Grading the States 2006: Delaware - Narrative

"The Diamond State" is not a diamond in the rough so much as a diamond going through rough times. Delaware faces problems that one would not expect to find in a small state with only three counties.

Within the Department of Health and Social Services, the state's Division of Substance Abuse and Mental Health (DSAMH) administers community-based services through four community mental health centers, as well as four community continuum of care programs (CCCPs). For more intensive care, the state has the Delaware Psychiatric Center (DPC) in New Castle. 

Introduction of the CCCPs in 2004 dramatically changed the system. Traditionally, people with serious mental illnesses had received intensive services fromcontinuous treatment teams (CTTs) based on the national Assertive Community Treatment (ACT) model. As part of a restructuring, DSAMH collapsed nine CTTs into the CCCPs. DSAMH reports that ACT teams are still embedded within each program, but advocates report decreased availability.

Advocates are concerned that the state is either not measuring the impact of the changes, or withholding information that may be less than flattering. According to one advocate, CCCPs are "gutted" versions of CTTs, with too large of a caseload to provide appropriate intensive services. 

Other concerns exist:

• In January 2005, DHSS imposed changes in Medicaid regulations that restricted access to medications through a variety of means: medication co-pays, a preferred drug list, step therapy ("fail first"), and prior authorization for clients with more than 15 medications per month. The state's House of Representatives recognized the adverse impact on individuals needing psychiatric medications and unanimously passed a bill to ease some of the restrictions, but the bill stalled in the Senate. In response to the legislative pressure, DHSS announced minor changes in the regulations - but the overall result still has been reduced access.
• Individuals in psychiatric crisis are routinely transported in handcuffs by police, rather than bymedical staff in ambulances. The result is additional trauma and unnecessary stigmatization, as well as increased pressures on already-overburdened law enforcement resources. Advocates have raised the issue before the legislature.
• According to advocates, DSAMH is seeking to narrow the state's involuntary commitment law, making it one of the most restrictive in the nation. One of its effects would be to keep those people in most desperate need of treatment out of the public system.
• A federal appeals court has upheld rulings in favor of a former DPC psychiatrist who lost his job after speaking out about problems at the hospital. The court found that the leadership of DSAMH "acted at least recklessly or callously, if not intentionally or maliciously" by not renewing the psychiatrist's contract after he wrote a series of memos in 2000 citing patient safety concerns, staffing shortages, and overcrowding of the hospital.

On the positive side, Delaware has moved to implement an evidence-based, integrated treatment model for co-occurring mental illness and substance abuse. There currently are 22 such programs across the state. 

Housing is an area of strength. The state provides consumers with a continuum of options. DSAMH supports a variety of group homes, supervised apartments, and rental subsidy programs. For ten years, NAMI Delaware also has provided housing using HUD Section 811 funds. 

Nonetheless, the maintenance of stable housing for consumers relies on community support services - one more reason for DSAMH to evaluate closely the switch from CTT to CCCP. Analysis needs to include effects on housing status to ensure that people do not fall through the cracks. 

A significant development is a growing partnership between law enforcement and mental health advocates. The Delaware State Troopers and New Castle County are moving to increase training about mental illnesses. The State Troopers have developed a Crisis Intervention Team (CIT), and the county recently passed a resolution encouraging the police departments to explore implementing CIT.

To continue the trend, NAMI encourages the state to review mental health services for inmates at the state prison to ensure that adequate, humane treatment is provided.

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