Summary: Systems may be encouraged to become more culturally-competent if they had resources/guidance available to them in the form of a Cultural Advisory Council or Board. Establish state- and county-level Cultural Advisory Councils to develop local policies for the delivery of culturally-appropriate mental health services.
  2. Description: Culture means more than race and ethnicity and county or community-level Cultural Advisory Councils can guide the unique cultural issues of a community.
  3. How to address: Local level policy.
  4. Who: Colorado mental health centers.
  5. Resources: Culturally competent advisors, training of board members, agencies and consumers.
  6. Other: There are no state standards,licensing of mental health workers are at risk due to financial constraints and need more advocates.

Other Areas Identified for Further Exploration
  1. Mandate multilingual service delivery as required through Title VI.
  2. Develop testing for race/language and culture of mental health workers.
  3. Feed the pipeline to increase workforce diversity.
  4. Provide incentives and scholarships to increase culturally-competent workforce.
  5. Utilize block grants to increase culturally-competent service delivery.

Research and Data

Top Priority
  1. Develop a research and data workgroup, supported with funding and/or staff, charged with developing common guidelines and grant requirements, creating and/or implementing technical assistance and training, and identifying best practices in data collection and research.

Priority #1: Develop a research and data workgroup
  1. Summary: Develop a research and data workgroup, supported with funding and/or staff, charged with developing common guidelines and grant requirements, creating and/or implementing technical assistance and training, and identifying best practices in data collection and research. The prioritized workgroup would focus on developing a common basis for data collection and research in health disparities that would be community-focused, culturally-competent and useful to policymakers, state agencies and local communities.
  2. Description: The activities, as noted above, would include:
    • Data/research guideline development (e.g., common measures, engaging communities and feed back loop to share findings with communities)
    • Developing technical assistance and training for communities, policymakers, and other researchers
    • Developing common grant requirements on data collection and program evaluation, including suggestions on resources needed for communities to effectively evaluate programs
    • Conducting a literature review of data best practices to identify how other states have addressed the issues Colorado is facing.
  3. How to address: The workgroup would ideally be a time-limited task force supported with funding and/or staff, perhaps a legislative task force or otherwise mandated group.
  4. Who: Participants in the workgroup should include, at minimum: providers, policymakers, evaluators and researchers (i.e., private, university and community), funders, state agencies, cultural groups and regional representation.
  5. Resources: The workgroup would need adequate funds to staff it, including research support and help in writing up guidelines, developing training/technical assistance materials, researching best practices, general logistics and facilitating the meetings.
  6. Next steps: Participants discussed the possibility of reaching out to the new administration to advocate for the creation of a workgroup and calling potential workgroup members to determine interest in participation.
  7. Other: The workgroup must include community involvement and the guidelines must recognize the complexities of collecting data to meet state and federal requirements.

Other Areas Identified for Further Exploration
  1. Addressing the disconnect between Institutional Review Board (IRB) requirements, Health Insurance Portability and Accountability Act of 1996 (HIPAA) requirements, mental health issues and community-based participatory research approaches.
  2. Ensuring the School of Public Health under development by Colorado State University and the University of Colorado Health Sciences Center incorporates integrated cultural-competency training into the curriculum.
  3. Increasing funding flexibility in grants to allow for planning time in community-based participatory research, adequate funds for good evaluations and feedback to communities when research findings are completed.
  4. Training researchers to be more community-based and culturally-competent.