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King County, WA, Ordinance Requiring Psychiatrists to Keep Track of How many People They Make Well:
 Passed Oct. 16, 2000.

AN ORDINANCE improving customer service and performance measurement for clients in the publicly-funded mental health system; and adding a new chapter to K.C.C. Title 2.

 

PREAMBLE:

A Wall Street Journal article (New Weapons in the War on Schizophrenia, August 25, 1999) noted that the economic cost to the United States of just one mental illness, schizophrenia, is thirty to sixty-five billion dollars per year, with two million five hundred thousand persons afflicted. According to the National Institute of Mental Health, depression cost thirty million four hundred thousand dollars in 1990 and currently affects another nineteen million Americans.

The 1999 Mental Health Report issued by the Surgeon General validated the costs of mental illness are exceedingly high. The direct costs of mental health services in the United States in 1996 totaled sixty-nine billion dollars. This figure represents 7.3 percent of total health spending. The indirect costs of mental illness include lost productivity at the workplace, school and home due to premature disability or death. In 1990, the indirect costs of mental illness were estimated at seventy-eight billion dollars. In summary, mental illness causes incalculable damage to individuals and families.

According to a New York Times article (Prisons Brim With Mentally Ill, Study Finds, July 12, 1999), jails and prisons have become the nation's new mental hospital. This is supported by the fact that the number of jail and prison beds has quadrupled in the last twenty-five years, with one million eight hundred thousand Americans behind bars.

The Times article reporting on a United States Justice Department study goes on to say that mentally ill inmates tend to follow a revolving door from homelessness to incarceration and then back to the streets with little treatment, many of them arrested for crimes that are related to their illness.

According to Kay Redifield Jamison, professor of psychiatry at Johns Hopkins School of Medicine, "there is something fundamentally broken in a system that covers both hospitals and jails."

Again, according to the New York Times, with the "wholesale closings of public mental hospitals in the 1960's, and the prison boom of the last two decades, jails are often the only institutions open 24 hours a day and required to take the emotionally disturbed."

Until recently, some severe mental disorders were generally considered to be marked by lifelong deterioration. Negative conceptions of severe mental illness perpetuated in part in professional literature dampened consumers’ and families expectations leaving them without hope. However, recent research provides a scientific basis for and supports a more optimistic view of the possibility of recovery.

Promoting recovery has become the rallying point for the consumer and family movement (1999 Mental Health Report from the Surgeon General). Throughout 1999 the public debate about mental health issues raised expectations about the recovery model as mentioned by providers, clients, advocates and citizens.

King County budgeted $90,199,426 to the mental health division to serve approximately twenty-eight thousand persons as well as budgeting significant dollars for related services in 2000.

The county’s mental health system has made great strides in recent years in developing a safety net for its clients. While that is an improvement over the system that existed thirty years ago, there is a need to seek further improvements that will help clients recover.

As the mental health system implements the integration of the inpatient and outpatient system in 2001, recovery is expected to be a key theme in individual treatment planning. Successful caregivers recognize that a client will recover or lead a more productive life when there is a high expectation that as a result of treatment, the quality of the client’s life will improve. Specifically, the division should assure contracts with caregivers promote an atmosphere of treatment that focuses on the importance of progression towards recovery and wellness.

BE IT ORDAINED BY THE COUNCIL OF KING COUNTY:

SECTION 1. Purpose. The purpose of this ordinance is to establish a policy framework in which the county's mental health system shall seek to assist clients to recover or become less dependent on the publicly funded mental health system.

SECTION 2. Codification. Sections 3 through 6 of this ordinance should constitute a new chapter in K.C.C. Title 2.

SECTION 3. Definitions. The definitions in this section apply throughout this ordinance unless the context clearly requires otherwise.

A. "Benefit period" means a defined course of treatment as determined by the King County mental health, chemical abuse and dependency services division or its successor.

B. "Dependence" and "dependent" mean the client experiences significant disability, is not employable, and is served by the publicly funded mental health system and other programs. A dependent client may be characterized as having a GAF score of 50 or below.

C. "GAF score" means Global Assessment of Function Scale score.

D. "Less dependence" and "less dependent" mean the client exhibits some disability, but significantly less than that of a dependent client. A less dependent client has made progress toward recovery, improved self-esteem, and enhanced quality of life and is more functional living in the community. A less dependent or recovering client may be characterized as having a GAF score between 51 and 80.

E. "Mental health system" means the publicly funded mental health system administered by the King County mental health, chemical abuse and dependency services division or its successor agency.

F. "Recovered" means that the client meets all of the following criteria:

1. The client is, whenever possible, engaged in volunteer work, pursuing educational or vocational activities, employed full or part-time, or is engaged in other culturally appropriate activities;

2. The client lives in independent or supported housing;

3. The client has been discharged from the county’s publicly funded mental health system or is receiving infrequent maintenance services to sustain their recovery; and

4. The client may be characterized as having a GAF score of 81 or above.

G. "Recovery" is a process, a way of life, an attitude, and a way of approaching the day’s challenges. It is the hope and expectation that a meaningful life is possible despite mental illness. Recovery emphasizes the restoration of self-esteem and on attaining meaningful roles in society. Recovery includes development of self-esteem through active participation in society.

SECTION 4. Goal of the mental health system. A central goal of the county's mental health system is to assist individuals in progressing towards recovery while achieving and maintaining the highest level of social, emotional and physical functioning possible. The county’s mental health system should support this goal by formulating plans and policies that increase the likelihood that persons with severe mental illness can have access to quality care that is comprehensive and culturally appropriate to achieve those goals.

SECTION 5. Improved customer service through better expectations. The division shall assure contracts with providers address development of individual treatment plans that engender realistic expectations for recovery in all aspects of clients’ lives. Within six months of the effective date of this ordinance, the division shall submit a written report to the county council on steps taken to develop an atmosphere of treatment in which the expectation is that clients identify personal goals with a focus on the importance of a progression toward recovery and wellness through engaging in activities that meet typical societal norms or cultural expectations.

SECTION 6. Annual reporting requirements.

A. To fulfill the purposes of this section, the mental health division or its successor agency shall annually evaluate all mental health clients receiving outpatient and residential services in the age range of twenty-one through fifty-nine years to determine the clients’ status and shall review the following outcome measures: 1. employment; 2. level of functioning; and 3. housing information.

B. The mental health division or its successor agency shall provide a written report annually to the council. The first report must be submitted by April 30, 2002, and shall describe the performance of the mental health system during the previous calendar year, January 1-December 31, 2001. Since the mental health system will implement a new recovery-based treatment model on or about January 1, 2001, the first report shall be a transition report. The mental health division report must indicate achievements related to the outcome measures referenced in this section. The report must describe those clients in a calendar year who have completed at least one benefit period during that year. Additionally, the report shall indicate the number of clients at the beginning and end of a benefit period who are in a category of dependence, less dependence, recovered but require infrequent maintenance services to sustain their recovery, recovered and have been discharged from the system, and those who have left the system because of some other reason. The report shall indicate by category the number of clients who have progressed, regressed or remained unchanged and, for those clients who have changed, the extent of progression or regression by category.

C. The annual report must list by diagnostic category the percentage of clients covered who have improved their quality of life according to the outcome measures. At a minimum, schizophrenia and depression, including major depressive, bipolar and dysthymic disorders, must be included in the diagnostic breakdown.

D. It is recognized that performance measurements are more easily achieved for adult clients in their traditionally most productive years. There are greater challenges in developing a methodology of applying performance measurements to younger clients, age twenty or less, and to older clients, age sixty or greater. Nevertheless, younger and older clients are very important segments of the client population, and after gaining experience with the provisions of this chapter, the division is encouraged to make recommendations to the council on ways to achieve appropriate annual reporting requirements for other age groups.

Ordinance 13974 was introduced on 5/8/00 and passed by the Metropolitan King County Council on 10/16/00, by the following vote:

 

Yes: 11 - Mr. von Reichbauer, Ms. Fimia, Mr. Phillips, Mr. Pelz, Mr. McKenna, Ms. Sullivan, Mr. Nickels, Mr. Pullen, Mr. Gossett, Ms. Hague and Mr. Irons No: 1 - Ms. Miller Excused: 1 - Mr. Vance

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