Bill proposes new mental health measures



R-District 3, Aurelia

Over the last several years I have had numerous contacts from people regarding mental health issues, and this year has been no different from others. My good friend and colleague, Rep. David Heaton from Mt. Pleasant, chairs the Human Services budget and is very knowledgeable in the area of mental health and mental illness. He wrote this column, and I thought it gives a good overview of what we are trying to do here in Des Moines, and wanted to share it with you.

Mental health and access to services has been one of the main issues that my constituents have contacted me about. Governor Branstad’s closing of Iowa’s two state-run mental health facilities at Mount Pleasant and Clarinda was a wakeup call to the condition of Iowa’s mental health system. Access has always been the big issue; access to psychiatrists, access to acute level beds, access to adequate services, and the list could go on and on. One thing is clear, what Iowa needed was a clear systemic approach in providing mental health services to its citizens. 

Three years ago, the Iowa Legislature began to reform mental health, making sure that mental health care would be consistent wherever a person lived in the state. Up to that time, certain counties provided adequate mental health services, and others did not. In response to these inconsistencies, core services were identified that would be provided to all in need. Counties were organized into 14 different regions across the state and placed in charge of delivering those identified services. Mental health was divided into two areas of responsibility. The state assumed the cost of all Medicaid-supported mental health, and regions were given the responsibility to provide the non-Medicaid services to those with mental health needs. A partnership was formed and most important, local entities were put in charge of administering their clients’ care. Organizing the delivery of mental health services in our state has not been enough.   

A Complex Needs Work Group was created last year that included members from all aspects of the delivery of mental health services in our state. They met this past summer and fall and presented their recommendations to the Legislature. House File 2456 contains all of the recommendations and other solutions discussed by the Legislature in the past. 

There has always been the criticism that our state lacked a systemic approach to mental illness, that what was lacking was a continuum of care that was evidence based and available beginning at the local level. The bill expands services along the continuum of care with proactive services to de-escalate mental health patients before crisis and treat patients in the proper setting. Up to now, treatment has been limited to local providers or a local hospital setting. Iowa has lacked mid-level services that provide shorter stays for treatment or access for those who need a “step-down” in care before returning to their community. 

Twenty-five percent of Iowa’s 725 acute mental health beds are occupied by patients who could go home, but there are no support services in their respective communities for them to return home and remain. Patients are sent to MH hospitals who don’t really need that level of care. They would be better served with mid-level care.

The bill changes the mental health commitment process with the assessment of a person in crisis completed in four hours. A hospital could offer a 23-hour bed hold to allow the patient to de-escalate and, provided with the proper level of care, avoid placement in a MH hospital.  

County Core Services would be increased to include mobile crisis, 23-hour crisis observation and holding, crisis stabilization community based services, crisis stabilization residential services, and sub-acute services provided in facility and community-based settings. 

Mobile response provides on-sight, face-to-face mental health crisis services for an individual experiencing a mental health crisis.  EMS and law enforcement could be trained to provide this 24/7 service.  A crisis line could also be available to provide tele-counseling. Our region, SE Iowa Link, is having conversations to establish a 24-hour chat line.  As to the 23-hour crisis observation and holding, this level of care must be provided for up to 23 hours in a secure and protected medically staffed setting.

The Complex Needs Work Group recommended the development of mid-level treatment entities, including access centers, intensive residential service homes, and expansion of Assertive Community Teams, (ACT).

Access centers are located in crisis residential and sub-acute residential setting with 16 beds or less, allowing them to be Medicaid eligible. These centers provide immediate short-term assessments for persons with serious mental illness or substance abuse use disorders, who do not need inpatient psychiatric treatment, but do need significant amounts in supports and services not available in the person’s homes and communities. 

Intensive residential service homes would serve adults that have a diagnosis of mental illness and may also have an accompanying co-occurring diagnosis of the developmental/intellectual disability and/or substance use disorder. The individuals need 24 hour supervised, monitored and focused treatment to maintain and improve functioning and avoid relapse that would require a higher level of care. 

ACT teams provide inter-disciplinary teams based individualized flexible treatment and support to individuals with mental illness in their home or community, 24/7, 365 days a year. Currently there are 10 ACT programs in the state. 

The bill states that there will be at least 22 ACT teams established, six access centers, intensive residential services that provide services for up to 120 persons statewide in strategic locations throughout the state. 

As this bill passed by the House and now being considered by the Senate makes it to the Governor’s desk for her signature, we have done a lot to provide a systemic approach toward the mental health of Iowans.

Challenges remain; where will we find the work force to provide the necessary services these new proposals will require? This bill only addresses adult mental health. What are we doing for the children?  Work is continuing on children’s mental health design this coming year and a report will be ready for next year’s new General Assembly. 

On another subject, the Revenue Estimating Conference will met on March 9 to present updated revenue forecasts to the Legislature. These new numbers will be used to finalize the FY 18 budget that we are currently in and will help us put together the FY 19 budget that begins on July 1, 2018. As you can imagine, everyone is looking to the REC report. We would like to adjourn in about 40 days, so these new revenue estimates are very important.  

You may reach me at the Capitol during the week by phoning me at 515-281-3221, or at home is 712-434-5880. You may write me at the State Capitol, Des Moines, IA 50319. My home address is P.O. Box 398, Aurelia, IA 51005. If you have email, please contact me at dan.huseman@legis.iowa .gov.