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have heightened community unrest and hostility, caused more dissension and in-fighting among line workers of the center staff, directly affecting continuity of care and causing services to become even more fragmented. The Director of the Department of Human Resources has publicly announced the closing of several clinics and outreach programs due to budgetary problems. Later the Director has rescinded that decision due to community outrage and pressure. At the crisis point. funds are as usual found from somewhere to continue the threatened programs. At the same time he requested a 20-percent increase in fiscal year 1975 budget to increase the size of the central DHR administrative staff. The most notable and recent example of crisis management and funding occurred when Judge Waddy cited city government officials for contempt of court for ignoring a 3-yearold court order mandating the District government to finance the education of all handicapped and emotionally disturbed children. The contempt citation resulted in the sudden finding of $130,000 by the Director.

These situations would not occur if the Department were not managed by crisis and if priorities were not determined by crises.

The programing of mental health in the District of Columbia is determined by those persons least knowledgeable of mental health needs and who are motivated by power, prestige, and politics. Competition for public dollars from the general coffers is magnified during economic downturns and crisis periods. However, if there were actual financial allocations to administration and actual accountability and responsibility (in this case CMHC) such eventualities could be anticipated, and necessary but absent long-range planning could take place. Funding for DHR programs appears to be based on the "deficit model," meaning that something is wrong or more explicitly you must be in the delivery system before services (funds) are available.

Constituent advocacy and opportunities for citizen input into mental health operations is noticeably absent beyond center levels. The effectiveness of such advisory boards or councils is determined by the outcome of the latest crisis rather than in planning, policymaking, or monitoring.

To remedy this system and to allow the mental health system to become untracked and come into its own, we strongly recommend a separate authority with direct mayoral accountability and financial responsibility. Problems relative to this new concept have been anticipated, however, the merits of the recommendation outweigh any bureaucratic consideration and is aptly supported in the Mayor's Task Force Report of 1970.

On the negative side of the argument is the idea that the health concerns of a single patient, physical and mental, are not to be separated. Unfortunately, this has not been the case heretofore. The mental and physical aspects have been divorced in the administration of the Health Department's programs. The new concept, in view of the District's unique jurisdiction over an entirely urban, predominantly poor and black population deserves serious consideration.

More than attempting to develop and implement new concepts of care, it is our intent to preserve those features found in the concept of CMHC's, outlined below and to bring about the maximum develop

ment of the mental health system and the delivery of services in the District of Columbia.

The proposed new organizational concept for mental health services for the District of Columbia is synonymous with the community mental health center concept and all its basic tenets at the service delivery level. The new concept proposes to bring mental health into appropriate focus by elevating the administration to a departmental or cabinet-level post, accountable to the Mayor and thus putting into place the machinery for the development of a more effective and efficient mental health services delivery system, both vertically and horizontally.

SPECIFICS OF SEPARATE MENTAL HEALTH AUTHORITY

The specifics of this proposal are as follows:

I. Reorganization of the Department of Human Resources

(A) It is proposed that the DHR administration offices be assigned as the city planning agency, including the present planning staff of the office and functions to include additional monitoring, coordinating, and compliance practices and to be designated "the City Planning Agency for Human Resources or Services." Since planning agency functions are well documented and since this paper deals primarily with mental health it would serve no purpose to go into planning details.

Accountability: Office of the Mayor

(B) It is further proposed that all primary human service administrations, SRA, public health, hospitals be elevated to Cabinet level positions and that mental health be elevated to Cabinet level status as a primary health system.

Inclusive of developmental disabilities, alcoholism treatment and substance abuse treatment as an integral part of mental health. One cannot argue against the proposition that community mental health should constitute the heart of the mental health system; however, other mental health programing should be accomplished with as much visibility as possible.

(C) Establish a District of Columbia Board of Health and Mental Hygiene.

II. Administration of Mental Health Services

(A) Organization on city level: Under the guidance of the District of Columbia Board of Health and Mental Hygiene, the District of Columbia Department of Mental Hygiene shall be given the responsibility for the city's mental health programs. The Board of Mental Health shall advise on policies, practices, standards, or program developments and changes; and to insure that the District government is in compliance with all laws and regulations pertaining thereto.

Within the framework of the comprehensive plan for CMHC, the Department should be requested to provide general leadership for the development of a network of coordinated mental health services with local programs in each of the city's subdivisions.

(B) Organization on local (area) level: Organization of CMHC in four geographic subdivisions of the District of Columbia should

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remain intact until such time as a feasibility study or other need analysis yields results in directing the need for other geographic and service delivery modes. For example, the companion proposal (Area C Community Mental Health Center Advisory Board) recommends that the present community mental health center boundaries be redrawn to reflect the boundaries of the eight election districts. I support and recommend this realinement and further recommend that to insure an effective delivery of services system that those boundaries be redrawn to represent as closely as possible their relationship to the present catchment areas. This could be accomplished through clustering.

The various components of a comprehensive mental health program need not necessarily be under one roof or under single sponsorship. However, all programs must be located and accessible within the subdivision, including 24-hour inpatient care. Center chiefs should be given full operational control with the degree of automony necessary for relative self-determination.

Citizens' boards of directors, advisory boards, councils or foundations must be developed and must be given budget, policymaking and review responsibility. These citizen groups should be representative of each local subdivision and should involve greater participation of the community's leadership.

Financing of Mental Health Services

Comprehensive mental health programs should be financed through three primary sources: public, third party (i.e. insurance, medicaid, medicare, etc.) and private purchasing. There should be a fee for service based on ability to pay and District or Federal impact appropriations for those free services provided which are considered in the public interest.

Each center and department should have actual financial control of their respective budgets and should strive to become self-supporting, using formulas similar to the HEW funding of health maintenance organizations. Under these formulas, careful attention should be given to impact funding (free service) for each fiscal year as each center's public appropriation should reflect the economic, social and ethnic composition of its community and clientele. Other prepaid, family or group plans should be the prerogative of each center in terms of what its community will support.

This statement is an attempt to identify issues and problems crucial to the delivery of mental health services to the residents of the District of Columbia. It also discusses in some detail possible alternatives or solutions to the broad range of problems which exist within the mental health system and the Department of Human Resources. It is not an attempt to explore the myriad of problems but to identify the core issues and patterns and to suggest solutions that go to the heart of the matter.

It will not suffice any longer to use the Band-Aid approach to problem solving or to continue to manage by crisis to which we seem to have succumbed.

The citizens of this city deserve the best possible health care delivery system.

Reviewing several volumes of literature has only served to reinforce the uselessness of this effort due to political and colonial nature of this city and unresponsiveness of absentee landlords (rulers). The citizens now have the right to vote and have elected their own Representatives. These Representatives must be held accountable. Accountability must not be for past misdeeds but for what they do now to correct those misdeeds and the deplorable conditions which directly affect the lives of the people of this city, especially in the area of mental health. Thank you.

Ms. MARTIN. On behalf of the chairman and other members of the committee, I would like to thank the panel for their testimony. I would like to say for the record, if this document is a coalition effort on the part of Areas A, B, and C, I think those committees could give the District government and the officials of St. Elizabeths a lesson in how to get together and get something done.

I might also say that I am going to suggest to the chairman that he send a copy of your testimony, the coalition testimony, to Mayor Washington and to Councilman Sterling Tucker because I think it is very important that they have the benefit of the transcript of this hearing.

BUDGET

I have two questions. One has to do with the District budget document which you may or may not have seen. In the narrative of that document, there is a statement that there is now a deemphasis on inpatient mental health in the District of Columbia and an increased emphasis on outpatient community health facilities. That does not seem to jibe with your testimony that there has been a continuing decline in District financial resources to support community health centers since fiscal year 1970.

It would be helpful to the committee if you could just document, either now or later for the record, your analysis of that decline, how it affects the operation of the centers; and if you could put it in terms of actual dollars, it would be very helpful to us.

Mrs. BROWNE. We can do that.

Ms. MARTIN. The other question has to do with the idea of a separate mental health authority for the District of Columbia. You said there was some community support from the public and the professional community on this issue. I think it would be helpful if we had some idea of the nature of that support, what form, the organization,

et cetera.

I don't know whether you heard the testimony of the Representative of the District Government yesterday, Mr. Joseph Yeldell, but he was specifically asked the question about the amount of money that the District had lost because they had failed to apply or had not applied timely for Federal funds. I don't remember what his answer was to that particular question, but if you could document for the committee, say over the last 3 to 5 years, your analysis of the amount of Federal program money, specific program money, that the District government had lost as a result of failure to apply or failure to apply timely, I think it would be helpful for us to understand your testimony. Mrs. BROWNE. We will see that you get this.

Mr. DABNEY. Madam Counsel, I would like to make one statement. A word to the committee, my name is Velvin Dabney, chairman of the Area C Board.

Sometime perhaps the committee could get together and reverse itself on its hearings and let the community be first and all the servants of the people be last so that we can be heard first, so that we can let you know what we feel. Because yesterday this place was picked, and we had quite a few people here this morning, and the place is now empty, and people can't hear what we are saying, although you are here to represent the committee. So maybe that might be a good idea. Reverse it, and then nobody will be ready for it.

Ms. MARTIN. I will convey that message to the chairman, there is, I believe, a protocol that we have been following for a number of years that may be outdated. Is that what you are saying?

Mr. DABNEY. Yes.

Mrs. PHYLLIS MARTIN. I am program chairman. My concern is not only with the mental hospitals, it deals with what is in them as well. On April 22, there was an article in the paper about the Sekels boy that went through the court system. The mother asked the boy to be committed to St. Elizabeths Hospital, and he went to the District Jail. I think the Senate Appropriations Committee should look at this. I am the victim of the same circumstances, where I had to go through the same thing, the District court, because of a misdemeanor, which was a traffic violation, of my son also. By not understanding the law, the judge went through the code, and I assumed that he would go to St. Elizabeths Hospital, but he didn't; he went to the psychiatrist of the court, and the psychiatrist told me because I asked him why wasn't he sent to St. Elizabeths Hospital, because he was a patient before, and he told me that was not his job, his job is only to say that a person who comes back to court is of a sound mind. But not knowing too much about the law, I thought my son would be at St. Elizabeths, but he was sent to District Jail. I had to take $300 out of my pocket to get him out of District Jail on a misdemeanor, to get him back into court to get him to St. Elizabeths Hospital.

So I think some of the things he says, the District Committee could really look at it. We can't wait until 1976, we have to do something about this now.

I have a statement that I sent to Councilman Willie Hardy; and I would like to leave this for Congressman Diggs' committee, the statement I sent to her, and I would like to leave a copy of this newspaper article.

Ms. MARTIN. We will take that into the record, and the Chairman indicated that the record will remain open for several days for submitting additional documents.

Mrs. PHYLLIS MARTIN. All right.

Mr. MATHIS. It is my understanding that St. Elizabeths Hospital provides facilities here on this ground primarily for the residents of Area C, Area B, and Area A. Do you feel that those services which they are providing are satisfactory, and if not, what problems are there that you could identify for us?

Mrs. PHYLLIS MARTIN. I would like to say in the court system, the court doesn't recognize the administration. From experience, from

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