Model continuum of care for adults with serious mental illness

Earlier this week, the SAMHSA Center for Mental Health Services convened about two dozen representatives from the field. The purpose was to provide advice to the agency on the development of a model continuum of care for adults with serious mental illness. Participants included representatives from states, counties, managed care, accreditors, the disciplines, providers, academia, the family and consumer communities, and other federal offices.

To a person, all members of the group concurred that such an effort is very important and that the center should undertake this work. Broad consensus also was expressed that the continuum should be developed as a set of principles and guidelines, and that the agency should help to implement these guidelines in the field.

The need for such guidelines is obvious. Currently, the nature and quality of care for persons with serious mental illness varies dramatically from place to place in the United States, at the same time that new demands are being placed on local systems almost every day. Moreover, services frequently are very fragmented, poorly coordinated, and almost always incomplete. Many rural areas offer no care at all.

Along the path to the group’s conclusions, several related issues also were raised and discussed. Here are a few major highlights:

• Definition of Adults with a Serious Mental Illness. The current federal definition, developed almost a quarter century ago, is based upon the concept of personal deficits rather than strengths. This definition requires updating to reflect current strength-based approaches now also employed in other disability fields.
• Community and Personal Services. With our advancing understanding of the key role played by one’s community in the genesis of trauma and mental illness, a need exists to extend the guidelines to include community interventions based in public health strategies, as well as the more traditional personal interventions.
• Integration Hub for a System of Care. The guidelines need to provide advice on the creation of an integration hub that will manage the services in a coordinated manner, thus reducing gaps among services and fostering true systems of care.
• Engagement of Key Partners. SAMHSA should not undertake this work alone. Several essential federal partners were identified. These include: Health Resources and Services Administration (training and federally-qualified health centers), Centers for Disease Control and Prevention (community care and prevention strategies), Centers for Medicare and Medicaid Services (payment and care guidelines), Administration for Community Living (social supports), Department of Justice (care in correctional settings and National Institute of Mental Health (implementation strategies), among others. An urgent need exists for the agency to reach out and work much more closely with CMS.
• Consumer Leadership. The group concurred that consumer and peer leadership are essential through all phases of care, from initial engagement to the recovery process, and that consumers have many first-person insights to offer on design of all of the guidelines.
• Human Resources. To a person, participants noted that we are in the midst of a human resource crisis in the field, and that this problem deserves very urgent attention. However, all also concurred that the Center should undertake work on the human resource issue separately from the guidelines effort. 

The center also was encouraged to develop guidelines that are direct and straightforward. Too much complexity can and will become the enemy of good implementation.

The center plans to summarizes the results of the meeting and then to discuss potential next steps with SAMHSA and Department of Health and Human Services leadership. All participants enthusiastically offered to assist the center in undertaking these next steps.

Our hats are off to Paolo Delvecchio, center director, and Tanya Gunn, center staff lead, for arranging a very important and much needed meeting. We all will watch with much anticipation for the next steps in this work.