Grading the States 2006: Wyoming - Narrative
Perhaps one indicator reveals more about the state of mental health treatment in the state of Wyoming than any other: Wyoming's rate of suicide is the country's highest, nearly twice the national average. The state legislature and Department of Health have responded to this community black-eye by creating a suicide prevention task force, mandating a prevention plan, and working collaboratively with Wyoming communities to develop local solutions. The plan includes all the appropriate strategies for addressing the crisis; however, the state has yet to demonstrate the political will to provide the needed resources to address the plan's recommendations.
Mental health advocates won an important victory in this state in early 2006 when a settlement was reached between the state and Wyoming Protection and Advocacy, Inc. (WPA). The ruling allows WPA "unaccompanied access to the State Hospital without advance notice when there is reason to believe that abuse or neglect has occurred or might occur."
This most recent ruling comes on the heels of a 2002 agreement to end the Chris S. v. Jim Geringer case of 1995. The case was initiated due to poor conditions at the Wyoming State Hospital. As part of the exit agreement, the state of Wyoming was required to develop a comprehensive community-based system of care and improve the standard of care for inpatient care at the state hospital.
Mental health services in the state are provided through a network of community mental health centers. Fifteen centers provide services for the state's 23 counties. Though not ideal, this network is a credible attempt at statewide care for this predominantly frontier state. Acknowledging the challenges of running a community-based system of care in a state with a population density of 4.6 persons per square mile, the state has prioritized engagement of general practitioners and allied healthcare workers as an important need for the state mental health system.
One area where Wyoming is a national model is in that of balancing fiscal constraints in Medicaid spending without compromising quality of care for participants. Using disease management techniques for all state Medicaid participants, the approach successfully curbed program spending without taking action to alter eligibility standards or available benefits.
The state's Medicaid program has carved out behavioral health services and contracted with APS Healthcare to provide mental health case management. APS has elected to provide disease management services for people living with depression who receive services through the state Medicaid program. The state's Medicaid program has also acknowledged the importance of access to a full selection of psychotropic medications by stopping short of implementing preferred drug lists and prior authorization for mental health medications.
Interaction between people with mental illness and law enforcement deserves special scrutiny in the state of Wyoming. One in four prisoners in the Wyoming correctional system receives mental health therapy, one of only four states to demonstrate such a high level of penetration. And, as recently as 2001, the state offered no special psychiatric facilities within the correctional system. Conditions in the state correctional system were so severe that the United States Department of Justice (DOJ) initiated an investigation under the Civil Rights of Institutionalized Persons Act (CRIPA) that led to specific mandatory improvements in the mental health services within the Department of Corrections.
The state has made progress across the community system of care in developing services that, at the surface, appear to be evidence-based practices (EBPs). With the exception of Assertive Community Treatment (ACT), the local community mental health centers have created numerous supported employment programs and illness self-management programs. ACT exists in two locations, but the state acknowledges that the programs are merely "ACT-like" and states that ACT programs are "too difficult to staff in a frontier state."
The state is appropriately skeptical of its own success in implementing these EBPs, stating in a recent block grant that "we rather glibly apply names to some services we purchase or supply, but really have little experience at monitoring fidelity or measuring well-defined and targeted outcomes."
In the broader policy context, the state can make an important step forward by passing a mental health parity bill. Wyoming is one of two states nationally that has not even added a non-binding mandate to the state legislative codes. Passing parity would not only be a significant anti-stigma statement, but for a state with a very modest unemployment rate of 3.2 percent, parity could free up state resources for providing care to the most vulnerable populations.
Improvement for this state is possible. A mental health administrator in the state reported that the legislature was contemplating a 50 percent increase to community service agencies as part of its 2006-07 legislative session. According to the administrator, a select committee is driving this effort and will continue to do so until the system is "transformed." This is welcome news and, if it becomes reality, the state could be a rising star in future report card efforts.
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