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STATEMENT OF REV. ANNIE M. WOODRIDGE, PRESIDENT, AREA B
COMMUNITY MENTAL HEALTH ADVISORY COMMITTEE
Reverend WOODRIDGE. I am Rev. Annie M. Wcodridge, president of the Area B Community Mental Health Center Advisory Board and a member of the Coalition on Mental Health Planning, which I represent today. I wish to thank the chairman and members of the committee for their invitation to testify at these hearings on St. Elizabeths Hospital and mental health services in the District of Columbia.
My remarks will be confined primarily to mental health in the District. However, we would like to go on record as being in opposition to the transfer of St. Elizabeths Hospital and that no further consideration be given to this idea until the District gets its ow. human service delivery system in order or until a separate menta! health authority exists as recommended by the Rome Committees Report.
MENTAL HEALTH AUTHORITY PROPOSED
The District needs a separate mental health authority. In the recent past, several attempts have been made to establish a separate mental ? health authority. One in particular was a bill, S. 2914, introduced by the then Senator Joseph Tydings, as reported by the Mayor's task force on public health goals. Commentary dated January, 1977 follows:
Some officials at NIMH have said informally that they are in favor of the lill because the 24 States that have such a separate department generally have more stable mental health programs. The Health Department and the City may be expected to oppose it-it would mean one more department and the administrative inconvenience of transferring funds and personnel and the inevitable addi. tional administrative overhead; it would constitute one more department to report to the Mayor. Many of the City's private agencies in the mental health field will support the bill because they think that mental health is ignored in the massive health department. The Health Department is currently the largest, most expensive department in the City. Its responsibilities are so immense and its record so spotty that perhaps mental health does need a voice of its own and an administration devoted to its own cause. The potential of any new authority transcends the Health Department, expanding into the concerns of the juvenile court, schools, welfare, and prisons. Currently, in each department, mental health has the problem of competing in priorities with the foremost focus generally always elsewhere. It has no clear voice of its own at the City Cabinet lerel, Mental Health needs revitalization of personnel ; candidly, many of the personnel interviewed were next to demoralized.
A new administration devoted exclusively to the advancement of mental health would attract new personnel; it would also be the cause for the centralization of responsibility now lodged in the several de partments. Since fiscal year 1970 there has been a continuing decline in District financial resources to support mental health centers
. The obvious result is the ultimate but slow death of the community mental health center if this dismantlement is allowed to continue.
The advantages and disadvantages of a separate mental health authority has long been debated in both Government and the community. The outcome of such debates and DHR reorganizations has always been obvious, as indicated by our present low priority status
. Today it is obvious that the District government is much further behind than it was in 1970 when
an NIMH official, as reported by the
DETC Mayor's task force on public health, suggested that the District of
Columbia needs its own community mental health services act to insure WIR
guaranteed funding and local Board control. Details of such acts are not available, however, it was noted in the same report, 1970, that 34 other jurisdictions have enacted similar legislation. The idea is worthy of further examination.
The idea of a separate mental health authority for the District of Columbia has significant community support from both the professional and lay public, as well as in the upper echelons and branches of Government.
Recent conversions and conferences and other written proposals specific to this subject overwhelmingly support and recommend a separate mental health authority, therefore we strongly recommend to the mayor and city council that the Department of Human Resources be reorganized to permit the action necessary to implement the recommendation with all deliberate speed.
For too long the mental health needs of this community have been neglected. The bureau and/or administration charged with meeting these needs have been tucked away either in the old Department of Public Health or the new Department of Human Resources. This even further removed from the levels of power where decisions are made which directly affect the lives of thousands of people, including clients, staff, and the general citizenry.
It is sufficiently evident that mental health is suffering financially even more today than ever with the current period of inflation and recession. This fact is compounded by a decision made by the city government in 1969 not to allocate or appropriate District funds as matching moneys for Federal grants supporting community mental health centers; in effect, pulling the rug from under the community mental health center and defaulting on its legally obligated commitment with impunity. This demonstrates the beginning of the process of dismantlement of the community mental health centers.
The effect of such actions are significantly pronounced at the center administrative and contact level. Programs have diminished in size due to loss of staff, large budget deficits occur without center or administration level knowledge, lack of financial accountability, numerous staff reorganizations and shifts occur to compensate for losses, staff
are asked to do twice the work, affecting both quality and quantity bek çf services provided. The staff has become highly demoralized and
has been driven to a degree of ineffectiveness due to fear of loss of jobs for those persons on expiring Federal grants. Confusion and job insecurity were results of city government indecision in the matter of expiring grants, which in fact was not attended until the problem reached crisis proportions, which is symptomatic of the crisis-run DHR management system. Efforts to expand services to increase the physical continuity of the centers in the form of satellites have been abandoned.
Staff shortages and numerous hiring freeze periods have caused the retrenchment of established outreach programs. These retrenchments
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 antieipated, 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:
(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
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 ( 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 founda. tions 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 centers in 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.