Funding mental health care: Why community-based care matters

When it comes to mental health care, or health care in general for that matter, a simple fact is that the sicker people get, the more it costs to treat them.  Sicker people need more acute services, and they need to continue accessing those services for longer amounts of time.  Acute care services are extremely expensive, far more so than community-based care.  So why is it that far too many people aren’t able to access critical services in the community, leaving them without care until they reach the crisis stage?

Shortsightedness in funding

It seems to be a sad truth that health care comes down to dollars and cents.  What matters is this year’s budget, so costs incurred right now tend to be seen as far more important than potential cost savings down the road.  Whether it’s a public payor system trying to woo votes with balanced budgets or private insurance companies wanting to deliver good numbers to their shareholders, short-term matters.

Putting someone on a waitlist right now for community mental health services costs very little, but this doesn’t factor in the fact that this same person might completely fall apart a few months down the road.  They might then have multiple emergency department visits, or an inpatient admission.  That costs a lot, but it’s just a maybe, while the low cost of putting someone on a waitlist is an immediate certainty.

Something I’ve seen in the area where I live is the notion that service levels shouldn’t need to increase because more stable clients should be offloaded to their family physicians (never mind how hard it is to even find a family physician).  The health authority had a tool for ranking each client’s level of need, and pushing for everyone beneath a certain score to be transferred out of community mental health services.  The problem was, a lot of those clients were stable only because of the support they were receiving.  When I was a nurse at a community mental health team, I had a client who was doing really well, but only because I was seeing her every day.  Based on the health authority’s scoring tool, she should have been transferred to her family doctor.  Had that happened, she probably would have been dead within a couple of months.

Funding of psychotherapy services

Psychotherapeutic services seem to be particularly difficult to access due to the cost involved.  Certainly where I am in Canada these services are available on a very limited basis through the publicly funded health care system.  Let’s consider dialectical behaviour therapy (DBT), the gold standard for treatment of borderline personality disorder (BPD). There are typically very long waits to access DBT, and because it’s a very intensive form of therapy, it may seem costly to offer.  But perhaps no one thinks about the fact that those with untreated BPD often bounce from crisis to crisis as a result of their condition, leading to frequent emergency department visits, some of which lead to inpatient stays.  Who’s saving money now?

Cost of acute vs. community care

What seems so obvious to me is that mental health care is best delivered with an early-intervention, community-based approach.  If people are treated early in the course of their illness, they are more likely to respond to treatment and maintain greater functional ability.  People who go chronically untreated or under-treated become more treatment-resistant.  If these people don’t respond well enough to be treated on an acute inpatient ward, they may need to be transferred to a tertiary hospital, where stays aren’t measured in weeks but rather months or years.  Early intervention certainly doesn’t guarantee someone won’t go down that road, but it significantly decreases the chances, and this is part of the reasoning behind proactive approaches like early psychosis intervention programs.

While community-focused approaches may seem more expensive at first, the potential ripple effect would likely be huge.  There would be savings in acute care costs.  Intervening early would likely keep more people working for longer, and that means taxes going into the government coffers.  People who are more mentally well would be better able to participate in the economy in other ways as well by getting out and engaging in their communities (i.e. spending money).

Perhaps I’m living in a fantasy world that this makes sense to me, but the short-sighted approach of underfunding community mental health services just boggles my mind.  We deserve to have care that’s not only effective but available.  No one who is seriously ill should be languishing on a waitlist, or shuffled from service to service because no provider is willing to take them on as a patient.  No one should be discharged from emergency, still suicidal, with instructions to call the crisis line until they can eventually get in to see a psychiatrist.  Are these things really too much to ask?

 

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15 thoughts on “Funding mental health care: Why community-based care matters

  1. Meg says:

    I completely agree, and I’m trying to ask myself if it’s this bad in the US, but I’m not sure. I’m pretty certain anyone can get ER treatment, regardless of whether they have insurance. And therapy, all forms including EMDR and the type you mentioned, are offered at a sliding scale of roughly $40 per hour for people who can’t afford more. And there are loads of therapists looking for clients here–or at least, that’s my observation. I can guarantee you that if I were to call a new therapist and request an appt right now, I’d be in within a week. (Although I don’t know how many of them offer the specialty therapies.)

    I love the passion with which you care about these issues!! It’s nice of you to champion the people!!

    I’m wondering about governmental benefits in Canada? I get SS disability, which covers drug costs and hospital visits. Does Canada offer that to mentally ill people?

    • Alexandra Ruberti says:

      I am a mental health therapist and shifting into a new role as an integrative healer combining psychosocial and spirituality into my practice. For reasons you have discussed above, I have decided to step out of the non-profit field and become a ‘community therapist,’ to aid agencies and organizations to come together, to improve overall mental health and cost issues. Thank you for this article. Beautifully said. And true. This needs to be further addressed in the United States as well, but we need not be afraid of calling things out, and holding people accountable.

  2. Revenge of Eve says:

    If it wasn’t for assistance from our government I would not be able to afford care. I am grateful to have the access that I do have although it is subpar care. I’ll take what I can get.

  3. marandarussell says:

    I fear having to rely on services like these because they are so often unsecure and they often seem to be the first things cut when the budget needs trimming 🙁 How I wish it weren’t that way!

  4. Liz says:

    In the UK it comes down to budget and I wonder just how many it affects when it comes to mental health.
    There are cuts coming all ways and directions and not just in the mental health side. To me it’s further signs of the UK in struggle and the NHS.

  5. thefenixfoundation says:

    I hope each state governs their community-based mental health care differently or at least regulate it correctly. I have worked as a community-based mental health social worker where I’ve provided psychosocial rehabilitation, case management and now therapy (the trajectory in community-based mental health :/) Without license, it seems if we eventually want licensing (in Georgia) we have to have a caseload, very few private practitioners provide supervision for unlicensed practitioners in their practice…therefore mostly regulating us to the streets. It also doesn’t help that employers don’t understand that a MSW as well as a LMSW is a destination degree, not a junior degree as in professional counseling (LAPC vs. LPC). We don’t have to want clinical or licensing designation, it doesn’t negate the ability to do the job.

    I’m not against community-based mental health, I’m against not being able to ward off eviction notices because of the lack of service users keeping their appointments. I never know what my income is going to be because if I schedule 6 – 8 people, I may see 4 – 5. Imagine having 3 – 4 hours cut from you work day 2 – 4 times a week. Confirming the appointment the day before isn’t always a guarantee of seeing someone…they’ll cancel 10 minutes before your arrival and I live at least 30 minutes from my caseload…so wasted time and gas.

    I feel some don’t respect the option of coming into the home as they do if they were being seen in the office…its like a friend stopping by. I keep NASW ethics and methods so there are no boundary issues. I personally feel home-based community health should be for those that are home-bound. The cases I work with have persistent mental health (not MR or severe situations) and live independently, in Georgia, Medicaid pays for transportation for all services they pay for which solves transportation to appointments.

    There is a revolving door situation in Georgia with c/b mental health workers and the consumers are the ones who are hurt because people take the c/b jobs because they have to have something but within 1 – 3 months they are gone. They don’t like using their vehicles and they don’t like going into the homes and communities of lower-income consumers. It’s hard to establish rapport because consumers say they are tired of telling their stories.

    Some core mental health agencies in the Atlanta area have ongoing payment issues. Corrected progress notes are always paid out and you are the one that has to do all the legwork to research and “prove’ your advocating for yourself. The paperwork, BHA’s, reassessments ANSA, tx plans, etc. on top of all practitioners not providing services as they should makes it rough for those that are trying to do our jobs. We are not always working from a strengths prospective and we should be. No one should still be with an agency over 5 years if they are getting the services they are supposed to as they are supposed to. In core mental health psychiatrist, nurse, therapist, case manager and a paraprofessional (psychosocial rehabilitation) are the service areas Medicaid/care recipients are given whether they are self-referrals or coming from a hospital. In most cases these services are connected to the person receiving social security benefits, so required if they want the benefits but still not accepted by a lot of them.

    Didn’t want to talk to much, I was actually going to write on my blog about this. I enjoy doing social work and mental health but it isn’t easy when you can’t pay your bills. I’ve left two agencies with $1,600 left on the table with one and $ 1700 on another. As a contractor the department labor doesn’t protect me and it seems the Department of Developmental Disabilities or the Department of Community Health are nonexistent and can’t refer to any department or entity that is concerned about how these services are provided.

    • ashleyleia says:

      It would make so much more sense if the system was set up to help mental health professionals do their work rather than throwing obstacles in their way at any opportunity.

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