Grading the States 2006
NAMI
The Nation's Voice on Mental Illness
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Grading the States 2006: Indiana - Narrative

Indiana is a state in transition.

The election of a new governor in 2004 led to a change in leadership in the state's Division of Mental Health and Addiction (DMHA). The state now has a new vision, seeking dramatic change in the public mental healthcare system. And given the system's failing grade in this report, a new vision for the future is sorely needed.

Advocates hope that the changes will be for the better, but are concerned about the scope and speed of changes being pursued, especially within the state's hospital system. Overly ambitious strategies have backfired in some states. Still, change is needed. In 2005 in response to NAMI's questionnaire, DMHA reported no innovations in the past three years. 

Perhaps the area slated to change most quickly is the state hospital system. DMHA plans to transfer three of the six state hospitals - Evansville, Madison, and Richmond - to local, non-profit entities. Some call the process "privatization." DMHA calls it "localization." No matter which word is used, the process is moving at great speed, with the first transfer to occur as early as summer of 2006.

The state insists the initiative is intended to enhance quality of care rather than manage costs, but the devil is in the details. In the past year, the superintendents of five of the state hospitals have been forced out. The most recent one to leave was quoted upon leaving as saying that shaking up the system should not mean sacrificing quality of care.

The state's Medicaid agency is also being closely scrutinized. That agency, along with the DMHA, is located within the state's Family and Social Services Administration (FSSA). After the 2004 election, FSSA Secretary Mitch Roob lambasted the agency in a press release, stating that even though Medicaid funds nearly one-third of the total mental health budget, the agency has "no accounting system and no systematic budgeting process."  An audit revealed a host of other problems. The state's Medicaid program also has no medical director or clinical oversight.

Waiting lists for community services are a problem. Sources at DMHA report that there typically are about 100 people waiting for services at any one time, but the information is hard to track, due to antiquated computer systems. The state Mental Health Planning Council has called on DMHA to obtain waiting list information from CMHCs, which is a logical first step. 

Yet, the state may be poised to turn a corner. Despite an unsuccessful application for a federal Transformation State Incentive Grant (TSIG), DMHA is moving forward to transform the system anyway. A Transformation Work Group is shepherding the process. It has defined several initiatives for immediate action:

  • changes in the state hospital system
  • better management of contract relationships with providers
  • better cross-agency collaborations
  • greater consumer and family participation
  • measurement of outcomes

It's an ambitious agenda. The state deserves credit for embarking on major transformation while working within a limited budget - so long as insufficient investment of resources doesn't prove its undoing. Consumer and family participation, and public transparency, also are essential for transformation to succeed.

One bright spot in the state's current system is Assertive Community Treatment (ACT). Since 2000, 26 teams have taken root with the assistance of the state-funded ACT Technical Assistance Center at Indiana University-Purdue University Indianapolis. The state has made ACT a Medicaid-reimbursable service, and tied provider reimbursement to model standards set by the Center. NAMI commends the practice; it also should be applied to other evidence-based practices.

Also noteworthy is NAMI Indiana's prison education program, supported by DMHA and the Department of Corrections. Trainers teach guards and staff at stateprisons about serious mental illnesses and prepare them for better interactions with inmates. Early indications show that the program has led to a significant reduction in the use of force against inmates at one prison. 

Collaboration between the DMHA, advocates, and the criminal justice system in the Fort Wayne area has also produced successful local programs. Overall, Ft. Wayne's commitment as a community and its services may be worth study - perhaps a case study - as a national model for successful community action.

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