Community Needs Assessment-Mental Health Services Copyrighted
June 5, 2017
City of Dubuque Consent Items # 6.
ITEM TITLE: Community Needs Assessment-Mental Health Services
SUMMARY: City Manager transmitting Project Hope's 2016 Community
Needs Assessment for Mental Health Services conducted
by the United Way and the Community Foundation of
Greater Dubuque.
SUGGESTED DISPOSITION: Suggested Disposition: Receive and File
ATTACHMENTS:
Description Type
Community Needs Assessment-Mental Health Services Supporting Documentation
PROJECT
HOPE
-V N
COMMUNITY NEEDS ASSESSMENT
MENTAL HEALTH SERVICES
KEY FINDINGS, NOVEMBER 2016
�1\ United
Community Foundation Way
of Greater Dubuque ,United
, ;
ACKNOWLEDGEMENTS
Special thanks to the following contributors to this project:
Community Assessment Working Group:
Lana Wood, Community Foundation of
Greater Dubuque
Chris Chapin-Tilton, United Way of Dubuque
Area Tri-states
Michelle Bechen, Loras College
Melissa Wachuta, Loras College
Rev. Lindsay Beal James
Community Advisory Members:
Sue Whitty, Mental Health America
Allison Schwab. Substance Abuse Services Center
Community Contributors:
Dale Lehman, Loras College
Eric Dregne, Kari McCann and Rachel Dilling,
Community Foundation of Greater Dubuque
Countless Dubuque-area mental health providers, both direct
service providers and administrators,who helped supply
information by participating in focus groups, surveys, meetings
and interviews.
Funders:
Community Foundation of Greater Dubuque
United Way of Dubuque Area Tri- States
American Trust 6 Savings Bank
Dubuque Bank and Trust
CITATION
Frazer, S., Howe, E.,Wood, L., Chapin-Tilton, C.,Wachuta, M., Bechen, M., and James, L., Bisiouhs, H. (2016).
Dubuque Community Needs Assessment: Child Care and Mental Health. Community Foundation of Greater
Dubuque, United Way of Dubuque Area Tri-States and Strength in Numbers Consulting Group: Dubuque, IA and
New York City, NY. www.dbgfoundation.org/initiatives/ProjectHOPE.
INTRODUCTION
Project HOPE, an initiative of the Community to mental health and child care services inhibits
Foundation of Greater Dubuque (CFGD), partnered with individuals from going to work or achieving other
the United Way of Dubuque Area Tri-States to conduct goals.
a needs assessment that took a focused look at needs
and barriers to economic opportunity in Dubuque.To Project HOPE seeks to increase access to education
select focus areas,75 professionals were surveyed and employment opportunities for all by creating
from a broad cross-section of service providers. Mental awareness and exploring solutions to systemic
health and child care services were overwhelmingly barriers. Our hope is that this needs assessment will
identified as pressing needs. serve as a resource to help inform the work of those in
the field; influence current programming; aid efforts to
The diversity of service providers who ranked these obtain funding and resources; and provide data to help
needs so highly points to the critical role that both engage policy makers.This summary focuses on the
mental health and child care services can play in a mental health findings.To obtain a complete report for
family's stability and ability to advance their economic both child care and mental health services, email
future. Both of these services are needed for personal office@dbqfoundation.org.
well-being, and in many cases, lack of access
METHODOLOGY
The needs assessment,which started in December them to focus on important, actionable research
2015 and concluded in June 2016, engaged the Project questions. Inputs to the needs assessment included:
HOPE network, as well as research firm Strength in
Numbers Consulting Group(SiNCG), and Loras College Key Informants:Three interviews were conducted
Social Work Professor Michelle Bechen to assist with by SiNCG. Informants were identified by the
data and research efforts. CAWG as knowledgeable service providers who
were willing to lend their perspectives early in the
CFGD, United Way and SiNCG convened a Community research process, helping to identify key themes.
Assessment Working Group(CAWG) composed of
representatives from each organization and additional Mental Health Focus Groups:Three focus groups
interested community members.The working group were conducted in January 2016—one with direct
also engaged advisory members,who were recruited service providers and two with administrative
based on their knowledge and experience in mental and management-level staff.Twenty-two total
health, along with their willingness and capacity to providers across multiple specialties participated
guide the needs assessment process on a voluntary in the three groups.
basis.
Mental Health Service Inventory: CFGD staff
During a kickoff event,40 social service providers, designed and distributed an online survey to
government stakeholders and business leaders known area providers.The survey requested
participated in a SWOT analysis(strengths, information about payment acceptance,
weaknesses, opportunities and threats).This analysis prescribing services, counselors,wait times,
helped identify themes of interest and then narrowed inpatient beds and substance abuse services.
Twenty-four providers responded to the survey.
PROJECT HOPE NEEDS ASSESSMENT- MENTAL HEALTH SERVICES, DUBUQUE, IA 1
KEY FINDINGS
This section describes the findings from
the mental health focus groups and the strengths1. What are the - Dubuque-area
mental health services inventory. While the health system d service providers?
inventory was not exhaustive, all known
providers were contacted, and only one 2. What are the mostpressing ' and
challenges in
provider did not participate.This inventory mental health in - Dubuque
does not include counseling services 3. Is coordinationof resourcesproblem in the area, and
provided by colleges and universities, and if so,what are the underlyingproblem?
many of the providers who participated What existing coordination
serve patients beyond the Dubuque city if any, new coordinationneeded?
limits. 4. Is Medicaid modernization
The focus groups addressed the following 5. What is the best way o address
research questions: . . do
n existing strengths?
MEDICAID AND FUNDING CHALLENGES
Overall,focus group participants reported operating in « The person needs to fit the
an environment where resources are diminishing,while
community need is growing and funding structures are funding and the funding
becoming more rigid. One provider summarized new doesn't fit the person. 11
funding challenges by saying,"The need goes up, but
the money goes down," (MHl').
Another provider noted that rigid funding structures
Funding in Dubuque is decreasing due to state-wide don't reflect the reality of complex mental health needs
regionalization strategies that have caused resources by saying,"The person needs to fit the funding, and
to be spread more thinly in order to serve a broader the funding doesn't fit the person,"(MHl).The funding
population.This strategy enables more people to have structures don't fit the reality of someone living with
access to services, but often affects the availability severe mental illness,who may be disorganized and
of those same services. According to one provider, unable to consistently attend appointments, as pointed
"In order for everyone [in Iowa who needs services] out by one focus group member who said: "If you don't
to have the 'core services', some who were doing well show up within the first 30 days,your file is closed,
and had extra services can't have those anymore and you have to start all over again," (MH2).
to ensure that everybody gets those core services,"
(MHl). Another provider mentioned that,"community Nearly as challenging as rigid funding structures is the
members in need of domestic violence services may increased uncertainty about Medicaid reimbursement
need to travel to Waverly, a two-hour drive,to access rates. Providers expressed anxiety with regard to their
services," (MH3). ability to provide continuity of care to patients due
to the statewide privatization of Medicaid. Of the 19
providers accepting Medicaid,five stated they are
1 MHl references a participant from mental health focus group 1.MHz and already accepting fewer Medicaid patients due to the
MH3 will represent participants from those respective focus groups.
2 PROJECT HOPE NEEDS ASSESSMENT- MENTAL HEALTH SERVICES, DUBUQUE, IA
proposed changes. For those continuing to accept Types of Payment Providers Accept
Medicaid patients,what remains to unfold in the
coming months is how changes in coverage will affect
patients' access to specific services and therefore their
continuity of care.
The combination of continually changing funding
streams, more rigid funding structures, and dramatic
changes to Medicaid creates uncertainty among Direct
mental health providers and limits service.
*Respondents were allowed to select multiple responses for this sedon
MEETING SPECIALIZED AND CHANGING NEEDS
Focus group participants discussed concerns services but are reluctant to seek them due to stigma
surrounding the increase in low-income residents with or are un- or under-insured because of challenges
mental health needs and residents who are at high related to citizenship: "...how do we involve and
risk for mental health problems.This increase has engage Marshallese families because they are so
elevated the need for specific types of services. For insular, and how do we reach out to the community
example, one focus group participant recognized that and use members of the community to reach back
recently there has been,"More poverty, more violence, in to help those people because some of them are
more exposure to trauma and violence," (MH]). extremely ill. And they're not eligible for Medicaid,
Another spoke specifically to the difficult backgrounds so they're uninsured,they have no money,"(MH2).
of some young people: "A lot of traumatized youth Service providers reported a strong desire to reach
[who are] in therapy at schools are coming from other out to underserved communities. Barriers to that
areas of Chicago...Dubuque wasn't quite ready to outreach include capacity for outreach and treatment
handle [this];they did not know what to do with kids of specialized needs, and funding to treat uninsured
who had literally watched people die in front of them clients.
[and] get shot at and...[who have lived in] extreme
poverty," (MH3). While it is unclear whether demographic changes or
reduction in resources is having the larger impact,
Another participant spoke of the challenges of the combination of the two is placing a strain on local
reaching out to community members who need providers.
LACK OF OPTIONS FOR DUAL-DIAGNOSIS PATIENTS
Focus group participants reported an increase in (MH2). Providers also cited more cases of serious
patients with dual-diagnosis needs(most often mental illness: "I feel like [the] chronic mental health
several co-occurring mental health conditions, or [e.g., schizophrenia, borderline, bipolar] thing is more
a combination of mental health conditions and serious than it was three years ago," (MH2).
substance use disorders). "We don't really have
anywhere [to refer people to who have a] dual Providers reported difficulty meeting patients' needs,
diagnosis...the increase in substance use disorders because many substance use disorder treatment
leads to an increase in mental health [problems]," programs cannot accept people with complex mental
PROJECT HOPE NEEDS ASSESSMENT- MENTAL HEALTH SERVICES, DUBUQUE, IA 3
health needs,while many mental health providers cannot
treat substance use disorders. Seven out of 24 providers in
the inventory indicated they offer treatment for substance use
disorder cases. Of those seven,two offer this treatment only as
co-occurring with other mental health factors and do not have Number
staff dedicated to this service. One of those two serves pediatric disorder counselors reported
patients only. Of the remaining five providers, one offers this five mental health providers.
service only to veterans, and one only to patients in their pediatric
residential program.Three of those organizations reported
operating at over 90% capacity in the past year,with only one of 1
these indicating their capacity is expected to increase over the 6
next three years. of substance _ disorder , , ,_
reported operating at over 90%
The increasing number of patients with a dual diagnosis, along capacity
with the limited number of providers and inpatient beds, leaves
many patients underserved or not served at all.
LIMITED CAPACITY AND BARRIERS TO CARE
Providers in the focus groups expressed a limited *
ability to meet the need for mental health services Inpatient Counseling Services:Available Beds
in the community,which is reflected in the capacity 1
reported in the mental health services inventory.
Inpatient care providers reported a frustrating lack of 11-4 11-4
options for inpatient mental health care that, in some 11-4 1111-4 1111-4 1111-4 1111-4 11-4 1111-4 1111-4
cases, resulted in very sick people being released I k . I. .
without treatment. For example, during discharge from 1 �1
inpatient care,"We get a lot of calls at the shelter for Substance use disorder and mental health (20)
[people] being discharged that have nowhere else
to go;'(MHl) or as a result of mental health centers 55+ only(9)
closing,"...it's huge.We don't have anywhere to send *Results from mental health inventory
anybody.We've had so few beds already, and now it's
like we don't have anywhere to put people who really
need help;' (MH3). home setting. Adult residential providers reported
operating at 100% capacity.
Two out of 24 providers reported offering inpatient
counseling services during the inventory; one offers Twenty out of 24 providers interviewed offer outpatient
20 beds and the other offers nine beds that serve care. Four of those providers serve pediatric patients
only adults 55 years old and older. Over the past year, only,while one serves only veterans and one serves
both have indicated running at 80% or higher capacity. adults 55 years old and older.When looking at
Long-term residential care for youth is available capacity, 90% of respondents (18/20 who provide
through one provider,with a capacity of 49 beds and 12 outpatient counseling) reported their outpatient
temporary"shelter beds"that are available to youth in counseling services were operating at or above 70%
the Department of Human Services and Juvenile Court capacity in the past year,with 11 of those operating at
Services system.There are 89 long-term residential 90% capacity. Some (11/20) expect their ability to see
beds available to adults-18 of which are in a group more patients increase over the next three years.
4 PROJECT HOPE NEEDS ASSESSMENT- MENTAL HEALTH SERVICES, DUBUQUE, IA
Another topic discussed among providers was the
myriad of barriers that prevent patients from receiving Highest Contributors to Wait Times
care. Providers noted that some patients had problems
keeping regular appointments. Missing appointments lack of available appointments
made it difficult for these patients to access care
in the future and lengthened the waitlist for other
patients in need of limited services, as echoed by one issues with scheduling
provider: "If you're not fully invested in your psychiatry transportation
appointment,you don't show up, so there's many days
that we have nine appointments and two people show
up," (MH1).
those believed wait times were a "moderate or above'
During the focus groups, child care and transportation barrier, citing many of the reasons above as factors
were also identified as barriers to accessing mental that contribute to longer wait times.
health services, along with insurance issues. "I think
it's always nice for people to have options in regards to Most inpatient and outpatient care providers are
primary care, really for any matter, so it would be nice operating at or near capacity and patients are facing
to see more providers accepting Title 19;' (MH2), said barriers such as lack of transportation or child care—
one respondent. Sixteen survey respondents answered leaving them with less flexibility, longer wait times, or
follow-up questions about client wait times. Seven of nowhere to go to get the care they need.
LACK OF PRESCRIBING PROVIDERS
In addition to a rise in complex mental health needs and a lack of options for
inpatient care,focus group participants reported a shortage of providers who Prescribing Providers*
could prescribe psychiatric medications. According to one respondent, "Some
Veterans
people are going without meds for quite a long period of time just because 0.5 FTE Pediatrics
of their mental illness or being irresponsible," (MH3). Another respondent 0.8 FTE
said,"It is hard to find prescribers and then once you get a prescriber for that Adults 55+
medication,they relocate,"(MH2). Community-based mental health treatment 3 FTE
programs reported difficulty recruiting and retaining trained providers. Providers
also reported challenges managing medications effectively and coordinating
care for complex mental health conditions. As of July 2015, Dubuque County is
a designated Health Professional Shortage Area for mental health according to
the Health Resources and Services Administration. However, providers did not _ General
feel that this designation has translated into increased resources to attract and 11.025 FTE
retain mental health professionals.
Seven out of 24 respondents to the mental health inventory reported offering
prescribing services. Of those seven,two served pediatrics only, one strictly
served veterans, one was dedicated to adults 55 years of age and older, and
Total: 15.325
one utilized prescriber services contracted through another agency. Over half
Full-Time Employees (FTE)
indicated that they have operated at 90% capacity or higher over the past year,
and only three expected their capacity to increase in the next three years. *from mental health inventory
PROJECT HOPE NEEDS ASSESSMENT- MENTAL HEALTH SERVICES, DUBUQUE, IA 5
COMMITTED PROVIDERS SEEK GREATER COORDINATION
While growing needs and shrinking resources have of services: mental health counseling,food orfuel
created many challenges for Dubuque area mental assistance, case management, employment services,
health professionals,they are also responding to these social support, medical services, children's services,
changes by nurturing their own community to ensure domestic violence and/or sexual assault services,
the best possible services can be provided at the access to public benefits, substance use disorder
local level.They draw upon unique assets including treatment, and disability services, among others.
the dedication of a supportive and well-connected Many service providers also reported participating
community of providers; mission-driven workers; in advisory groups, such as the Homeless Advisory
and the cooperation of multiple agencies in a robust Council Coalition,where they connect with other
referral network. service providers and discuss pressing issues in their
community.
Focus group participants described the supportive
and well-connected community of providers in these Despite, or perhaps because of,the robust referral
ways: "Passionate people surround you at your work, network, one of the top goals that emerged from
whether it's the people you are working directly with focus group participants was to further strengthen
or the people in your organizations who are working coordination by providing a "one-stop-shop"for mental
diligently;' (MHl) and"All of us are willing to do all that health services. Providers stated,"My dream is to
we can,within our limits,to have a health and human
help...that's why were here 66 My dream is to have a health and services campus in the
today;' (MHl). Another said: human services Campus In the Washington neighborhood,
"We have our staff do theirso that lots of people who
own mission statement, Washington neighborhood, so that live down there have easy
safety plan and stress plan. lots of people Who hve down there access to whatever they
Whether it's for anxiety or have easy access to whatever they need under the same roof;"
stress or fear or whatever need under the same roof. 11 (MH2) and "It would be
it might be,you can talk nice to have us all ... in the
about it;' (MHl). same area where it's like,
and so how do I say this, a one-stop shop;' (MH3).
In addition to describing how they manage their
own stress while remaining committed to their Providers also discussed how existing structures and
jobs, providers described a robust referral network, systems could better meet patient needs. For example,
often naming the employees from other agencies or coordination of crisis care between the mobile crisis
organizations that they would reach out to when they unitz, community-based mental health care options,
have a client in need of services. "...we try to contact and the hospital emergency room were identified as
that provider or that service or whoever we refer the areas that could be enhanced (e.g., MH3).
client to and I think it's more of a courtesy to who we
are referring to, like I don't want to just dump people Providers value the close network of providers and
on you or have people calling and you have no idea the supportive community, but see opportunities to
of their background or what they're asking for or what improve coordination to enhance services.
their needs might be;' (MH3).
2 During the mental health inventory,Hillcrest Mobile Crisis Services
More than 30 different social service agencies, reported availability for crisis stabilization services with a capacity
medical providers and nonprofit organizations were of two beds,alongwith a mobile clinic Capacity has substantially
increased over the past three years,and is expected to continue to
mentioned by name during the focus groups. Providers increase over the next three years.This service is available to anyone 18
stated they referred clients for the following types years and older experiencing a mental health crisis and is mostly mobile
outreach,reducing the need for inpatient beds.
6 PROJECT HOPE NEEDS ASSESSMENT- MENTAL HEALTH SERVICES, DUBUQUE, IA
Challenges in coordinating timely care amidst a shrinking resource pool can have detrimental effects on
patients with serious mental illness. The following story highlights the experience of a patient utilizing
mental health services in our community.
Brynn's Story
After a series of traumatic life events, Brynn was diagnosed with major depression in 2013.
Throughout her college career in Michigan, she was able to manage her depression with the help of
good insurance,a campus healthcare system, support from her friends and the structure that school
provided. Upon graduation, Brynn moved out of Michigan for the first time in her life to Dubuque in
June 2015, where she had accepted a position as an AmeriCorps VISTA.After signing up for Medicaid,
Brynn made an appointment to see a general practitioner,where she waited three months before she
could be seen to obtain a referral to a psychiatrist. It wasn't until January 2016 when Brynn was able
to see a psychiatrist.
Throughout that eight-month period, Brynn was able to
rely on medication left over from her previous physician to I was doing everything
help, along with talk therapy, but still struggled to get by right, I was asking for
without the structured therapy provided by a psychiatrist.
help, demanding help
"I was extremely depressed,to the point where I wasn't and I still wasn't getting
able to get out of bed. I was functioning, but just enough what I needed. 91
to get by," Brynn continued."In September, I ended up in
the emergency room because I became so depressed that
I wasn't responding—to the point where my doctor was
concerned about my safety."
In January 2016, Brynn was finally able to see a psychiatrist.Through therapy and changes in
medication, she was able to slowly start climbing out of the darkness she had been living in for
months.While Brynn's workplace was supportive throughout her experience, Brynn knows that the
stigmas around mental health and socioeconomic status are real, and ones that she has experienced
personally.
"Even if there are services available to low-income individuals,there's still this culture where you
are treated differently because one, you're poor, and two,you have a mental illness. I'm not sure if
it's implicit bias, but it's very different. People just don't understand,and that's reasonable because
you really have to feel how terrible someone with a mental illness feels to really get it," said Brynn.
"I was doing everything right. I was asking for help, demanding help and I still wasn't getting what
I needed. My hope is that some day, severe mental illness is treated with the same seriousness as
Leukemia or another major disease."
CONCLUSIONS AND RECOMMENDATIONS
The key findings show that challenges such as limited and changing funding streams, limited capacity of providers,
and state-wide regionalization of services has affected the ability to provide services.The recommendations that
follow are intended to offer ideas to local stakeholders to address some of the challenges found in the key findings.
Recommendations were provided by the Strength in Numbers Consulting Group,with additional insight from review
with nine local providers.
Strengthen Collaboration Among Stakeholders
Increase collaboration among providers and stakeholders by developing a shared mental health agenda.
Actions to consider:
Convene mental health providers and • Share data and other information to improve
stakeholders to explore ways to improve understanding and awareness of mental health
coordination. needs in the community.
Explore partnerships that could support solutions • Increase resources for professional development
to challenges faced by patients, providers and for providers and stakeholders.
stakeholders.
Develop Solutions to Address Dual Diagnosis
Create a task force to identify community solutions for dual diagnosis. Actions to consider:
Ensure providers are aware of existing resources, Advocate for new resources, such as funding,
and proactively develop mechanisms for for existing counselors to obtain training for
coordinating care. substance use disorder certification. For gaps
h
d
ifie ,the
• Explore the possibility of establishing a detox dentCommunity Foundation and United
center to support patients with a substance use Way could also consider inviting proposals for
disorder diagnosis. funding to address them.
Alleviate Barriers that Prevent Access to Care
Engage existing networks—Changing Minds, NAMI, and Mental Health America—to develop a coordinated
effort to build capacity and alleviate barriers. Actions to consider:
Collaborate with stakeholders to explore barriers Build strategic partnerships with social service
to care among underserved populations. providers and community groups to form more
Support existing initiatives that promote inclusion trusting relationships with mental health
and cross-cultural exchange in the community providers and explore alternative locations for
and/or develop new ones. counseling, including primary care locations.
Incorporate new mental health outreach efforts Convene a group of stakeholders to research
into existing projects to reach communities that expanding awareness and preventative education
are disconnected from services. efforts in schools and the broader community,
including awareness of Hillcrest Mobile Crisis
Services.
8 PROJECT HOPE NEEDS ASSESSMENT- MENTAL HEALTH SERVICES, DUBUQUE, IA
Expand Mental Health Prescription Services
Establish a working group to explore options for increasing mental health prescription services.
Actions to consider:
Identify and engage stakeholders knowledgeable practitioner tax credit to recruit additional
about recruiting health professionals and prescribers who can work with low-income, un-
work together to identify programs, resources insured, and/or under-insured people.
and opportunities to attract new providers to Explore options that leverage technology or other
Dubuque. innovations to bring mental health prescription
Research and implement best practices in services to the community.
creating awareness around leveraging the
Expand Mental Health Advocacy Efforts
Convene a group to map existing advocacy efforts and incorporate the needs and concerns of local providers
into local and state policy advocacy. Actions to consider:
Identify stakeholders already engaged in Identify potential regional and state-level
advocacy with the goal of increasing coordination relationships with entities that have existing
and support for advocacy efforts. advocacy efforts to share the Needs Assessment
• Work to increase opportunities for input into findings in an effort to receive support for local
advocacy agendas, and work to establish new advocacy efforts.These organizations could
ones. include the United Way of Iowa, Iowa Council
of Foundations,the Mental Health/Disability
• Provide training to local mental health providers, Services of the East Central Region Board of
consumers and concerned residents on how to Directors, and the Iowa DHS Children's Mental
expand and maximize local advocacy efforts, Health and Well-being Working Group.
working with our local elected officials.
NEXT STEPS
The challenges identified in key findings and the would like to support.These actions by Dubuque's
recommendations to address these challenges offer mental health stakeholders could lead to new
a possible road map for next steps. Providers can grantmaking activities, new programming, and/or
use findings and recommendations to support or new collaborations—resulting in improved conditions
prioritize their own goals or advocate for new ones; for both service providers and mental health service
administrative leaders can find causes to champion; recipients alike.
and funders can identify projects or activities they
PROJECT HOPE NEEDS ASSESSMENT- MENTAL HEALTH SERVICES, DUBUQUE, IA 9