Grading the States 2006: Georgia - Narrative
The mental health system in Georgia is a work in progress. Several initiatives have been started that are national models of excellence. However, although many providers have moved towards evidence-based services, they are are hard to establish and even harder to maintain with shortages of adequate funding. Additionally, possible Medicaid changes in the works cloud the horizon.
As home to the Carter Center in Atlanta, which has a special focus on mental health, and former U.S. Surgeon General David Satcher at the Morehouse School of Medicine - who was responsible for the landmark Surgeon General's Report on Mental Health in 1999 - the state is an important link in the national movement to transform the nation's mental healthcare system.
In 1998, the U.S. Supreme Court decision in Olmstead v. L.C. focused national attention on the fact that Georgia, as much as any state, continued to concentrate resources for people with serious mental illnesses and other disabilities in institutionally based care. The Court's ruling that people with disabilities have a right under the Americans with Disabilities Act to services in settings most appropriate to their needs has been the direct catalyst for a slow transition in Georgia to a system with greater emphasis on community-based care.
This transition has been hampered by cuts in general mental health funding, resulting in increased reliance on Medicaid as a predominant funding source for people with serious mental illnesses.
Georgia has reorganized its system into seven regions that correspond with seven state psychiatric hospitals - the theory being that it will facilitate seamless transitions between inpatient and community-based care. The state also has amended its Medicaid plan to allow for flexible funding of evidence-based services such as Assertive Community Treatment (ACT) and integrated treatment for co-occurring mental illness and substance abuse. The state is in the process of implementing a voluntary disease management initiative for Medicaid recipients with specific medical conditions, including schizophrenia, with the intention of both saving dollars and improving care.
The results from these steps - positive or negative - are not yet known. In the meantime, shortages of community services remain a problem. ACT and long-term care options in the community, such as supported housing, are essential for the transition to a community-based system. In building the community system, the state needs to learn from the painful lessons of other states, approaching the transition from institutional care carefully—and reinvesting savings on a dollar-for-dollar basis. Adequate numbers of inpatient beds, community residential treatment programs, and crisis intervention services must be maintained to address acute and long-term care needs.
In January, 2006, Georgia Governor Sonny Perdue announced that he had decided to postpone implementing proposed Medicaid reforms until 2007 and that when those reforms are implemented, they will not be as far-reaching as previously anticipated. The Governor should be applauded for this wise decision. However, advocates must remain vigilant to ensure that changes that are ultimately implemented do not further impede access to services for people with serious mental illnesses.
Multiple restrictions on access to medications for Medicaid recipients with serious mental illnesses are already in place in Georgia. These changes include prior authorization for non-preferred medications and a limit of five prescriptions per month for adult Medicaid recipients, unless a physician rules them "medically necessary."
Restrictions of this kind are misguided. Limiting access to medications for people with serious mental illnesses can lead to significant increases in other costs such as hospitalizations and incarceration in correctional facilities. They ignore several unique concerns involving psychiatric medications, including the length of time often needed for them to take effect, and the degree to which individualized side effects are part of the equation.
The state has done little to achieve greater efficiencies for Medicaid prescriptions through less onerous means such as physician feedback and education programs, which have been effective elsewhere.
In moving to build its overall system, Georgia has invested significantly in Integrated Dual Disorder Treatment (IDDT) and other services for individuals with co-occurring disorders. The state has 35 integrated treatment programs and has contracted with national experts to provide training to providers statewide. One interesting initiative is "Double Trouble in Recovery," a 12-step self-help program based in part on the Alcoholics Anonymous (AA) model, while recognizing the importance of continuing psychiatric medication as part of a treatment program.
Georgia was the first state to provide reimbursement under Medicaid for Certified Peer Specialists who work with consumers. The federal government has contracted with the state to develop a "toolkit" based on the program to disseminate throughout the nation as a best practice.
The Georgia Bureau of Investigation and NAMI Georgia are collaborating on a statewide police Crisis Intervention Team (CIT) initiative that includes auniform training curriculum approved by the Georgia Peace Officers and Training (POST) Council and co-sponsored by the Georgia Division of Mental Health, Developmental Disabilities, and Addictive Disorders (MHDDAD). Numerous counties throughout the state have hosted the training, and some have taken the next step by designating CIT officers to respond to people with serious mental illnesses in crisis. Other jail diversion initiatives have been implemented in five Georgia counties.
The state is attempting to address the significant challenges of providing services to people with serious mental illnesses in its numerous rural counties througha variety of outreach efforts. Particularly noteworthy is the Department of Human Resource's Unified Transportation System - targeted specifically for rural regions. The system provided transportation to appointments for mental health treatment and services to approximately 5,000 mental health consumers in FY 2004.
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