In 2011, the United States Department of Justice (DOJ) investigated the State of Mississippi’s public mental health system, issuing a Findings Letter in December 2011 that alleged the State of Mississippi fails to provide services to qualified individuals with disabilities, including mental illness and intellectual and developmental disabilities, in the most integrated settings appropriate to their needs, in violation of the Americans with Disabilities Act. Since 1997, the United States Department of Justice has been involved with more than two dozen states with regard to allegations of Olmstead/ADA violations. DOJ’s involvement ranges from filing Statements of Interest in cases to formal investigations and the issuing of Findings Letters to States with the hope of states entering into multi-year, multi-million-dollar settlement agreements. In 2009, on the tenth anniversary of the Supreme Court’s decision in Olmstead v. L.C., 527 U.S. 581 (1999), President Obama launched “The Year of Community Living” and directed federal agencies to vigorously enforce the civil rights of Americans with disabilities. Since then, the Department of Justice has made enforcement of Olmstead a top priority.
In 2016, DOJ filed a complaint against the State of Mississippi, alleging that the state failed to provide adults with mental illness with community-based mental health services.
Federal Court Order
Following a four-week trial in the summer of 2019, United States District Judge Carlton Reeves issued a Memorandum Opinion and Order, writing that the United States proved its case, while also acknowledging the complexity of the mental health system and the progress the state made in moving towards a community-based system of care. The Memorandum Opinion and Order stated: “This case is well-suited for a special master who can help the parties craft an appropriate remedy-one that encourages the State’s forward progress in a way that expedites and prioritizes community-based care. The evidence at trial showed what the State needs to do. The primary question for the special master is how quickly that can be done in a manner that is practical and safe for those involved. The parties are therefore ordered to submit, within 30 days, three names of potential special masters and a proposal for the special master’s role. A hearing will be held this fall. The proposals and lists may be separate, but the parties should confer prior to that date to see if there might be any agreed-upon candidates respected, competent, and neutral enough to do the job.”
The Mississippi Department of Mental Health (DMH) was notified in September 2019 that Judge Carlton Reeves issued a Memorandum Opinion and Order in response to the Department of Justice (DOJ) lawsuit. The lawsuit against Mississippi alleged the State has insufficiently complied with the principles of the 1999 Supreme Court case Olmstead v. L.C. In finding the State in violation, the Court recognized the efforts that have been made toward expanding community-based care. In the Memorandum Opinion and Order, Judge Reeves said, “Since the United States has proven its case, the Court could order the remedy proposed at trial by the Department of Justice and its experts. Acknowledging and understanding the complexity of this system, the progress that the State has made, and the need for any changes to be done in a patient centered way that does not create further gaps in services for Mississippians, however, the Court is not ready to do so. The Court is hesitant to enter an Order too broad in scope or too lacking in a practical assessment of the daily needs of the system. In addition, it is possible that further changes might have been made to the system in the months since the factual cutoff. This case is well-suited for a special master who can help the parties craft an appropriate remedy-one that encourages the State’s forward progress in a way that expedites and prioritizes community-based care.”
In his Order, Judge Reeves also acknowledges that, “at no point during the four weeks of trial was any expert willing to parade their home state as an example of a mental health system without flaws. States from every corner of the country have struggled to provide adequate mental health care services. Mississippi has its own unique challenges due to its rural nature and limited funding.”
We want to provide hope to Mississippians by supporting a continuum of care for people with mental illness, alcohol and drug addiction, and intellectual or developmental disabilities. By inspiring hope, helping people on the road to recovery, and improving resiliency, Mississippians can succeed. To help in our mission, over the past several years many services and supports have been expanded and new ones implemented, including mobile crisis response teams, community transition homes, crisis stabilization beds, Programs of Assertive Community Treatment, Intensive Community Outreach and Recovery Teams, supported employment, supported housing, Mental Health First Aid trainings for the public, court liaisons, and Crisis Intervention Teams. DMH is also working to enhance transition planning as people leave the state hospitals and return to their communities. DMH has and will continue its commitment to the mission of the agency and the people of Mississippi.
Order Appointing Special Master
On Tuesday, February 25, 2020, Judge Carlton Reeves issued an order appointing a Special Master, Dr. Michael Hogan. Click here to read the order. Below is background information on Dr. Hogan.
According to the order, “What we need is a seasoned executive to propose a timeline for the State to reach full compliance. By when can the Department of Mental Health and the Division of Medicaid deliver the necessary community-based services-realistically-and how should we measure success along the way?” The order mentions the “complexity of this system, the progress that the State has made, and the need for any changes to be done in a patient-centered way that does not create further gaps in services for Mississippians.” This was also mentioned in Judge Reeve’s Memorandum Opinion and Order in September 2019.
Michael Hogan, PhD, served as New York State Commissioner of Mental Health from 2007 to 2012, and now operates a consulting practice in health and behavioral health care. The New York State Office of Mental Health operated 23 accredited psychiatric hospitals, and oversaw New York’s $5 billion public mental health system serving 650,000 individuals annually. Previously Dr. Hogan served as director of the Ohio Department of Mental Health (1991 to 2007) and commissioner of the Connecticut Department of Mental Health from 1987 to 1991. He chaired the President’s New Freedom Commission on Mental Health in 2002-2003. He was appointed as the first behavioral health representative on the board of The Joint Commission in 2007, and as a member of the National Action Alliance for Suicide Prevention in 2010. He served (1994-1998) on the National Institute on Mental Health’s National Advisory Mental Health Council, as president of the National Association of State Mental Health Program Directors (NASMHPD) (2003-2005), and as board president of NASMHPD’s Research Institute (1989-2000). His awards for national leadership include recognition by the National Governor’s Association, the National Alliance on Mental Illness, the Campaign for Mental Health Reform, the American College of Mental Health Administration and the American Psychiatric Association. He is a graduate of Cornell University, and he earned a MS degree from the State University College in Brockport, New York, and a PhD from Syracuse University. (Information provided by National Health Policy Forum)
State Report to Court Order
The State of Mississippi filed a response and report to the court on Friday, April 30, 2021. The report includes an overview of core community-based services, which includes intensive community services, crisis response services, peer support services, supported employment, and permanent supportive housing. Mississippi has continued to expand these services since December 31, 2018, the trial evidentiary cut-off date, and there has been increasing availability of these services since the trial took place in 2019.
Intensive community services includes PACT, ICORT, and ICSS. Mississippi had eight PACT teams as of December 31, 2018, but now has 10. As of December 31, 2018, Mississippi had no ICORTs. Mississippi has developed ICORT as a modification of the PACT model to provide intensive community services in less densely populated/rural counties. Mississippi is implementing and will sustain a total of 16 ICORTs in the state. The state will also fund and sustain 35 full-time Intensive Community Support Service positions.
The state will also fund and sustain Mobile Crisis Response Teams, with one team in each CMHC region except Region 12, which is operating one team in Hattiesburg and another in the former Region 13. Mississippi now has crisis residential services provided through Crisis Stabilization Units for every CMHC region except Region 11, though funds are available to implement those services. Prior to 2019, Mississippi had only eight, 16-bed CSUs; the state now has 13 CSUs and a capacity of 172 crisis residential beds for adults in mental health crisis.
The expansion of services and supports since 2018 has also included Peer Support, Supported Employment, Supportive Housing, and more. Response to Court Order, Report, and Exhibits – April 2021.
Court Appointed Monitor and Report
In September 2021, United States District Judge Carlton Reeves appointed Dr. Michael Hogan to serve as monitor in this case. The order of appointment sets out Dr. Hogan’s duties as follows:
- The Monitor shall assess compliance with each obligation in the Court’s Remedial Order and shall provide the State with technical assistance as necessary to support the State in reaching compliance.
- While conducting the Monitor’s regular assessment, the Monitor shall review and validate data and information, speak with State officials, providers, and individuals receiving services, and participate in the annual Clinical Review required by the Remedial Order. When speaking with State officials, counsel for the State may be present.
- The Monitor shall provide written reports on the State’s compliance with the Remedial Order every six months. Each report shall describe the State’s level of compliance (e.g., noncompliance, partial compliance, or substantial compliance) as to each obligation in the Remedial Order and include a summary of the data that led to the Monitor’s assessment of compliance.
- The written reports shall be filed on the Court’s docket and the Court will hold a status conference following submission of each report. The Parties shall establish procedures for review and comment on draft reports by the State and the United States before the reports are filed with the Court.
In March 2022, Dr. Hogan released the first Report of the Court Monitor. In this first report, Dr. Hogan acknowledges the stresses that have been caused by the global COVID-19 pandemic and the challenges that have resulted for people who depend on and provide care. He noted that this first report is a “stage setting” report that includes some early findings on compliance, as well as background and context on mental health care in Mississippi. He stated that future reports will focus more exclusively on compliance with the court order, but that it is not possible at this time of this first report to to make definitive determinations of compliance for many requirements of the order. The first report includes an appendix titled The Context of Care and Compliance in Mississippi that is intended as a complement to the assessments of compliance, with Dr. Hogan noting he hopes the information and perspectives there are useful to stakeholders and officials.
The Mississippi Department of Mental Health has appreciated working with Dr. Hogan during his visits to the state, and has also appreciated the opportunity to provide him with the data he has requested. His report acknowledges progress that has been made in the state’s mental health system in a variety of areas, such as the facilitation of a warm hand-off in the discharge transition process. DMH plans to continue enhancing this process over the next year, including partnering with the Community Mental Health Centers to complete intakes prior to discharge. The agency also appreciate that he acknowledges the effectiveness of intensive community services like PACT and ICORT as these services relate to the data around readmissions to state hospitals. DMH is moving forward with conducting fidelity reviews for PACT, ICORT, ICSS, Supported Employment, and Mobile Crisis listed in the remedial order. More initiatives under way are planned to assist with crisis services, including the implementation of the 988 system. DMH has also proposed the utilization of federal ARPA funding to expand he number of Crisis Stabilization Unit beds in the state by approximately 60 beds, to add 18 court and law enforcement liaisons around the state to intervene during the commitment process and connect people to appropriate services in their communities, and to pilot three peer support respite programs that offer support to individuals at risk of a behavioral health crisis. The agency has recently provided training for judges and other judicial professionals on mental health services and alternatives to civil commitment, as well as facilitated technical assistance from experts from other states for several topics relevant for Mobile Crisis Response Teams. DMH is also working with several other states on technical assistance related to several of the areas in the order as well, and is adding an Office of Utilization Review to be responsible for tracking and analysis of the utilization of behavioral health services for state operated programs and key community-based services.
DMH is committed to expanding the availability of community-based services in Mississippi.
Progress Update on the Mississippi Mental Health System
Since the DOJ issued its Findings Letter in 2011, DMH and the public mental health system have continued to make strides to improve the availability of community-based services for individuals with a mental illness and/or intellectual and developmental disabilities. Included below are examples of the progress the State has made.
Shift From Institutional Budgets
With state source level funding in FY19, DMH shifted funds from institutional budgets to the Service Budget to expand community-based services to reduce the reliance on institutional care. A total of $8 million was granted to the 14 Community Mental Health Centers (CMHCs) for the expansion of crisis services, including crisis stabilization beds, court liaisons, crisis counselors, and an additional PACT team. In addition, $900,000 is for the continuation/expansion of the development of Community Transition Homes, which are community-based living opportunities for individuals that have been receiving continued treatment services at Mississippi State Hospital. A total of $400,000 is for the continuation of jail-based competence education project involving Forensic Services at Mississippi State Hospital.
Since 2011, the number of people served at DMH’s behavioral health hospitals and the number of beds available at those programs has decreased. In FY11, 4,119 adults received acute psychiatric services at the four state hospitals, while 258 adults received continued treatment services. In FY20, 2,197 adults received acute psychiatric services and 85 received continued treatment services. Bed capacity has also decreased. In FY11, there were 646 acute psychiatric beds available at the four state hospitals. As of July 2019, there were 401, including 75 beds available for continued treatment services. As of July 2020, there were 391 acute psychiatric beds, including 65 beds available for continued treatment services.
Crisis Stabilization Units
The role of a Crisis Stabilization Unit is to provide stabilization and treatment services to persons who are in psychiatric crisis. Many people with mental illness can be treated at the unit and returned to the community without an inpatient admission to the state psychiatric hospital. The beds offer time-limited residential treatment services designed to serve adults with severe mental health episodes that if not addressed would likely result in the need for inpatient treatment. The more quickly a person receives treatment, as opposed to being “held” without treatment, the less likely his or her condition will worsen. An individual can receive involuntary and voluntary treatment at a Crisis Stabilization Unit. After treatment, individuals will already be connected with their local Community Mental Health Center. As of July 2020 there are 13 Crisis Stabilization Units that include 172 beds. Previously, there were eight, 16-bed Crisis Stabilization Units across the state. The funding shift from DMH programs to the DMH Service Budget in FY19 allowed additional crisis stabilization beds to open in CMHC regions that did not have CSUs: LifeCore Health Group (Region 3) opened eight crisis beds in Tupelo; Community Counseling Services (Region 7) opened eight beds in West Point; Singing River (Region 14) opened eight beds in Gautier; Hinds Behavioral Health Services (Region 9) opened 12 beds in Jackson; and Region One Mental Health Center opened eight beds in Marks. Additional funding is available for CSU services in Region 11. In FY20, the CSUs served 3,525 individuals.
Mobile Crisis Response Teams
In 2014, each of the 14 Community Mental Health Centers (CMHCs) developed a Mobile Crisis Response Team (MCRT) to provide community-based crisis services to the location where an individual is experiencing a crisis. These MCRTs deliver solution-focused and recovery-oriented behavioral health assessments and crisis stabilization services, working hand-in-hand with local law enforcement, Chancery Judges and Clerks, and the Crisis Stabilization Units to promote a seamless process. The Teams ensure an individual has a follow-up appointment with his or her preferred provider and monitor the individual until the appointment takes place. In FY18, the Teams provided 18,651 face-to-face interventions. A total of 27,349 calls were received by the Teams in FY19. Out of those calls, 21,366 were diverted from a more restrictive environment, and 20,529 calls involved face-to-face interaction. In FY20, Mobile Crisis Response Teams received 36,921 calls. Out of those calls, 31,017 were diverted from a more restrictive environment, and 20,322 involved face-to-face interaction.
Programs of Assertive Community Treatment (PACT) Teams
In 2011, Mississippi had two PACT Teams. Now, Mississippi has 10 PACT Teams that are operated by the following Community Mental Health Centers (CMHCs): Warren-Yazoo Behavioral Health, Life Help, Pine Belt Mental Healthcare Resources (operates one in Hattiesburg and one on the Gulf Coast), Hinds Behavioral Health, Weems Community Mental Health Center, Life Core Health Group, Region 8 Mental Health Center, and Timber Hills Mental Health Services (operates one in Desoto and one in Corinth). PACT is a person-centered, recovery-oriented, mental health service delivery model for facilitating community living, psychological rehabilitation and recovery for persons who have the most severe and persistent mental illnesses and have not benefited from traditional outpatient services. PACT Teams are mobile and deliver services in the community to enable an individual to live in his or her own residence. In FY19, 500 people received services through PACT Teams. In FY20, 535 people received services through PACT Teams.
Intensive Community Outreach and Recovery Teams (ICORT)
In FY19, DMH piloted an Intensive Community Outreach and Recovery Team (ICORT), with the Region 2 CMHC, Communicare. In FY20, DMH provided four grants for ICORTs in regions that did not have a PACT Team. ICORTs are able to target more rural areas where there may be staffing issues or clients are spread out over a large geographical area. ICORT is a recovery and resiliency oriented, intensive, community-based rehabilitation service for adults with severe and persistent mental illness. ICORTs are mobile and deliver services in the community to enable an individual to live in his or her own residence. An ICORT has fewer staffing requirements and higher client to staff ratios than a traditional PACT Team. An ICORT is staffed with registered nurse, a Master’s level Mental Health Therapist, a Certified Peer Support Specialist, and an administrative assistant. ICORT can also utilize a part-time Community Support Specialist if needed. Services are provided 24-hours per day, 7-days a week just like PACT. An ICORT is an opportunity for CMHCs that are unable to sustain a PACT Team to provide a similar intensive service to help keep people out of the hospitals.
At the end of FY20, there were six ICORTs operating in Mississippi, with 115 people receiving services through those teams. In FY21, ICORT expanded to 16 teams in the state.
Intensive Community Support Services
Intensive Community Support Services are provided by specialists who have a direct involvement with the person receiving services and are designed to be a key part of the continuum of mental health services and supports for people with serious mental illness. Mississippi is providing funding for 35 ICSS specialists throughout the state.
These services are similar to targeted case management, but they maintain lower client to staff ratios and provide services primarily in the community instead of office settings. In FY21, Regions 3, 6, 9, and 10 each received grants for two ICSS, and Region 11 received a grant for four additional ICSS. Each county in Mississippi now has access to intensive community services through either one or more PACT, ICORT, or ICSS service.
CHOICE Housing Program
Supported Housing is available in Mississippi through a program known as CHOICE – Creating Housing Options in Communities for Everyone. CHOICE ensures people with a serious mental illness can live in the most integrated settings in the communities of their choice by providing an adequate array of community supports/services. While CHOICE provides the assistance that makes the housing affordable, local Community Mental Health Centers provide the appropriate services. The CHOICE program is a partnership between DMH, Mississippi United to End Homelessness, Open Doors Homeless Coalition, Mississippi Home Corporation, and the CMHCs. In June 2019, CHOICE housed the 600th person through its program. In FY20, 258 people received housing services through CHOICE.
Supported Employment programs for people with severe mental illness have also expanded. In FY18, there were four Supported Employment sites, located in Regions 2, 7, 10, and 12. These sites provided Supported Employment through an Individual Placement and Support (IPS) program. To help expand the programs, DMH provided funding in the second quarter of FY19 to Community Mental Health Centers to add seven more Supported Employment programs at Regions 3, 4, 8, 9, 11, 14, and 15. This Supported Employment Expansion program is taking place through a partnership and memorandum of understanding with the Mississippi Department of Rehabilitation Services. Through the collaboration, CMHCs have hired or designated Supported Employment Specialists to work alongside vocational rehabilitation counselors to coordinate employment services and monitor the health of the employees. There were 280 people employed through these Supported Employment programs in FY20. In the first half of FY21, Supported Employment expanded to the remaining CMHC regions that did not have a program. All CMHCs now provide Supported Employment through the IPS program or the Supported Employment Expansion partnership.
Community Transition Homes
As part of the shift in funding from the institutional budgets to the Service Budgets, DMH moved $900,000 to continue and expand the development of Behavioral Health Homes for individuals who have been receiving continued treatment services at Mississippi State Hospital. DMH, Region 8 Community Mental Health Center, Hinds Behavioral Health Services, and The Arc of Mississippi have partnered to provide community-based living opportunities for individuals that have been receiving continued treatment services at Mississippi State Hospital. Region 8 began a Community Transition Home for four females in Simpson County in April 2018 and have added an additional house for four more females. Region 9 began a Community Transition Home in May 2018 for four males in the Jackson area. Individuals served in these homes have been unsuccessful living in the community in the past. Now, with 24/7 support and assistance, the individuals pay their own rent, purchase their own food and participate in the community.
Certified Peer Support Specialists
Mississippi’s Certified Peer Support Specialist (CPSS) Training is an intensive, 34-hour course followed by a written exam. CPSSs are individuals who self-identify as a family member or an individual who received or is currently receiving mental health services. Upon completion of the training, successfully passing the CPSS examinations, and obtaining employment by a DMH certified provider, participants become Certified Peer Support Specialists. The training and certification process prepares CPSSs to promote hope, personal responsibility, empowerment, education, and self-determination in the communities in which they serve.
The first CPSSs with a designation of a Parent/Caregiver completed their training at DMH in March 2017. The Parent/Caregiver designation is an expansion of the CPSS Program. This designation of peers focuses on those who will be working with children with behavioral health issues. The training is a customized, two-day block within the current CPSS training program. In FY19, a total of 20 Parent/Caregiver designations were received.
In June 2019, DMH completed the first training for people with a designation of Youth and Young Adult CPSS. A Youth/ Young Adult Peer Support Specialist is a person between the ages of 18-26 with lived experience with a behavioral health or substance use diagnosis. Thirteen young people participated in the training, which was developed in conjunction with NAMI Mississippi. The Youth and Young Adult training is a 2.5-day block in the CPSS training that consists of several youth-specific modules.
A designation of CPSS – Recovery designation was developed throughout 2020 as a designation for adults with lived experience of substance use disorder. The first training took place in September 2020 with 24 participants. Mississippi held five CPSS Trainings in FY20. During the year, six young people participated in the CPSS Young Adult training, which was developed in conjunction with NAMI Mississippi. Also in FY20, a total of 33 Parent/Caregiver designations were received. DMH also continues to use CPSS Ambassadors to support CPSSs and educate interested stakeholders about peer support. FY20 was the first year to utilize CPSS Ambassadors to support CPSSs upon hire and provide individualized support for up to six months.
At the end of FY20, there were 271 CPSSs (actively employed) in Mississippi.