NAMIGrading the States: A Report on America's Health Care System for Serious Mental Illness
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Grading the States 2006: Florida - Narrative

Florida is a big state with a big opportunity to advance its mental healthcare status. But access to services for Floridians living with mental illness has been an afterthought for too long. For the state to rightfully claim leadership in social services, it must demonstrate that leadership internally.

Today Florida is squarely in the spotlight as the nation watches efforts in Broward and Duval Counties to implement Governor Jeb Bush's Medicaid Reform Plan. Incorporating the concepts of personal responsibility and promoting healthy lifestyles, the reform offers risk-adjusted premiums that service recipients can use to purchase desired health plans from the community marketplace. 

The reforms become operational in two counties this year and are expected to be implemented statewide by 2010. Florida has a history of effective Medicaid growth containment: Florida Medicaid expenses grew at a considerably lower pace than the rates of growth experienced by private insurance plans in the early 2000s. But Florida's rather daring innovations put the state's most vulnerable citizens at risk, so the state must monitor the impact of this reform effort very closely to assure that innocent people do not get hurt.

For healthy populations, the reform project appears to be a reasonable experiment to control increasing Medicaid expenditures. However, the plan can put people who have disabilities at significant risk. Because plan designs are at the discretion of competing commercial providers, it is possible that recipients will face new restrictions on access to needed medications, increased co-sharing, and reduction in benefits from the current Medicaid program. There are other possible risks. With the current Florida Medicaid plan, in a given year a person who has a significant medical emergency, such as a psychiatric hospitalization, could exhaust the premium allotment with one or just a few visits. Their choice would then be either to go without care or to enter the system at a more expensive level of service. 

Florida's mental health system is organized and delivered primarily through 15 distinct districts. The state provides most of its money through Medicaid reimbursement. Counties have the option to invest additional resources to strengthen the community mental health system, and some counties, such as Orange, Broward, and Dade, have funded innovative programs and core supports this way. But funding is spread disproportionately across the districts, creating a barrier to the development of consistent systems of care.

The state could ease pressure on its Medicaid program and community mental health services if it would advance and sign a mental health parity bill. Florida is one of a handful of states that have yet to make this important public policy commitment.

Florida boasts several examples of strong evidence-based services. However, an analysis of the locations of the programs confirms that there is great variation in the quality and quantity of services among districts. The wide variation of available services suggests that the Department of Children and Family Services has not yet fulfilled its obligation to promote a statewide system of care that is consistent in quality and availability across the state. The Florida Assertive Community Treatment (FACT) program, for example, falls short of important standards, including the failure to include vocational rehabilitation among FACT's services.

In its response to NAMI's survey, Florida listed consumer/family involvement in advisory boards as a positive example of Florida's efforts to engage stakeholders. But in interviews for this report, stakeholders suggest great inconsistency in family/consumer involvement in advisory boards: Only 25 percent of the 32 boards include family/consumer representation.

When it comes to bed availability in Florida, there are pockets of excellence, but not consistent quality of care for consumers. Reflecting a disconnect between state leadership and service provision in the districts, the state Mental Health Planning Council fails to identify access to inpatient beds as a priority for the system. According to interviews, access to state-operated hospitals is heavily rationed, and county hospitals frequently discharge patients prematurely to avoid the cost of unsubsidized inpatient hospitalization. The chronic shortfall of beds is made more problematic by inadequate discharge planning, including the failure to provide direct connections to desperately needed supported services. As a result of this shortage, many discharged patients end up in the custody of law enforcement authorities, through minor criminal offenses or civil commitment proceedings. 

The Department of Justice recently closed an investigation of the G. Pierce Wood Memorial Hospital involving allegations of improper treatment and discharge planning. The complaint was closed without federal intervention, but it is indicative of the inpatient system of care within the state. The hospital closed recently, removing additional state-operated inpatient capacity - and placing more pressure on the counties and service districts.

From a statewide perspective, Florida has demonstrated leadership in the development of a comprehensive housing plan for persons with mental illness. Currently, through service districts and counties, Florida offers 62 supported housing programs throughout the state. Though this still is an inadequate number of units for the state's population, progress is evident. 

By necessity, the criminal justice community has become one of the most visible mental health advocacy constituencies in Florida. Criminal justice professionals have taken steps to address the pressures of untreated mental illness by establishing eight mental health courts and developing Crisis Intervention Team (CIT) models in 12 counties and numerous communities. However, the criminal justice/mental illness crisis remains severe. The Florida Department of Corrections currently houses almost 11,000 individuals receiving treatment for mental health disorders. Among women, 40 percent of those incarcerated require mental health treatment. The problem in county and municipal jails is more pressing: An estimated 23 percent of incarcerated individuals have a mental health condition.

In contrast to its overall lack of statewide coordination, the state deserves credit for initiatives to incorporate recovery and resiliency, and consumer and family involvement, into the culture of the state system of care. The state recently established a recovery and resiliency task force to help steer the state toward the introduction of recovery-based services. Florida has also recently established an office of consumer affairs and offered meaningful involvement for consumers in the development of the state system's transformation grant application.

Florida has demonstrated national leadership in its efforts to gain competitive employment for persons with mental illness. Nearly 20 percent of adults with severe persistent mental illness are employed in the state of Florida, significantly higher than the national average. 

Florida has made significant progress in aiding individuals with mental illnesses that collide with the criminal justice system, but the state's ambitious Medicaid reform program may contain risks for those with serious mental illnesses.

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