[PRIORITIES & RECOMMENDATIONS FOR MENTAL HEALTH AND SUBSTANCE ABUSE SERVICES &

SUPPORTs]

2015 UPDATED VERSION

Submitted by: The Eastern Regional Mental Health Board, Northeast Communities Against Substance Abuse (NECASA), and the Southeastern Regional Action Council (SERAC)

2014

DMHAS Region 3

Note: for the 2015 Priorities Update, any relevant information can be found at the conclusion of each section in blue text.

The ERMHB utilized feedback gathered through our review & evaluation process, at focus groups, and from conversations with stakeholders. Appendices A & B also

summarize the feedback received in response to our online Priorities Survey and our “Service Barriers Report.” A variety of stakeholders, including provider management

and staff, consumers, and family members, participated in both processes.

I. INTRODUCTION Every two years, the Department of Mental Health and Addiction Services (DMHAS) Planning Division is required to carry out a statewide needs assessment and priority planning process in order to capture needs and trends on the local, regional, and statewide basis. Regional Mental Health Boards (RMHBs) and Regional Substance Abuse Action Councils (RACs) assist in this process by gathering local and regional data and perspectives. Information gleaned from this process is used to inform the DMHAS Mental Health Block Grant and DMHAS biennial budgeting process as well as the planning and priority setting process for each RMHB and RAC.

This report summarizes the findings of the 2014 DMHAS Region 3 biennial needs assessment and presents recommendations for improvement in mental health and addictions services for Eastern Connecticut. Region 3 includes 39 towns in Windham County, New London County, and Tolland County: Ashford, Bozrah, Brooklyn, Canterbury, Chaplin, Colchester, Columbia, Coventry, East Lyme, Eastford, Franklin, Griswold, Groton, Hampton, Killingly, Lebanon, Ledyard, Lisbon, Mansfield, Montville, New London, North Stonington, Norwich, Plainfield, Pomfret, Preston, Salem, Scotland, Sprague, Sterling, Stonington, Thompson, Union, Voluntown, Waterford, Willington, Windham, and Woodstock.

II. PROCESS For the first time in many years, the Eastern Regional Mental Health Board (ERMHB) worked in close collaboration with the Regional Action Councils in Eastern Connecticut throughout all stages of the 2014 DMHAS Priority Process. In past years, the Eastern Regional Mental Health Board conducted the process separately from the two RACs in the region, and there was little or no communication between the ERMHB and the RACs until the formal presentation to the Office of the Commissioner of DMHAS. With a vastly different process in place this year, along with the new leadership at the ERMHB, it made sense to emulate the collaboration between RMHBs and RACs that has traditionally existed in other regions.

Beginning in early 2014, the Executive Directors of the RMHBs and RACs met with DMHAS staff and members of the Adult Behavioral Health Planning Council to plan the 2014 DMHAS Priority Process. Discussion centered on how the RMHBs could implement a uniform needs assessment and priority planning process in 2014 that would identify strengths, needs, and issues across the service system.

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The Executive Directors of the Eastern Regional Mental Health Board, Northeast Communities Against Substance Abuse (NECASA), and the Southeastern Regional Action Council (SERAC) held two planning meetings in March and April of 2014 to determine how to gather information and data from throughout Eastern Connecticut. After holding a total of 7 focus groups throughout the region, the three Executive Directors met again in May 2014 to share and consolidate feedback from the various focus groups and to determine how to format the findings and recommendations gathered during this year’s process. It was immediately evident that all of the focus groups garnered very similar feedback, which will be reflected in this report’s recommendations.

Regional Surveys The DMHAS Office of Evaluation, Quality Management & Improvement developed a web-based survey to capture the perspectives of DMHAS-funded and operated mental health and addiction providers regarding access and barriers to mental health and addiction services. Surveys were sent online to the chief administrators of mental health and/or substance abuse service providers throughout Connecticut. Surveys were completed by 10 of the 20 DMHAS- funded providers in Region 3.

Providers were asked to respond to the following questions (See Appendix C for a summary of their responses):

How could the Regional Action Councils (RACs) and/or the Regional Mental Health Boards (RMHBs) collaborate with your agency to improve the service system?

What do you identify as the greatest strengths of the mental health and/or substance abuse service system?

Where does the system have insufficient services or barriers to meeting service system demands?

If you were in charge of the DMHAS service system, what would you change to improve it?

A number of comments made by provider representatives with regard to the RMHBs made it clear that there is a great deal of confusion in Region 3 regarding the role of the RMHBs in the state-funded system. This situation is largely due to the fact that in recent years, relationships with Region 3 providers and towns have not received enough attention, and our membership has been at an all-time low. Please see Appendix A for more detail on this subject, and Appendix B for the statutory language governing RMHB membership. Revitalizing these crucial relationships is a top priority for the Eastern Regional Mental Health Board, and since the transition to the new Executive Director took place, structured and persistent outreach to the region’s provider organizations and Town CEOs , including face-to-face meetings and special presentations, has been conducted . In addition, the new Executive Director is working more closely with the RACs in Region 3, and has conducted the first program site visits in several years.

Focus Groups

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A total of seven focus groups were held throughout Region 3. Participants included community members, people in recovery, family members, community organizations, and providers of mental health services, with a total of approximate 90 participants.

Participants were asked to respond to the following questions based on their own direct experience or perceived experience of people in their sphere of influence:

1. What are the biggest challenges facing those in your community with substance abuse and/or mental health problems in your community?

2. Are people willing to talk about their substance use and/or mental health problems? Why or why not?

3. How can the community best support its members with mental health and substance abuse problems, especially those at risk of winding up in the prison system?

4. What are the strengths and weaknesses of your community with respect to caring for people with mental health and/or substance abuse problems?

5. If you, or someone you know, had a substance use and/or mental health problem, would you know what resources were available and how to access them?

6. Has the Sandy Hook school shooting and the resulting media coverage changed how you feel, think, or act with respect to mental health issues in your community?

7. What kind of impact have you seen in your community as a result of healthcare reform (otherwise known as the Affordable Care Act or Obama Care)?

8. If you were responsible for mental health and substance abuse services in your community, what kind of changes would you make?

9. How are mental health, substance abuse, and medical problems intertwined in your community?

Evaluations Throughout 2013-14, the ERMHB participated in CSP/RP reviews at four state-operated or state-funded providers within Region 3, conducted site reviews at three Outpatient Clinical Programs in the region, and facilitated numerous discussions at Catchment Area Council meetings regarding barriers and/or unmet needs as perceived by those receiving services or provider staff. In addition, meetings with Region 3 clubhouses and Town CEOs elicited information that has been included in this report.

III. PRIORITIES & RECOMMENDATIONS FOR BEHAVIORAL HEALTH AND SUBSTANCE USE SERVICES

Many of issues and recommendations identified below are not intended to be addressed solely by DMHAS. As the Eastern Regional Mental Health Board works to re-establish and strengthen relationships within the region, we intend to partner closely with DMHAS, the RACs, Region 3 towns, institutions of higher learning, provider agencies, and other community organizations, as well as at the grassroots level with people in recovery, family members, and concerned citizens to address many of the concerns identified. We fully expect that these issues will be central to the work of our Catchment Area Councils during the next biennium.

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It is important to note that a number of strengths in the current system were identified during the focus groups, including:

Town substance use prevention coalitions Church and community centers offer safe places for teens & young adults The Regional Board structure is grassroots style; integrates local voices & gives the

ordinary citizen to change the system. The Catchment Area Council (CAC) meetings provide a huge level of support for members and local citizens.

The clubhouses and social programs provide great support for independence and strength

The Southeastern Mental Health Authority (SMHA) network of providers is highly collaborative and connected.

The community college model offers an open door policy on counseling and seeking help

A. PUBLIC EDUCATION General PublicThere was unanimous agreement among all focus groups regarding the pressing need for more general public education about substance use issues, including problem substances, risk factors, warning signs, etc. Participants voiced significant concern about the growing problems with heroin addiction and overdose in the community, and several mayors and first selectmen within Region 3 have specifically identified this as a top concern within their towns.

It is also difficult for most people to know where to begin when mental health services are needed. Most people in the focus groups admitted that they would not know where to tell someone to start if asked for help. This included employees from the publicly funded mental health service system, who stated that given the entirely separate nature of privately funded services, they feel unprepared to assist friend and family members in need. Most people in the general community don’t understand how to identify warning signs of behavioral health problems, and find the huge array of available medications and services confusing. Those who understand that publicly funded services include a variety of wrap around services and supports resent that the same options aren’t available to those with private insurance.

Changes under the Affordable Care Act (ACA)During our focus groups, it became evident that a great deal of confusion still exists, even among mental health professionals, regarding the impact of the Affordable Care Act (ACA). The conflicting, and sometimes erroneous, stories in the media exacerbate the problem. Management level staff for Region 3 providers say they need training and resources on structure and implementation for Behavioral Health Homes and the State Innovation Model (SIM). And with regard to billing, they are aware that their documentation needs to meet certain standards in order to maximize their billing potential and meet their costs, but say they need more information on how to document properly, i.e., a “representative note”.

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Many in the general public don’t understand that the ACA and “Obamacare” are the same thing. People without access to computers or internet, or who lack basic computer skills, are at a disadvantage. We are also hearing that despite enactment of mental health parity, many insurance policies are still not offering proper levels of coverage.

Although on an individual level, people that couldn’t qualify for insurance previously (some people who went without care for chronic conditions) are now able to get coverage, municipal officials say the cost of health insurance for employees is now higher. In addition, small nonprofits have such limited resources due to flat funding, that as operating costs rise each year, their ability to assist employees with health insurance becomes more restricted each year. They believe that there has been some cost containment recently, but one provider in Region 3 for example experienced nearly $50,000 in health insurance cost increases over two years.

ProfessionalsPrimary care physicians and school professionals are quite often the starting point for those seeking help, but these professionals often have only rudimentary knowledge of the community resources and referral options available for the people they serve. As a result, people who desperately want help for themselves or for loved ones, mistakenly believe that no help is available, leading to delayed diagnosis and treatment, and often worsened outcomes that are often complicated by problems in school or at work, substance use problems, involvement with the criminal justice system,

A number of clubhouse members who participated in the focus groups also said that even their own providers don’t tell them about all available treatment options, including non-pharmaceutical supports, nor are they informed of the full array of possible side effects of the medications they use. As one consumer member stated, “We can’t advocate for our needs if we don’t know our options.

We recommend the following approaches: Provide more community education at local levels to promote better understanding

of mental illness and available resources. The Community Conversations model has proven effective in other regions, and we would like to pursue this possibility in our communities.

Education & awareness campaigns, including Mental Health First Aid trainings, targeted at primary care providers and school professionals, will aid in early recognition of problems, promoting early intervention that will hopefully minimize the damage to a person’s relationships and prospects in life. RMHB and RAC staff in Region 3 have the training and expertise to offer this kind of outreach, but funding issues, along with resistance to discussing mental health issues in school settings make progress slow.

Utilize more family-based therapies and approaches, including family psycho-education, to ensure that families understand diagnoses, treatments, and helpful responses to a family member living with a substance use or mental health problems.

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Many focus group members favor approaches to community education that don’t talk about “stigma”, but rather consider mental wellness as just a part of overall wellness.

2015 Update:SERAC trained 125 school/community professional in Mental Health First Aid in the last year, over 100 in QPR and 150 in Current Drug Trends. The agency continues to offer these trainings and others to Community, School professional that work with young kids or those at risk. They also address stigma. We have worked very hard to address stigma especially with our first responders and police when talking with them in one-on-one meetings.

NECASA, working with DCF and the State Police trained the Killingly School system and the Brooklyn School system in Dug Endangered Children’s issues. Also, the Governor’s Bill on Prescription Drug Abuse mandates training for physicians that prescribe opioids. This bill was signed in July 2015.

The Eastern Regional Mental Health Board and DMHAS-funded mental health providers are working to increase community awareness about mental health issues in a variety of ways.

Efforts to promote Mental Health First Aid training through the ERMHB continue; however, we are having less success than last year. Many agencies and individuals have expressed strong interest in the material presented, but find the time commitment too onerous. Employers are often unwilling to release staff for a full day, and those who are taking the training on their own free time are not willing to give up 8 hours. Our inability to offer the training for free creates an additional barrier to scheduling trainings. We need a training model that requires a shorter investment of time, and which the ERMHB can offer to the public for free. One Norwich provider offered a free 2-hour training to employees at the Otis Library, and is considering making this available on a broader scope, due to the excellent feedback they received. Its value was that it was highly tailored to the specific needs of those working in a downtown library setting, offering critical community connections, along with valuable de-escalation and crisis intervention techniques for non-clinicians.

We have received feedback that community education efforts in the region appear to have strengthened over the past year. We attribute this partly to the ERMHB’s strengthened use of social media, our hugely successful Candidate Forums last fall, our Legislative Breakfasts earlier this year and our 40th Anniversary Celebration in June, all of which were extremely well-attended by candidates and legislators, and garnered excellent media coverage.

Additionally, as part of the ERMHB’s Annual Library Project, which takes place each May in honor of Mental Health Month, we sent informational packets to 37 libraries in Eastern Connecticut, providing general information about mental health issues and about the grassroots activities of the ERMHB, along with Resource Brochures offering

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contact information for mental health and addictions services and a full range of non-clinical services in the 39 towns of Region 3. We provided this information to town officials and legislators, and have received a great deal of positive feedback, along with requests for more of the brochures.

ERMHB plans for late summer and fall include the beginning of filming on a video project that will tell the stories of individuals with mental health issues who are dealing with transportation barriers as they work on recovery, self-sufficiency and community integration. These videos will “put a face” on the problem, and be used to inform the general public about the increased costs to society when appropriate and accessible transportation options are not available to everyone, and to build grassroots advocacy efforts to address the problem.

The ERMHB also will begin recording formal interviews shortly, in connection with our Norwich State Hospital Oral History Project. These important first person accounts will help to preserve important stories that might otherwise be lost, as well as an important period in the history of mental health care in our state.

B. STIGMA, DISCRIMINATION & SHAME Focus group members identified the issue of “stigma & discrimination” as a top concern, as has consistently been the case in past Priorities and Planning processes. Mental illness and substance abuse continue to carry major stigma (defined as “a mark of disgrace associated with a particular circumstance, quality, or person.”) leading to discrimination (defined as “the unjust or prejudicial treatment of different categories of people or things.”) against those identified as members of these “groups”.

Fear of being singled out for discriminatory and disrespectful behavior is seen by many participants in our focus groups as one of the most significant barriers to getting help for mental health and substance use issues. Even family/friends/community members who want to help those with behavioral health issues encounter stigmatizing and discriminatory attitudes by association. Because so many in the community have misconceptions about mental illness and substance use in general, and because of the continued belief in the connection of mental illness to violence, all too many individuals delay seeking help, sometimes not seeking it at all, and fear disclosing their diagnoses to the people that would be naturally supportive with a diagnosis of cancer, diabetes, or heart disease.

Another common theme was discrimination by providers towards those with mental health and/or substance use issues. Many report that when a provider or Emergency Department staff become aware of their mental health or substance use issue their physical complaints are taken less seriously or even ignored, leading to needless suffering or even dangerous consequences. In addition, some clients continue to report when they express concerns to their psychiatrists about medication side effects, their preferences are not taken into account. It is clear that these individuals don’t understand their right to be informed of the full array of choices, along with the pros and cons of each. They often feel intimidated into remaining silent because “the doctor knows more than I do.”

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In addition, with mental illness and substance use issues, it is much more difficult to get time off from work or school to seek necessary treatment, because of the risks of disclosure to an employer or school official.

Some focus group members stated that a substance use disorder carries more stigma than a mental health problem, while others said substance abuse issues seem to be more readily accepted than mental illnesses. Some said that this is because different substances generate different responses

People say they are ashamed, and that it is embarrassing to talk about their substance use problems

When an illness is disclosed some people are surprised or taken aback because it doesn’t “look” like they had thought it would

Some consumers in the focus groups said they believe that disclosure is a matter of convenience for some individuals; if it validates/justifies their behavior then they will share they have a problem; if not they won’t. Those individuals feel that this hurts those who are trying to improve their lives

The perception of shame also varies among peer groups; younger populations may be more comfortable sharing and seeking help because the pressures of life increase with age

As a result of the tragedy at Sandy Hook, focus group members said that while there is more awareness regarding mental health issues in our local communities, people don’t necessarily feel that this is a positive development. The perceptions of mental illness and of people who have mental illnesses are worse overall, people said. People are more afraid of bad things happening in general than before, and there is an assumption that mental illness is a cause of mass violence. Also, the linking of gun policy and mental health policy seems to be ever-present in any discussion; the discussion has been “co-opted” by the gun control argument. This dynamic ensures that the real underlying issue—grossly inadequate services for children and adults—will ever be effectively addressed. Mental illness seems to have become a scapegoat for issues that are larger societal and cultural problems.

Some people feel that the overwhelming media coverage of recent episodes of mass violence provides a degree of sensationalism that use to get attention when they are marginalized or dismissed by society.

It is also widely believed that Adam Lanza’s problems were common knowledge, and yet nobody took action. This seems to highlight a general tendency to isolate those who don’t fit in, and not to get involved in the problems of others.

Some town officials believe confidentiality laws are used as a way to keep necessary information from them and from the general public, and that the laws are too restrictive. One town CEO shared concerns about signing off on gun permits, when he “knows there are problems in the family”.

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We recommend the following approaches: Across the board trainings for providers and clients regarding informed consent

laws. The Connecticut Legal Rights Project has expressed a willingness to support such an activity to some degree.

Provide opportunities for people to talk about issues—i.e. Community Conversations, focus groups, Mental Health First Aid

Teaching caring and compassion towards those who are “different” from a very young age, so that children will not be isolated or bullied to the point of rage.

This feedback suggests the need for more community education of town officials, including Mental Health First Aid, due to the obvious confusion about the rights of those living with mental illnesses, what constitutes an actual diagnosable mental illness, the possibility for recovery with the right supports.

RMHBs/RACs should conduct outreach/education (including Mental Health First Aid trainings) and share resource & referral information with Primary Care Physicians (PCPs), pediatricians, schools/school-based clinics, town halls, and senior centers.

Improved collaboration with RACs at regional level Regional level coordination of all community education/anti-stigma efforts by

providers and advocacy agencies to ensure consistent messaging to public and avoid unnecessary duplication.

Stop using the word “stigma”, because it reinforces prejudice and discriminatory treatment of those with mental illnesses.

2015 Update:SERAC members sit on the local hospital Opioid Task Force, Backus (Hartford Hospital). Members of the group are discussing and working to improve follow-up care for those that come in from an opioid/heroin overdose. There has been an increase in repeat cases of overdose patients.

A Drug Trends Training that includes conversations about reducing stigma has been presented for Backus Hospital and American Ambulance. Attendance: 55 Total with more scheduled in the future.

The ERMHB finds that general attitudes toward those with mental health problems has not changed, even understanding about mental health issues in general has improved. Consumers continue to report discriminatory treatment by health professionals, including in the Emergency Departments. Physical complaints tend to be ignored or trivialized once professionals learn there is a psychiatric diagnosis.

C. TRANSPORTATION Region 3 is unique in that it is the largest geographically, yet possibly the most sparsely populated. Individuals lacking their own vehicles and living in small towns and rural areas continue to encounter barriers in accessing both basic needs and appropriate services, which limits overall potential for self-sufficiency (e.g., shopping, appointments, employment and education, housing). Public transportation is usually a poor choice for those needed to get to appointment, given the length of time needed to get to a destination and the lack of bus routes

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and available times. In addition, a number of individuals who participated in the focus group experience such severe anxiety about navigating public transit that they are unable to do so. We heard at one provider meeting that the primary cause of no-shows is transportation problems.

Although those on Medicaid have access to Med-cab services for medically necessary services, they encounter an array of barriers through the contracted providers, particularly Logisticare:

Numerous reports of rude treatment by Logisticare staff Consumers say they are required to call numerous times to confirm their rides, yet rides

are still more often than not late, or don’t show at all, leading to penalties from providers who have strict appointment attendance policies (one provider won’t see clients who are 5 minutes late.)

Logisticare does not offer services outside regular business hours, which is problematic for those whose primary care providers or psychiatrists want them to get specialized services like sleep studies.

We recommend the following approaches: Enforcement of contracts with med-cab providers. DMHAS assistance in promoting

contracts with med cab providers that treat consumers with respect. Duplication of Reliance House model that allows clients to purchase inexpensive “punch

cards” for a specified number of rides that can be used to meet any of their needs. Encourage substance abuse and mental health providers to share existing

transportation resources to support all clients of state funded providers. Provide supports and resources to support client-owned and operated “limousine”

services. One provider said that it would be helpful to have a “mobility coordinator” position

within each agency to alleviate transportation issues that are barrier to engagement in services.

2015 Update:Lack of accessible, affordable or appropriate transportation options in Eastern Connecticut continues to be the most significant barrier to effective treatment, appropriate services, and community integration for those with mental health problems. Although SEAT has added several bus routes in Southeastern Connecticut, a significant number of individuals continue to spend 2-3 hours commuting to work, school, shopping or appointments. The lack of frequency and number in routes means that an entire day is spent on one errand or appointment, and that many people are unable to accept viable jobs in a region where a significant number of the jobs are outside the normal 9am-5pm work week.

Although clients in the Northeast report that a new med-cab provider in the Putnam area has been helpful, complaints about Logisticare in general have worsened—late pick-ups and no-shows leading to missed appointments and delays in vital services. We have heard stories of individuals being dropped off hours before a provider’s doors are open,

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twice in the extreme cold. Provider staff in our region report having had to stay with clients after closing time to ensure safe pick-up by medcab. These types of issues lead to unbillable time for providers, and prevent individuals from being able to access behavioral, primary and specialized health care services that they desperately need in a timely manner, placing their health, and possibly their lives, in danger. One individual who uses an electric wheelchair, and cannot get to her appointments without a special wheelchair accessible van has reported cancellation of her rides on the morning of critical medical appointments by Logisticare multiple times within the last couple of months. Logisticare personnel continue to lack awareness of how to interact with those who have mental health issues and may be in crisis.

Med-cab policies force clients to change therapists if they move and another provider is closer in distance. These types of policies interrupt successful therapeutic relationships, damaging trust and recovery in ways that could end of costing more than providing rides for slightly longer trips.

These are issues of respect, overall wellness, and safety; and we urge DMHAS to put pressure on DSS to enforce respectful treatment and adherence to the med-cab contract.

D. SPECIAL POPULATIONS Seniors/Elderly PeopleAn increasing number of elderly individuals have substance use problems, often co-occurring with behavioral health issues, dementia and serious physical health problems, but according to those in our region who work with seniors, there is a serious lack of appropriate geriatric services. Often these individuals are physically unable to remain in their homes, but facilities won’t take them because of the behavioral health issue. In addition, many seniors still have high level of discomfort discussing and/or accepting the possibility of a mental health issue.

We recommend the following: Membership in DMHAS’ workgroup on the elderly for all RMHBs and RACs, as they are

in a unique position to understand specific challenges in their regions, and to perform outreach to the elderly community.

Enhanced training in mental health issues and resources, crisis intervention, and motivational interviewing for staff who work with the elderly.

2015 Update:SERAC has done work around Problem Gambling among seniors this past year. So we have made inroads with many of the senior social groups. In our discussions, mental health came up a lot. It showed the need for more discussions among this group. The trick is going to be how to reach them because of the “lack of trust” to anyone not in their group or approved organizations.

Clinicians report to the ERMHB that they struggle with assessing and serving the elderly, who often need neurological testing, and may be experiencing dementia that

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makes it impossible for them to engage in Cognitive Behavioral Therapy. Region 3 lacks referrals for geriatric specialists.

Adolescents/Young AdultsWe are including feedback about children & adolescents because, all too often, these individuals don’t get the appropriate help during childhood, and as a result, have mental health and substance use problems that continue into adulthood, limiting potential, independence and wellness.

For young adults experiencing first episode of mental illness and their families, understanding of behavioral health issues limited and access to services difficult.

Schools and town social workers say there are limited referral options for youth and adults, especially those with Medicaid or Husky D

Schools have too many unfunded mandates and are overwhelmed and unable to address behavioral health issues.

Lack of accessible providers (therapists, psychiatrists—esp. for kids) in local communities. There was anecdotal information about good experiences with great therapists for kids, but people had to have the ability to travel and pay.

School officials say that parents are often part of the problem; they often don’t support schools in disciplinary issues and policies. At the same time, they say, communities lack commitment to supporting parents in raising their kids

School guidance needs to play a larger role and be better educated about issues & treatments, as well as referral sources.

A gap in care exists when a young adult becomes legally responsible for his/her own care at 18; many are not mature enough to take over from the parents. Not enough is done to prepare for the transition to adulthood, and when the young adult lacks basic life skills or the ability to manage his/her own care, parents/families are left feeling helpless.

Many problems begin during college, and due to confidentiality, parents aren't informed about serious problems that are emerging at school.

Some schools don't accept students with mental health issues; parents must pay for expensive alternatives

As a result of the tragedy at Sandy Hook, town social services personnel say that asking asking youth about homicidal and suicidal ideation has become more of a standard practice. In addition, referrals have increased for children who are quiet or isolated, when before they might have slipped through the cracks.

We recommend the following: More outreach to pediatricians, high schools, colleges and universities, and the

general community to promote early identification and intervention with young adults experiencing a first episode of mental illness. These groups should be included in outreach for Mental Health First Aid Trainings and membership in the RMHBs.

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Provide safe places for kids to seek help when they aren't able/willing to talk with their parents

Improvements in family supports offered by school guidance departments School guidance professionals need to be more involved and better educated,

especially with regard to behavioral health diagnoses, warning signs, treatments, and local resources. They need to provide non-judgmental supports for the entire family

Keeping parents in the loop could help to avert serious crises. Better access to the appropriate educational programs for children with mental

health issues.

Adolescents:The areas of concern still exist on treatment and not enough resources for this age group. Parent involvement is slowly being discussed and address in our town’s coalitions meetings. A resource booklet is at the beginning stages of being created for parents that may

need local mental health, substance abuse and other youth related concerns or issues.

Again, MHFA is being offered and accepted by schools for their administrators and staff (non-teachers)

NECASA met with the Juvenile Court Judge in Willimantic along with representatives of DCF to facilitate additional access to treatment for the adolescent offenders. This issue continues to be of concern especially for the population aging out of DCF care.

It is understood that a Methadone program has been added to the prison system in Connecticut to increase treatment for opioids.

Young Adults: Northeastern Connecticut lacks a Young Adult Services (YAS) site. Young adults living in that area can’t access the sites in Willimantic and Norwich, due to the highly rural nature of the region and the severe lack of transportation options. This needs to be addressed, as does the lack of services for other young adults who don’t qualify for YAS, and are struggling with the transition to adulthood. Of further concern are the 3000 young adults in our state who meet the federal definition of homelessness and the countless others who don’t because they are couch surfers or basement dwellers.

Some recommendations that have been made by providers in our region include:

Utilize the “Host Home” model that has been successful in the Midwest. Contract with local colleges, which would provide free room and board to young

adults who lack stable housing and want to get degrees. These young adults would give back to the colleges in some way, similar to financial aid work-study programs.

Another emerging issue of serious concern is the stress and/or reluctance that many direct service staff in the YAS program feel over serving clients who are becoming

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parents for a variety of reasons. Some have even stated that young adults with children don’t belong in the YAS program. First, although staff are allowed to transport clients’ children when taking clients into the community, there is a general belief among staff that they can’t do so. Second, transporting children is complicated, because staff must have a police inspection each time they place a car seat in an agency vehicle. Staff say they hate to get too involved with a client who has a child, because after watching so many babies get removed from parental custody, they fully expect the same outcome each time a client has a child. It is necessary to provide additional supports and education to staff serving YAS clients who are parents, and to clarify the expectations and policies that impact this area of service.

Criminal Justice SystemProvider staff, along with those receiving services and their families say there is still a great deal of fear among those with severe mental illnesses of law enforcement; they fear encounters that they believe will inevitably lead to arrest and incarceration. While there is a an excellent veterans’ jail diversion program at the Southeastern Mental Health Authority, and a number of town police departments have CIT trained officers, there have been a number of well-publicized accounts of encounters between those with mental health concerns and the police that have turned deadly. And often calls are made to 911 when a person is in crisis; many health professionals tell families that this is the appropriate action. Better education about Mobile Crisis Services for professionals and the community in general could significantly decrease involvement in the criminal justice system for those who would be better served by treatment for their illnesses.

We recommend the following: Better education for law enforcement about mental health issues and the benefits of

access to the appropriate services. A condensed training for officers who can’t be released for the 40-hour CIT training would be helpful.

Police officers, EMT’s paramedics and firemen also need the specialized training on mental illness and substance abuse and the de-escalation techniques that CIT teaches. According to many reports, they are frequently disrespectful and inappropriate when responding to crises

Incorporate the full CIT training module in the training for all new police officers at the Police Academy.

More consistency in the court system; better education among judges about the benefits of jail diversion.

Because of high rate of co-occurring disorders, many are landing in the jails and prisons, making our prison system the “new treatment system”.

Discharge planning/recidivism. One first selectman who is a former corrections officer says he sees people in his town still wearing a prison shirt and going right back to his/her old haunts; he says it is not unusual for re-arrest to occur within a day.

Expansion of jail diversion programs in Eastern CT

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Mandate and funding for State Police and local police departments to support training of at least half of their current forces.

Veterans/Law Enforcement Those working with active duty military members, veterans, and members of law enforcement are concerned about the suicide rate, which is exacerbated by the culture of not seeking help in these communities; when the “helpers” need help; it is still seen as a sign of weakness. There is still a strong fear, based in reality, of losing career advancement opportunities if a behavioral health issue becomes known. This is exacerbated by the 2013 law that prohibits a person from holding a gun permit if they voluntarily enter inpatient psychiatric treatment.

We recommend the following: Greater engagement between the RMHBs and the designated veterans’ advocates in

their regions’ towns. Peer mentoring for law enforcement/military members to alleviate the stigma of

seeking help for behavioral health issues. One example is expansion of the state-funded “State Troopers Offering Peer Support” (STOPS) program that is currently offered to state troopers to include municipal police officers who are experiencing behavioral health issues.

Co-occurring disordersMany feel that mental health and substance abuse services need to be more connected and streamlined. Silos still exist between the two systems, which is not helpful when so many people with substance use issues have an underlying mental health problem. Provider staff and clients alike said that those with co-occurring disorders often don’t get appropriate treatment and/or medication from primary care providers or doctors in the emergency rooms, due to fears of prescribing medications to those with a history of addiction. We heard stories from several consumers who live with chronic and severe pain but can’t get relief because of addiction histories, some of which are in the distant past.

Additional concerns presented during this discussion included: People with a mental health diagnosis who couldn’t be placed in detox programs and

other substance abuse treatment programs. The cycle is never ending: physical health affects mental health; mental health affects substance use which in turn affects physical health…

The continued high rate of smoking/tobacco use among those receiving mental health services, as well as direct service staff in the state-funded system.

We recommend the following approaches: Create a “no wrong door” policy for entering services. Increase collaboration with the medical directors of addictions programs; one

psychiatrist said that he would like to invite the medical director from the local addictions program to visit his clinic once a week to see clients with co-occurring disorders.

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Offer more peer trainings and mentoring by those with experience in treating co-occurring disorders.

Institute accessible and evidence-based smoking cessation programs in local communities.

2015 UpdateProviders report having hired APRNs and clinicians with training and experience in offering services to those with co-occurring disorders. It is too early to assess how helpful this has been, and we hope to have more information next year.

Co-morbid health issuesDuring the focus groups with clubhouse members in particular, many individuals said they had serious health concerns that required a visit to a specialist, a difficult prospect in view of the scarcity of such specialists in Eastern Connecticut. Most of these individuals find that it is a hardship to attend specialist appointments due to lack of transportation. Clients, along with those who work for service providers say that there is continued poor coordination between behavioral health and primary care providers. Moreover, a significant number of clients say they fear this kind of coordination, due to the belief that it will give them even less control over their own lives.

Many clubhouse members tell us they rely on cheap and easy meal choices like TV dinners and Ramen noodles because they don’t have the skills to plan and prepare food on their own. Many also can’t afford fresh produce or get to places where such items are available.

A psychiatrist in Region 3 mentioned recent research showing that obesity exacerbates schizophrenia and bipolar disorder, and that actual brain changes occur. He says that general awareness about nutrition and health food choices is greatly lacking in the population he serves.

We recommend the following approaches: Clients should have the opportunity to work closely with a Registered Dietitian as part of

their regular visits to outpatient clinical programs. Service Coordinators and Clubhouse staff must be provided with expanded resources

and trainings that enable them to educate clients more thoroughly about meal planning, reading and understanding food labels, and accessing fresh meats and produce in their communities. A free on-line cookbook entitled “Good & Cheap” can help people to cook and maintain a healthy diet while on SNAP benefits.

Coordination of care, like patient portal, so that providers can see the entire picture of a client. Many feel that mental health and substance abuse services need to be more connected and streamlined. Focus group participants said we need a continuum where we treat everything at once in a holistic manner.

2015 Update

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With the Behavioral Health Homes coming on-line in Eastern Connecticut, it is expected that the ability to coordinate care for those with complex behavioral and primary health care conditions will improve. We look forward to assessing the progress of this program in our region within the next year.

E. ACCESS, AFFORDABILITY, APPROPRIATENESS EmploymentAnother significant concern raised during the focus group sessions was the lack of employment opportunities for those with mental illnesses. There was a general agreement that meaningful employment builds self-esteem and empowers individuals, giving them control over their own lives and helping them to be independent. But a variety of factors make it difficult for those with any disability to become employed and to sustain employment:

The fear of losing a job due to the need to get time off for appointments or get certain accommodations.

The general scarcity of employment opportunities in general, many of a menial nature and paying only minimum wage. Even these jobs are more competitive than in the past.

Lack of jobs that pay a living wage means that people still need public assistance to live. Many people with mental health problems who want to work are only able to work

part-time, jobs that are part-time are more difficult to find, especially for those who may also have physical limitations that impact their ability to stand for long periods or carry heavy loads.

People with history of incarceration, even for nonviolent crimes, have difficulty in obtaining jobs.

Many people can’t explain gaps in employment history due to hospitalization, which makes employers suspicious and less disposed to hire the individual.

Lack of affordable, reliable child care for those who are working. Applications that must be submitted online are a barrier due to lack of access to

computers and/or internet, as well as a lack of computer expertise. A history of mental illness can impact eligibility for certain professions; e.g. a police

officer or security guard who must have the ability to carry a weapon cannot have a history of voluntary inpatient hospitalization for a mental illness.

We recommend the following approaches: Increased capacity in existing supported education and employment programs, including

expanded services for those living in rural areas. Another need is a greater array of supported employment models; the Individual Placement and Support (IPS) model, an evidence-based practice that is highly effective when used with a certain population, is not the ideal solution for everyone seeking employment.

Small grants/start-up support for consumer-run businesses, similar to the DMHAS initiative several years ago.

Broader availability of community education to Chambers of Commerce, Rotary Clubs and organizations in the business community, including Mental Health First Aid training, to dispel misconceptions and fight discrimination. The RMHBs and RACs are ideally suited to conduct these efforts in collaboration with the supported employment

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programs in their regions. It would also be helpful to create a “condensed” training that could be used with groups that may not have the time or resources for eight-hour training.

Discharge Planning and Follow-up Services: During all of Region 3 focus groups, we heard complaints about the lack of appropriate planning for services following discharge from the hospital, prison and detox services. More supports following discharge to ensure that a person doesn’t begin using, especially if a housing or family situation is a trigger. When follow-up appointments are made, there is often such a lag that individuals run out of prescribed medications or experience symptoms during the interim, and have to return to the Emergency Department. This is particularly true for people who aren’t connected with family or another support network.

Better discharge planning prior to release from the criminal justice system can help prevent recidivism, particularly if people leaving the prison setting can avoid having to return to settings and relationships that might put them at risk. Mechanisms need to be established to ensure that individuals are connected with a community based mental health provider before release. Peer mentors could be helpful in this regard as well, especially if the relationship is established prior to release, similar to the Peer Bridger model, and could offer support in encouraging individuals to follow through with discharge plans.

It is essential to establish a mechanism, along with collaborative relationships between hospitals and community providers, for ensuring that those being discharged from the hospital or the Emergency Department experience no gap between vital medications running out and their follow-up appointments with behavioral health providers. Value Options and the existing Community Care Teams in Norwich and New London, along with the newly formed one in Windham County, can be extremely helpful in this regard.

2015 Update:As mentioned before, the hospital and area treatment providers are working to coordinate and improve the discharge plans for those entering in with overdose and/or psych concerns.

The Peer Bridger Program, though an excellent resource for those leaving the hospital, is reportedly being under-utilized. The reasons for this need to be addressed. Department of Social Services (DSS): DSS too slow to process paperwork; clients must wait on the phone for hours to get an answer (many often have limited minutes on their cell phones), or must go to a DSS office to speak with someone (lack of transportation is a barrier to visiting DSS offices). The ERMHB regularly hears reports from staff and clients of benefits that terminated due to redetermination forms that were lost or misplaced in a stack of paperwork after submission. DSS needs to address its problems with inadequate staffing and phone access. It also needs to reinstate the ability for clients to directly contact their workers by phone.

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2015 UpdateThis is a growing problem. Provider staff report that because of the worsening problem with DSS losing redetermination forms and other paperwork, clients are experiencing damaging interruptions in services and medication. Clinicians and staff spend a great deal of time, “putting out fires,” taking away from the therapeutic process and skills-teaching nature of their jobs, delaying recovery and independence. One service coordinator has established a “weekly run” to DSS with her agency’s clients, because clients can’t reach anyone by phone at DSS in order to resolve issues.

Access to services at the appropriate level: All focus group participants agreed that the system is a confusing hodgepodge. Even those working in the state-funded mental health service system said that they would not know where to refer a friend or family member with private insurance, given the separation between the two service systems. For the most part, people said that to help someone connect to services, they would first do a “Google” search for service options, talk to a pastor, consult with a primary care provider, or ask someone who “works in the system.”

Participants say that too many people are going to the Emergency Departments because of long waits for appointments, lags in public insurance coverage, or lack of access to an appropriate specialist for a serious health condition (one staff member said some clients in the Northeast experience delays as long as 2 years). Those with private insurance don’t have coverage for the same non-clinical supports that are available to those on public insurance, and focus group participants said that sometimes traditional outpatient clinical services or even a Partial Hospitalization Program just isn’t enough.

Most people know about 211, but find it user-unfriendly in numerous ways. There are long hold times, frustrating in the best of circumstances, but rendering the service useless to those with limited cell phone minutes, and to those in crisis who can’t wait for a “real” person to come on the line. 211 operators also seem to be in need of more training to help them interact more effectively with people in crisis, and with those who have poor interpersonal skills. Most people in the general public don’t know about Connecticut’s web-based Network of Care site, and those who do say is often inaccessible, especially for people who don’t have computers, computer skills, or access to internet.

Those depending on Medicaid for health care coverage say there are too many gaps in coverage. For instance, dental care is difficult to obtain; many experience long waits for appointments, due to the dismally low number of participating providers. Medicaid beneficiaries also report that Medicaid eyeglass coverage allows new glasses every two years. For older individuals with vision changes and or eye conditions, this is not often enough. People are entitled to one eye exam per year, and even when they have significant changes in vision, they must wait for another whole year before they can replace glasses.

We recommend the following approaches:

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Address problems with 211 through better marketing, specialized trainings (motivational interviewing, etc.) for operators, higher levels of staffing during busier times, and better follow-through with referrals to help. Wait times are far too long for those with limited ability to cope with a situation or with limited cell phone minutes. Many feel that 211 is not direct enough; operators won't make phone calls to help people in need, and many lack the interpersonal skills to handle calls themselves.

Provide education about resources, including Emergency Mobile Psychiatric Services, to primary care providers, pediatricians, school staff, and local officials. In recent local encounters with school and town officials, the ERMHB has discovered that these individuals do not know about mobile crisis services.

Develop ways of reaching those who are not connected to existing resources or lines of communication about resources.

Offer better pay for state-funded nonprofit employees to ensure they have a decent standard of living. Better compensation would alleviate heavy turnover and create more consistency in services to clients, leading to stronger trust in the service system.

Make more services available at local level; regionalization of services would help towns that can't afford resources. Currently, there is a disparity of services between towns. Also availability of services at the local level would make them more accessible for those who lack transportation.

Inform community members about appropriate points of contact and actions to take when they are concerned about a neighbor or friend. Those receiving the reports must be held accountable for following through, or community members will lose confidence.

Provide the same wrap-around supports to those under private insurance that are available to individuals who are eligible for state funded programs, particularly service coordination.

Ensure that providers know what is in their contracts and to hold them accountable to program guidelines/contract language. Involvement of the Local Mental Health Authorities (LMHAs) in the contracting process for substance use services in a way that is similar to current process for behavioral health services contracts would be a good way to ensure that they know the "big picture" locally. RMHBs should be empowered to review contract language for all state-funded programs to ensure that everyone is meeting the terms of their contracts

Regionalize funding for social services departments to ensure that services are available in every town.

Change Medicaid rate structure to enable providers to meet costs. Increase capacity to ensure same-day access. Some local providers are working to

implement same day access, but face challenges in making sure they can meet their costs. They say doing so would help to eliminate the problem of no-shows, however.

Peer Support:Participants in all of the Region 3 focus groups said that peer support specialists need to be fully integrated into all aspects of the service system. Interaction with professionals that have lived experience of mental illness is a significant factor in helping a person to engage. Peers offer specific supports that helped them in the past, along with hope for a better future, to those

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who are newer to their diagnosis and the behavioral health care system. This supports the building of mutual respect and meaningful relationships that promote “compliance” with recovery plans. Statewide expansion of existing peer support services, including Peer Bridger services for those preparing for discharge from inpatient units or prison, and for young adults, is recommended.

2015 UpdateUnionized nonprofit provider say that it is difficult to hire peers, due to productivity standards that must be met by everyone, challenges with the Rehab Option, and the lack of upward mobility in the Recovery Support Specialist structure. Providers expect that it will be easier to incorporate peers into the Behavioral Health Home.

Family Involvement:This area continues to be a challenge throughout the region. Fidelity reviews of Community Support Programs/Recovery Pathways (CSP/RP) have consistently shown that programs have difficulty engaging families in the kinds of programs they plan. Some clubhouses have had better luck with family participation.

However, we would like to see providers broaden their family involvement activities to include regular and aggressive outreach to families through the offering of general information about diagnoses, treatments, and services offered. Many staff still have misconceptions about what types of communication are allowed under HIPAA, or view family members as an additional barrier to helping their clients. We would like to see more “classes” offered to family members to teach general mental health information, strategies for helping their loved ones with mental illnesses, and caring for the caregiver. It is also important for providers to demonstrate buy-in to family involvement at every level, from CEO down to direct service staff. Often trainings and information are offered to management staff, but fail to be disseminated through the ranks. Approaches that treat the whole family help to ensure that individuals and families don’t fall back into old patterns that cause setbacks.

2015 UpdateProviders continue to struggle with true family involvement. Barriers include poor understanding of the definition of family and of how to involve family without violating confidentiality, and for some staff, negative perceptions about the involvement of family members as a helpful process. We also find that while most providers ask at intake if they want family involved, this practice doesn’t seem to include follow-up questions to further explore the opportunity, nor do providers seem to revisit family involvement on a regular basis. Providers in our region do have “Friends & Family” social events that are well attended, but addressing the previously mentioned barriers, will be key to true family involvement.

Holistic Wellness ApproachesOur focus group participants expressed their desire to see greater integration of holistic and non-traditional practices into behavioral health services. They say that many clients don’t want to be on heavy medication regimes, and would like to have access to such approaches as music

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and art therapy, meditation, and yoga. Also important is client access to registered dietitians and resources for fitness and exercise. Some clubhouses do have memberships to gyms, Each year, the Behavioral Health Partnership sponsors a fitness challenge among the clubhouses, distributing pedometers and nutrition information to members, but these activities serve a limited number of people. We would like to see such initiatives offered through CSP/RP and outpatient clinical programs.

Cultural CompetenceRecognizing and effectively responding to mental health and substance use issues is heavily dependent on cultural competency in schools, churches, primary care settings, and behavioral health care settings. Family dynamics based on cultural/ethnic backgrounds need to be taken into account. Focus group participants recognized that Eastern Connecticut is ill-equipped to intact with the many cultures and ethnic backgrounds represented in our region. One provider shared that in treating a Vietnamese woman, it wasn’t enough to provide a translator. The also had to ensure that the translator was a female, due to the cultural interactions between males and females in the Vietnamese community. Some minority populations are disproportionately affected by certain issues, but may be less likely to address those issues, due to cultural taboos. Community outreach that is culturally competent, through faith communities and other organizations that offer supports to these populations is essential.

Housing and Homelessness:Participants in the Region 3 focus groups said that there is a continued lack of an appropriate array of housing options, ranging from more independent scattered site housing to 24/7 on-site supports. While some individuals are relatively self-sufficient and need few supports, others lack basic skills needed for independent living and need constant on-site supports to maintain wellness. Those with higher needs often end up in the Emergency Departments or on inpatient units when symptoms escalate because they lack proper supports, and this could be avoided.

Too many individuals that are homeless don’t meet the federal definition of homelessness and are falling through the cracks, i.e., young adults who are couch surfing or living in parents’ basements without educational or vocational prospects. Homelessness prevents services from being consistently available or effective; lack of stable home environment/address means individuals can’t own necessary medical equipment or be easily contacted by providers. Barriers to shelters/housing for those who are actively using are another issue that worries staff and clients. One town CEO informed us recently that, in the wake of closing a boarding house whose owner mismanaged rent payments and didn’t pay bills, he is having great difficulty getting housing placements for the former tenants through 211.

Staff and those receiving services say that financial limitations force individuals to live in areas with drug trafficking and other triggers. They would like to change their environments but can’t afford rents in safer areas. To help people maintain wellness and recovery, Eastern Connecticut needs expanded supportive housing placements and options.

F. OPIOIDS

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Prescription drug misuse and heroin use/overdose are increasing dramatically in Eastern Connecticut and are the primary concerns on the prevention front. We recommend the following approaches:

Coordinate state efforts to address prescription drug abuse across Connecticut Identify and begin addressing barriers to prescribers’ engagement in preventing

prescription drug abuse Develop a public awareness campaign to reach multiple levels of communities across

Connecticut Mandate registration and use of the Prescription Drug Monitoring Program As efforts produce a decrease in prescription drug abuse, increase options for opioid

abusers to seek treatment due to the likelihood of increased heroin abuse

2015 Update:CPN /SERAC received 200 donated injectable Narcan kits. We are working with the local Medical Director for our first responders to determine the best way to train and distribute those interested in the kits. We are hoping to get them to police, treatment and recovery professionals.

CPN/SERAC/NECASA supported a statewide prescription drug awareness campaign at the local level. The campaign is just being released but local venues are ready to support the campaign.

CPN/SERAC/NECASA supported changes in Connecticut law regarding Opioids during the 2015 legislative Session, including the support of the Governor’s Prescription Drug bill and the abuse deterrent formulation bill. Increased education for physicians, the mandated use of the Prescription Drug Monitoring Program (PDMP) and the availability of Narcan to first responders is now law.

NECASA, representing CPN, served on the Prescription Drug Task Force that helped to work on the Governor’ Bill and continues to work on the messaging group to create an information campaign with DPH.

G. SUICIDE AWARENESS AND PREVENTION/POSTVENTION ACTIVITIES With the recent and very highly publicized death of Robin Williams, it has become evident that our communities are deeply affected even when the person is not personally known to them, but is a very well-loved and popular public figure. The power of such a tragedy to impact the wellness of people in our local communities and lead to suicide contagion is significant. The American Foundation for Suicide Prevention cites several environmental factors as increasing a person’s risk of suicide, among them “Exposure to another person’s suicide, or to graphic or sensationalized accounts of suicide (contagion). In the weeks following Robin Williams’ suicide, news media reports and social media activity (Twitter, Facebook) went viral with graphic accounts of the method of Mr. Williams’ suicide, along with messages such as, “Genie, you’re free,” encouraging the public perception that suicide is a positive response to the pain of mental illness. During a recent focus group at a clubhouse in the Northeast, it was evident that members were deeply traumatized about Mr. Williams’ suicide. One woman stated, “I know I

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could have stopped him if I had known him.” Others wondered what it meant when someone as talented, successful and universally admired as Robin Williams could experience such a profound loss of hope and the will to live.

The National Suicide Prevention Lifeline reported a sharp spike in calls to its hotline after Mr. Williams’ death—from about 3,000 the on Aug. 10th to 7,375 on Aug. 12th, the day after the highly publicized death, and also the highest number of phone calls the organization has ever received. The National Alliance on Mental Illness (NAMI) also experienced a 20 percent rise in calls to its hotline in the days immediately after Mr. Williams’ death. There is ample reason to be concerned about the risk of suicide contagion. A study by University of California professor David Phillips in 1974 looked at 34 widely publicized suicides, and reflected that suicide rates did increase following celebrity deaths. The most significant was that of Marilyn Monroe in 1962, which was followed by an increase of 197 suicides in the month after her death was reported. With the significant changes in the flow of information and misinformation in the era of the internet and social media, there is a need for concern.

Confusion and fear regarding the open discussion of suicide continue to be rife in our communities, for very good reason, but this leads to a failure to address the topic in a proactive meaningful way that can effectively prevent suicide and minimize the impact of a suicide on a community. Many people believe that asking an at risk individual whether he or she is considering suicide will cause the person to take his or her own life, when in fact showing concern, listening respectfully, and offering concrete help can often prevent a suicide.

Recommendations:The RMHBs and RACs are trained in a variety of models that teach useful skills and provide useful information and resources to the community, including Mental Health First Aid and Question, Persuade and Refer (QPR). Mental Health First Aid in particular has received an overwhelmingly positive response in Region 3; however, not all employers will pay the cost or allow the necessary time off. It would be helpful if the RMHBs and RACs could offer “scholarships” for the trainings.

Theses trainings are particularly needed for those working with the elderly. During a recent round of meetings with Town CEOs in Region 3, the ERMHB Executive Director learned that senior centers are ill-equipped to address many of the problems they encounter in the elderly individuals they serve. The lack of skills and resources can lead to people being “banned” from the senior centers, increasing their isolation and the likelihood that they will fall through the cracks. About one-third of those 65 and over experiences depression, and there is widespread belief that depression is just “part of getting old.” Furthermore, while the elderly (age 65 and older) make up only 13% of the U.S. population, they account for over 18% of all suicides. Since untreated depression is a major factor in suicide, it is important to promote early identification and intervention in elderly depression. Outreach to services and programs that serve the elderly is greatly needed

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Since suicide is the third leading cause of death among youth 15-24, all individuals who work with children and adolescents need to be able to recognize the signs and symptoms of mental health problems and take appropriate action. A recent study published in JAMA Psychiatry found that one in eight of the 6500 teens assessed had contemplated suicide, and one in 25 had attempted suicide. Since feeling safe in school and having trusted adults to talk to are among the protective factors against suicide, all professionals working with youth should be trained in the Mental Health First Aid and QPR models. However, it is often difficult to foster a meaningful conversation with school officials, given the fear of liability. Upon learning about Emergency Mobile Psychiatric Services (EMPS) for children recently, a mayor in Region 3 told the ERMHB’s Executive Director that parents would never countenance the school utilizing this service for a child in crisis. It is important that school districts handle this kind of emergency response in the same way that they would a physical injury. There is little awareness in general at the local level, even in the schools, about EMPS in general, and this needs to be addressed.

2015 Update:QPR Training- SERAC provides 8 free at the beginning of each fiscal year. Subsequently, SERAC provided the trainings at low cost.

The statewide campaign is still being promoted and utilized in the region (billboards, informational resources, articles, and PSAs.

IV. Conclusion

Thank you for the opportunity to present the information gathered in this year’s Region 3 Priorities Planning Process. We look forward to partnering with DMHAS and our community partners to meet the needs of those served by the state-funded mental health systems.

NEW TRENDSThree new grow sites and five new medical marijuana dispensaries are to become available. This adds to the difficulty to do prevention of marijuana use with young people as it continues to erode the perception of risk and harm for adolescents and parents. In addition, law enforcement has a difficult time distinguishing between Medical marijuana wax (sold legally) and butane oil wax (high potency marijuana) which is illegal.

Heroin continues to be a challenge to prevention, treatment and law enforcement as well as “synthetic” drugs such as K-2/Spice which while made illegal are being sold through the black market or brought across state lines from states where they are still legal.

Also, on a positive note, Prescription drug drop boxes have been added in many police stations and Narcan is being carried by first responders including police.

The Behavioral Health Homes (3 in Region 3) are a new, and very positive, addition to Eastern Connecticut. It is too early to determine how effectively they will impact the

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coordination of care for those with complex health histories, but providers are extremely optimistic, and the ERMHB looks forward to conducting reviews of these programs.

NEW PRIORITIESTo institute a comprehensive information campaign on opioids and to work to ensure that the new law on prescription drugs is followed and that prescribers use the PDMP.

Workforce/Private Nonprofit Operational Issues: The ERMHB has heard a great deal about operational and funding issues that disproportionately and negatively impact private nonprofits:

Medicaid rates are chronically low. Upper payment limits that prevented Behavioral Health rates from being raised last year need to be addressed. The decrease in grant accounts makes it increasingly difficult for the private nonprofits to sustain outpatient clinical programs that cost more than they bring in.

The flat funding of nonprofit workers is creating a steadily worsening situation for agencies and workers. While operational costs rise, funding is level, resulting in the inability of agencies to pay a living wage or offer decent or affordable health insurance. Health insurance costs for private nonprofits have increased at such a steady rate that employees are burdened with outrageously high deductibles—often as much as $5000-$10,000. This leads to unacceptable delays in care for underpaid staff who work in highly stressful situations. DMHAS should look at ways to decrease insurance costs for private nonprofits, including the ability to create a larger pool of coverage in order to reduce premiums.

The low pay for private nonprofit workers, even those with advanced degrees, forces those workers to rely on public assistance, or to get a second job, in order to survive. One clinician reported that she can earn as much in two days of working in a local hospital ER as she does in an entire pay period at the private nonprofit where she works. Another clinician relies on Section 8 housing for his family.

Staff retention at the private nonprofits is highly problematic, due to chronically low salaries, which can be as little as half of what is offered for the same work at the state-operated agencies or hospitals. Many leave the nonprofits after getting their LCSW licenses, after the agencies have invested a great deal of training and resources in those employees. We spoke with one client who has had 4 therapists one year, and has been burned out by having to build new relationships and constantly revisit old and distressing history to bring her therapist up to date. This constant turnover is costly in many ways, and inhibits the building of vital and trusting relationships that contribute to recovery. United Services’ Dayville location has qualified for a federal loan forgiveness program for rural sites, and five clinicians have qualified and signed contracts through this program. More opportunities like this are needed.

Underserved PopulationsBrain Injuries: This is a difficult-to-serve and growing population. Even with an ABI waiver, there are no appropriate referrals in Eastern Connecticut, ie, in home services to

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deal with ADLs and counseling. Serving those with ABI/TBI in a traditional outpatient setting is problematic because of cognitive and memory problems that make it difficult to retain things.

The DDS Population: Providers report an overlap in DMHAS and DDS clients that leads to confusion and even disputes in who has primary responsibility for clients. As a result, clients with cognitive issues are not receiving the proper supports. Cognitive Behavioral Therapy is not appropriate or effective for those with cognitive limitations, but clinicians feel that DDS takes advantage of the mental health system and “dumps” clients on them, when the clients’ problems are really more about frustration, due to the lack of ability to process. (“We have a contract; you have to take him/her.”) Often these clients have to bring staff to appointments with them to interact with clinicians on their behalf. The issues that come up are not clinical, but can be more effectively addressed through case management or vocational services. Providers say that this diverts already limited resources away from their target population.

Transgender Adults: Clinicians report a lack of supports in Eastern Connecticut, including support groups and peer-run services.

Non-English-Speaking Individuals: The city of Norwich reports that 38 languages are spoken in the public school system. Clinicians in the Norwich often have to rely on the language line because of the diverse languages presenting for treatment. The city of Willimantic has one of the highest concentrations of monolingual Spanish speakers in the state, and this is reflected in the population served at the programs in Windham. For private nonprofit providers, especially those with unions, it is extremely challenging to retain Spanish speaking clinicians, who command a high salary because they are in such high demand throughout the state. Private nonprofits are simply unable to offer competitive salaries.

ADDITIONAL COMMENTSNECASA was part of the group that SAMHSA brought to Bethesda, Maryland in August of 2014 and one of the warnings was that “as prescription drug abuse is curtailed, Heroin use may spike due to lack of availability of the prescription drugs (opioid pain killers) on the street”

A continuing strength in Eastern Connecticut, especially in these times of dwindling budgets and greater burdens on the region’s mental health system, is the high level of collaboration that exists within the system:

Community Care Teams in Norwich, New London and Windham, which bring providers together to coordinate services for the region’s homeless population.

Regular and systematic cooperation between providers through mechanisms like the Centralized Intake Meetings and Utilization Review process, which promotes effective partnerships that maximize limited resources.

Strong relationships built by the ERMHB and local providers with the media, with partners in the community, and with town and state officials, that promote better

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public understanding of mental health issues and help to fight misunderstandings and discrimination.

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