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Fragmentation and Gaps in Care—for Adults with Serious Mental Illness

Adults with serious mental illness, one of our Nation's most vulnerable groups, suffer greatly from the fragmentation and failings of the system. The evidence of our failure to help them is most apparent and most glaring on our Nation's streets, under our bridges, and in institutions like nursing homes and jails. Some are homeless, and some are dependent on alcohol or drugs. Many are unemployed, and many go without any treatment. Most strikingly, less than 40 percent of those with serious mental illness receive stable treatment (Kessler et al., 2001). An estimated 25 percent of homeless persons have a serious mental disorder and, for the most part, do not receive any treatment (Dickey, 2000). Among those who are "chronically homeless," the prevalence of mental illness is even higher. Providing them with quality treatment and flexible supports leads to symptom relief, recovery, employment, less homelessness, less substance abuse, and less incarceration.

Model Programs

Efforts begun in California, Texas, and other states offer a glimpse of solutions that other communities could adopt. In California, mental health leaders realized that a lack of flexibility and focus in existing programs meant that homeless people with severe mental disabilities regularly slipped through the cracks. For example, funding for treatment programs—often based in clinics on the assumption that clients would readily come for care—was not flexible enough to support the months of outreach sometimes needed to convince homeless mentally ill individuals to accept care (see Box 4). Building on successful pilot programs, California created a network of efforts known as AB-34 projects (after the Assembly bill that created them). The AB-34 projects emphasize outreach to homeless individuals where they are. Their goals are to arrange safe and flexible housing and to work assiduously to engage people in care. The projects have yielded a remarkable 80 percent drop in homelessness and 82 percent drop in incarceration (Figures 3 and 4).

Unfortunately, not all states can count on the substantial new resources that California devoted to this problem, and many of the major Federal and state programs that fund mental health care do not provide the flexibility and focus that has been the key to the AB-34 success. Community leaders seeking to provide integrated care must either painstakingly knit together disparate funding sources with sometimes conflicting requirements, or seek major new appropriations of "flexible" dollars. Bureaucracies should not block integrated, effective care for such needy populations, while easily reimbursing ineffective approaches.

Another program shows that high quality, research-based care can be delivered to people with serious mental illness. The Texas Medication Algorithm Project (TMAP) has been so successful it has been adopted in Nevada and at least five other states (Box 5). Launched in 1996 through a public-university collaboration and funding from the Robert Wood Johnson Foundation and Meadows Foundation, TMAP fills a critical link in the system: it provides up-to-date and research-based procedures—and expert advice—for doctors to consider when prescribing medications. The quality treatment facilitated by TMAP, including information for consumers and families, leads to improved consumer satisfaction and adherence with recommended care, greater symptom relief, and fewer side effects. With the focus and accountability provided by TMAP, both Texas and Nevada also made efficient state-level investments to provide medications to those consumers ineligible for Medicaid or whose only insurance is Medicare. Given that many individuals with serious mental illness are uninsured—yet ineligible for Medicaid—coverage for medications is of great importance.

Every policymaker—and nearly every citizen—knows that many people with mental illness are at risk for homelessness. Contributing factors include the lack of appropriate and affordable housing and the lack of access to medications and rehabilitation supports. These are necessary to help people achieve the personal stability that is key to housing stability. Our review finds that ending chronic homelessness—as the Administration has proposed—requires special attention to the adults with serious mental disabilities who are over-represented among the most needy homeless.

The ACCESS program is oriented to address chronic homelessness. It is a 5-year demonstration program in nine states, funded and administered by SAMHSA⁴, designed to show that homeless people with serious mental illness can be served by pulling together disparate programs that span mental health, housing, drug and alcohol, benefits and entitlements, and medical treatment (Box 6). Over 5 years, the program demonstrated its mettle: it improved symptoms and everything else that flows from better mental health—quality of life, income, and, of course, housing. It can be done.

"ACCESS took 7,200 chronically homeless, seriously mentally ill, addicted persons off the streets in this country and gave them back their lives."
   —ACCESS Program Director of West Philadelphia, May 2001

Other communities can emulate the three special programs described here—TMAP, AB-34, and ACCESS—to serve people with serious mental illness. However, reform in Federal programs is needed to help states and communities adopt and sustain improved efficiencies. Model programs with flexible funding (e.g., ACCESS at the community level, and AB-34 at the state level) are useful to propel innovation and galvanize change, but the process must exist to translate proven models into more widely adopted services. In order to achieve the goal of ending chronic homelessness, the successes in pilot programs must be widely replicated. The needed changes may include flexibility to enroll individuals who are not yet disabled enough by a mental illness to qualify under current requirements. Changes may also include requiring the promotion of more timely access to housing certificates and placements. The Commission will study these programs more closely and make specific recommendations for change.

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