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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