Grading the States 2006: Kentucky - Narrative
Fifteen years ago, Kentucky had the potential for developing one of the best mental healthcare systems in the nation - and a reputation for innovation. Unfortunately, its promise never was fulfilled, due largely to the lack of adequate resources. The public community mental health system has been flat funded for more than a dozen years, leaving Kentucky in the bottom quartile of states in per capita mental health funding.
Significant, recent innovations have come in the area of criminal justice, but only after outstanding investigative reporting by the Courier-Journal in 2002 exposed the plight of people with serious mental illnesses locked in jails.
Economics may be one reason. Kentucky has one of the highest percentages of people living below the poverty level. Eastern Kentucky in particular is one of the poorest regions of any in the United States.
Medicaid is by far the largest payer of public mental health services in Kentucky. The Federal Center for Medicaid and Medicare Services recently approved a plan to restructure Medicaid in the state. Known as Kentucky HealthChoices, the stated intent of the plan is to contain costs while improving quality. However, as structured, the plan threatens to jeopardize access to care for many Medicaid recipients with serious mental illnesses because:
- The plan imposes a limit of four prescriptions per month. Although described as a "soft cap" which can be overridden by "medical necessity," the practical effect is to establish a barrier to needed medications for persons with the most severe mental illnesses - particularly those with multiple medical problems; and
- The plan imposes co-pay requirements on Medicaid recipients for non-emergency care in emergency rooms. While NAMI appreciates the need to decrease the burden on hospital emergency departments, shortages of appropriate community treatment and service options - plus sharp limitations in the number of physicians willing to accept Medicaid - often leave people with serious mental illnesses no choice but to turn to emergency rooms for care.
Access and quality of public mental health services vary across Kentucky. There are 14 designated mental health regions in the state. In 2005, only two regions reported having Assertive Community Treatment (ACT) teams, with a third working to develop one. The Kentucky Department of Mental Health and Mental Retardation Services (DMHMRS) acknowledges that these programs do not meet national standards. Nor does it appear that the department is exerting leadership to achieve these standards.
To its credit, DMHMRS has provided regional centers with funds for emergency services, mobile crisis services, residential crisis stabilization units, and overnight crisis beds; however, these services are effective at best only for short-term emergencies, rather than long-term treatment needs. Moreover, funding levels for emergency services in some regions have not been raised since 1996, and these services are particularly in short supply in the more populated regions of the state.
Implementation also lags statewide for integrated treatment for mental illness and substance abuse, another key evidence-based practice. Efforts in this area arehampered by lack of Medicaid funding for adults with substance abuse disorders, other than for pregnant women.
A shortage of inpatient beds is also a serious and growing problem. Since 1995, non-forensic state hospital beds have eroded steadily. Convergence with inadequate community services and the loss of psychiatric beds in community hospitals has increased the burdens on other sectors in responding to acute psychiatric crises - such as law enforcement and emergency rooms.
Following a Courier-Journal investigative series in 2002, the legislature appropriated $550,000 to DMHMRS to develop and implement statewide training on mental illness and suicide prevention. In 2004, the legislature passed a law mandating a statewide telephonic triage system to screen jail inmates for mental, cognitive, or substance abuse disorders - and to provide linkages to treatment. The system is funded by court costs.
In Louisville, a highly effective police Crisis Intervention Team (CIT) program and a federally funded mental health court have successfully diverted people with serious mental illnesses into treatment rather than jail. Another CIT program is located in Frankfort; others are planned in other parts of the state. NAMI has played a key role in developing these CIT programs in communities across the Commonwealth.
Governor Ernie Fletcher today deserves praise for his decision in late 2005 to allocate $5 million over two years for housing for people with serious mental illnesses who are homeless or at risk of homelessness. The Governor's intervention is timely. Housing resources throughout the state are scarce, and waiting lists for Section 8 housing vouchers are years-long in some parts of the state. However, limited funding for community mental health services, plus potential restrictions on access to treatment through the new Medicaid restructuring initiative, threaten to undermine this progress.
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