Grading the States 2006: Washington, DC - Narrative

Washington, D.C.'s current level of achievement in mental healthcare is the result of court-ordered changes that are being dictated to the system. The real test comes when the District has to proceed on its own.

It is too early to tell when - or whether - the District will live up to the high standards set by the court. It is important for advocates to monitor the changes and continue pressing for reform.

The key to understanding the District's system is the 1974 court case Dixon, et al. v. Williams. In that case, a group of individuals civilly committed to the city'ssole public hospital, St. Elizabeth's, sought community services as alternatives to hospital treatment. As a result of the case, the federal and District governments in 1980 agreed to a consent order and implementation plan to ensure that treatment occurred in the least restrictive setting possible.

Throughout the 1980s and 1990s, the court maintained close oversight of the mental health system. After the District repeatedly failed to meet its court-ordered obligations, a court-ordered Receiver was appointed in 1997 to oversee the system and ensure the development of community services in compliance with the Dixon case rulings. 

In 2001, the city reached a major milestone with the adoption of a Transitional Receiver's Court-Ordered Plan (the Plan) that is intended to be the blueprintfor eventual resolution of the Dixon case. The plan established specific "exit criteria" that must be met in order to close the case.

Nearly all aspects of D.C.'s current system - even the establishment and structure of the city's Department of Mental Health (DMH) - are tied directly to the 2001 Plan. DMH has three, separate court-ordered mandates: to act as the mental health authority; to provide services, through the D.C. Core Service Agency (CSA); and to oversee the city's sole public hospital, St. Elizabeth's. In addition to acting as a service provider through the CSA, DMH also administers contracts with a variety of other service agencies across the city.

Community services are delivered primarily through an entity called the Mental Health Rehabilitation Services (MHRS) system. The Dixon case and the 2001 Plan placed great emphasis on leveraging as muchfunding as possible from Medicaid using the Medicaid Rehabilitation Option (MRO). By tying services to Medicaid reimbursement, the DMH reports that it has created increased consistency across providers, while allowing the information to be more closely tracked by the city. However, the court monitor has noted that the city "does not appear to have a credible process in place to ensure that data collection is consistent and reliable" to measure progress toward exit criteria.

The District acknowledges that "DMH has not yet matured as a service delivery system" after undergoing such a "major paradigm shift." As DMH transforms from "largely an office- and clinic-based system" to one in which a "minimum of 50 percent" of services are delivered in non-office or -clinic settings, several barriers exist that slow the pace of reform.

• The court monitor has noted a need for stable leadership. Since October 2005, an interim director has been overseeing the department. In 2006, the incumbent mayor is stepping down.
• Construction of a new, consolidated hospital at St. Elizabeth's is over two years behind schedule, and assuming no further delays, the earliest occupancy date is in 2009. The court monitor recently expressed the "highest concern" for the hospital's clinical staffing, staff training and competence, and patient safety.
• A recent survey of 15 different DMH and provider programs revealed that approximately 60 percent of staff surveyed know little or nothing about principles of recovery.
• Over three years, $16.3 million in unpaid provider claims accumulated which resulted in a "a major crisis in cash flow for providers" in 2005. After an emergency hearing, the federal court ordered immediate payment of $8 million - which was accomplished in 48 hours. The City Council was expected to approve payment of the rest in February 2006.

DMH is required to serve all residents up to 200 percent of the poverty level, regardless of Medicaid eligibility. The cost of housing in the District is extremely high - it ranks second nationally. Monthly rent for a one-bedroom apartment is 185 percent of monthly Supplemental Security Income (SSI) payments. DMH has worked to create a continuum of housing subsidies and other options, and through its housing finance authority, the city is developing targeted affordable housing for persons with serious mental illnesses, but supply does not yet meet the overall need. Still, there is progress.

• Evidence-based practices are beginning to take root. The city has eight Assertive Community Treatment (ACT) teams - although advocates report that some fail to meet model standards.
• Six supported employment programs have been developed through partnership between DMH, Dartmouth University, and Johnson & Johnson.
• Integrated treatment for co-occurring disorders is being implemented, aided by a federal grant.
• The CSA offers a Multicultural Community Support Program to serve the city's large minority and ethnic population. DMH also has created a toll-free access helpline to immediately connect individuals in need with the city's service system.
• The city has a jail diversion program. Additional programs to decriminalize serious mental illness are being developed.
• A DMH Training Institute at Georgetown University was created under the Plan for continuing education of providers, consumers, families, and other system stakeholders.
• An Office of Multicultural Services was established by the DMH to reach out to the city's diverse population. Specifically, the DMH has developed action plans for Spanish/Latino, Asian and Pacific Islander, and other communities with limited English proficiency. To monitor implementation of these plans, DMH produces quarterly reports that address selected outcome indicators, such as translation of materials, workforce diversity, multicultural training, and outreach and community partnerships.

In the District, there is considerable distance - metaphorically speaking - between the White House and city hall. In this case, the District still has a long way to go to fulfill the vision of the President's New Freedom Commission. But it slowly is making progress.

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