Local governments step in to fill unmet SUD-related needs

The opioid crisis may be driving many of the governmental responses to gaps in behavioral healthcare services, but the problems are larger than the opioid crisis alone, a new report suggests. And while federal and state initiatives tend to receive the most attention, it is in the trenches of local government where much of the impactful activity is taking place.

“Cities and counties are not waiting for states and the federal government to act,” Chris Cantrell, a co-author of the report Communities in Crisis: Local Responses to Behavioral Health Challenges, tells Addiction Professional. Cantrell is a manager at Manatt Health, which co-released the report with the Robert Wood Johnson Foundation last month.

Yet the report also points out that in their zeal to improve outcomes and reduce societal costs associated with untreated substance use disorders (SUD) and serious mental illness (SMI), some local governments have not taken advantage of important opportunities in accessing funding and in program coordination.

“Many communities have multiple programs, but many times they are not working in coordination with each other,” report co-author Jonah Frohlich, managing director at Manatt Health, tells Addiction Professional. Frohlich adds, “It was a huge surprise to us that Medicaid was not sufficiently leveraged across all these programs.”

The report states that many local leaders who were interviewed for the project were either unfamiliar with the ability to use Medicaid dollars (the largest funding source for behavioral health services) to cover case management, housing and other supports or were frustrated by a lack of engagement from state Medicaid officials in calling attention to these opportunities.

“This failure to make maximum use of Medicaid suggests a breakdown in communication between state and local officials as states, most particularly [Medicaid] expansion states, are intent on expanding coverage and services to individuals with SMI and SUD, including justice-involved populations and homeless individuals—precisely the target population of these local initiatives,” report authors wrote.

Multiple goals and approaches

The report identifies five prominent goals of localities' efforts to address the needs of individuals with untreated SUD and SMI:

• Reducing drug-related crimes and overdoses;

• Alleviating calls to first responders;

• Reducing homelessness;

• Reducing volatile confrontations with local law enforcement; and

• Reducing overcrowded courts and jails.

The local initiatives seek to identify individuals with unmet needs at several potential “intercept points,” including the justice system, homeless shelters and emergency care settings. An array of intervention models are used. Two popular pre-booking interventions for justice-involved individuals are the Crisis Intervention Team (CIT) and Law Enforcement Assisted Diversion (LEAD) models, but there are several others, and the report points out that most localities use more than one approach. “They have recognized that none of the models on their own are sufficient to address the needs and impact of individuals with untreated SMI and SUD,” the report states.

Among the important components shared among successful local initiatives, according to the report's authors, are a client-centric system of care, community engagement to combat stigma, and sustainable financing.

Lack of outcome data

Those communities that have prioritized interagency coordination have seen promising results. For example, in Bexar County, Texas, where efforts include a jail diversion program and a multi-service substance use treatment and recovery program at the county's Center for Health Care Services, the diversion of more than 17,000 people from county jails and emergency has saved taxpayers more than $10 million a year, according to data released in 2016.

Disappointingly, however, comparatively few communities can cite specific data about the effects of their initiatives. “Few localities have established programs that conduct evaluations tracking long-term client outcomes and financial impact to public agencies,” the report states.

Frohlich adds that given the deadly nature of the opioid crisis, “There should be an additional funding stream for rigorous evaluation.” This in turn would allow for the identification and sharing of best practices.

Frohlich and Cantrell say they hope the report will bring about a greater awareness of what is happening on the ground in local communities. “It felt to us that this angle wasn't being covered,” Frohlich says.