Cuyahoga County is often considered a bellwether for mental health services. It's home to some of the most respected clinical programs in the state, and a disproportionately high number of people with severe mental disturbances. This is the place to find agencies making the best of a complicated situation.
Mental Health Services, one of the county's thirty-four provider agencies, maintains an extremely quiet, 12-bed facility in the upper story of a Midtown Cleveland building. This is a transitional home for people with serious mental illnesses, and it's here we found a man we'll call Joshua. He's 48 this year but looks much older. He's diagnosed with schizophrenia and AIDS, and spent many years on the street before coming here.
Joshua: Oh I've been out a long time - I stayed down in the welfare building, across from the welfare building.
Joshua has some family in town, but his condition is too serious for the average household to deal with. Besides, he doesn't stay in one place long if he can help it. Part of the reason he's spent so much time homeless is that he hears spiritual voices that urge him to keep on the move.
Joshua: I have to travel. (April, off mike: "How come?") When God sends me, God sends me, I go, wherever he's at. (April, off mike: "If you weren't here right now, where do you think you'd be staying?") Under the bridge! (Laughs)
It took the staff of this agency seven years to form a relationship with Joshua strong enough to convince him he should come to Safe Haven.
Steve Friedman: He's not the kind of fella who will walk into an agency and say 'help me'.
Steve Friedman, is the executive director of Mental Health Services.
Steve Friedman: He will be on the streets or at a shelter and he needs very specialized services that will work over a long period of time to engage him, to get him interested in treatment. And that does take a long time with people like him. The value of these outreach services is that it find clients who are very appropriate for the community mental health system, they meet all the criteria, but they themselves don't identify themselves as needing treatment and even if they do they won't seek it out.
Friedman wishes he could reach them all, but because of the way mental health is funded, there's very little money available for things the state's menu of Medicaid services - things like office visits, short hospital stays, and medication. Friedman says for someone like Joshua, psychiatric help is very important. But doctor visits become meaningless when consumers have no place to live. Like many others across the state, Friedman believes that if Ohio continues to limit Medicaid to clinical services, the funding crisis will deepen.
Even agencies that are doing relatively well have become extremely frustrated by the funding limits on support services. Cleveland's Positive Education Program, or PEP, is a widely recognized success story. It provides help for kids with behavioral problems, like 14-year-old Aminah, a budding musician whose home life has been less than stable. When she was enrolled at Cleveland's School of the Arts, Aminah's rambunctious behavior landed her in trouble a lot. PEP placed her in a small class with plenty of supervision-three teachers for about ten kids.
While Aminah's very lively and articulate, her behavioral problems give her difficulty with things that most people would consider ordinary. But PEP's teachers are trained to help kids spot the patterns of their behavior, and teach them how to deal with it, through highly-structured activities.
Aminah: It helps me work on my anger, calm myself, calm down, instead of getting real mad. We have goals to accomplish - when someone makes me mad I try not to use sarcasm against them. And we have contracts. They diagnosed me ADHD, and I have a LOT of energy. So they let me walk around. I get three walks a day. And if I can do that, they reduce them.
Aminah's main goal is to go back to the school of the arts and resume her studies in voice and cello. Her mother believes she's making progress - the hurricane-force tantrums have all but stopped. Her treatment story is a success, but ironically, the integrated approach that makes the program work also what makes it tricky to fund. PEP's executive director Frank Fescer.
Frank Fescer: The Medicaid system clearly distinguishes between mental health and education. So anything that is considered academics, is not billable.
These things are in the real life of the kid. You can't separate out when they're going to have an emotional conflict, and what it's going to be about. And often times it is around academics. The part that is billable - through partial hospitalization money - is group work, individual counseling, those kinds of things that occur around a crisis, when you're helping a child to regroup and refocus. And throughout the course of the day this happens frequently.
Depending on what happens at the statehouse this week, PEP may lose even this limited guarantee of funding. This week leaders in the Ohio department of mental health proposed eliminating Medicaid funding for partial hospitalization, as part of the continuing effort to balance the state budget.
PEP's solution to the dilemma is by going outside the mental health system for funding. It now relies on school districts, which pay tuition for students like Aminah. Even with that extra revenue, there are dozens of support services PEP provides for kids and their families, for which the agency is never compensated.
Frank Fescer: You have to do things sometimes, like help mom get a job. That's not billable under Medicaid. You have to connect Dad up with AA sometimes. A lot of work is done to stabilize the environment in which the child lives every day is necessary for the kid's growth. But it's not billable.
Some have suggested that Cuyahoga County could relieve the pressure on agencies like PEP and Mental Health Services by increasing local funding for services. Right now, Cuyahoga County's Human Services levy generates about $14 million per year for community-based services. Franklin County, the only one whose caseload is comparable, raised forty million dollars in a similar levy last year. While that forty million is meant for both mental health AND addiction programs, it still represents a much greater financial commitment.
Also state leaders have considered asking the federal government for a Medicaid waiver, which would give more leeway in spending state Medicaid dollars to all Ohio's mental health agencies. Those discussions are still underway. For ideastream, I'm April Baer in Cleveland.