by: Linda Rosenberg
Juan was a delivery driver, but his health problems were putting him at risk
of losing his job. His diabetes was poorly controlled and had caused foot
ulcers that made it difficult for him to walk. He also had bipolar disorder,
which was not being controlled. When he joined the Working Well program in
Harris County, Texas, Juan worked with a case manager to get orthopedic
shoes, to receive support in developing a diabetic diet and exercise plan,
and to make an appointment with a psychiatrist to bring his mental health
condition under control. As a result, Juan was able to continue working full
time as a delivery driver and received a raise for exceptional performance (Bohman,
Stoner, & Chimera, 2009).
Working Well is part of the Demonstration to Maintain Independence and
Employment, which is funded by the Centers for Medicare and Medicaid
Services. The DMIE is one of the federal initiatives currently evaluating
the impact of earlier intervention for people with mental illnesses (earlier
interventions in the context of this article refer to interventions prior to
application for Social Security Benefits but do not include first onset
interventions).
Current federal policy provides support - through Social Security Disability
Insurance and Supplemental Security Insurance - for people who are no longer
able to work. These programs, in turn, act as gateways to health insurance -
Medicare in the case of SSDI and Medicaid for those who quality for SSI.
This safety net is vital for people who are too disabled to work. Once
people qualify for Social Security, however, they rarely move off it,
despite strong evidence that many people with mental health problems want to
and can work. People with mental illnesses now constitute the largest and
most rapidly growing group of Social Security disability beneficiaries, and
every year only 1 percent of people who qualify for SSDI on the basis of a
mental illness leave the rolls and return to work.
The DMIE represents a break with existing policy. Its purpose is to actively
support people who are at risk of becoming too disabled to work, so that
they can remain in their jobs and do not apply for public disability
programs. Two of the demonstration sites, Texas and Minnesota, focus on
people with serious mental illnesses and people with chronic physical health
problems who also have a mental health condition. The ingredients that make
up the service packages in Minnesota and Texas are similar: comprehensive
health insurance, including dental and vision services as well as behavioral
health benefits; employment supports; and a "broker" who works with
participants to help them keep their jobs. The broker’s role is broad; it
can range from helping a participant get an appointment with a psychiatrist
to finding him or her place to live to organizing child care (Gimm &
Weathers, 2007).
Early results are promising. In Minnesota, the DMIE intervention is proving
to be effective in improving clients’ access to healthcare services, health
and functional status, job stability, and earnings. It has also reduced the
number of applications for SSDI (Linkins & Brya, 2009). Analysis indicates
that earlier interventions, such as the DMIE, could make sound financial
sense for the federal government as well as for clients. A new study by
Drake, Skinner, Bond, and Goldman (2009) concluded that providing integrated
behavioral healthcare and supported employment to a third of Social Security
applicants with mental health conditions to help them return to work and
stay off the disability rolls could save the government $48 million in
providing all the necessary services.
One of the challenges of adopting a more comprehensive approach to earlier
intervention is the absence of strong evidence as to how to effectively
support people before they become Social Security beneficiaries. DMIE is one
federal effort to address this evidence gap; the Recovery After, an Initial
Schizophrenia Episode program is another. RAISE is a major new initiative
from the National Institute for Mental Health that will be launched this
summer. For most people, the first onset of schizophrenia occurs in
adolescence or early adulthood. Emerging evidence suggests that intervening
at this point can reduce the likelihood that a patient will develop
full-blown schizophrenia, but researchers have not reached a consensus as to
which early interventions work best. RAISE will test two sets of
interventions to assess whether they can effectively prevent the development
of the condition and reduce long-term disability as a result of mental
illness.
Research has indicated other opportunities for earlier intervention to
prevent long-term dependence on disability programs. A recent study by the
Urban Institute showed that close to 14 percent of recipients of Temporary
Assistance for Needy Families have an emotional or mental health problem (Loprest
& Maag, 2009). States have to meet strict work participation criteria for
the TANF population, and participation in mental health treatment does not
qualify as work participation. As a result, it is often in the state’s
interest to try to move women with mental health problems and other
disabilities onto SSI. A focus on earlier intervention, by contrast, would
seek to address the mental health needs of women on TANF and support them
back into work, following the principle that economic self-sufficiency is in
the best interest of their families. The Social Security Administration is
currently working with the Administration for Children and Families to look
in greater depth- at the movement of beneficiaries between TANF and SSI.
Drake et al. (2009) concluded their analysis of the potential savings from
earlier intervention with several policy proposals. First, they suggested
that states provide supported employment and mental health services early in
the course of mental illness. Initiatives such as the DMIE and RAISE are
testing that approach. Second, they suggested that health insurance be
delinked from disability status. The two recommendations are intimately
connected. For people with any kind of chronic condition, including a mental
illness, access to healthcare is vital. The only way some people can access
healthcare is to qualify for disability benefits. Fear of losing healthcare
then becomes a major barrier to moving off benefits. In this respect,
current discussions around extending health insurance to the uninsured are
particularly important. Earlier intervention will only take hold if patients
have a route to accessing healthcare that does not depend on qualifying for
disability benefits.
About The Author
Linda Rosenberg is the president and CEO of the National Council for
Community Behavioral Healthcare. TNC specializes in lobbying for research
toward the diagnosis and treatment of mental illness, including bipolar
depression. Lean more at
www.thenationalcouncil.org.
Source :
ArticleCity
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