U.S. DEPARTMENT OF HEALTH & HUMAN SERVICES

Substance Abuse & Mental Health Services Administration

Center For Mental Health Services

www.samhsa.gov

2005
ii Trends in Mental Health System Transformation: The States Respond 2005

Numerous people contributed to the development of this document. The document 

was written by Susan Hills of the Advocates for Human Potential, Inc., and AFYA 

Inc., under Contract Number 280-02-0400, with Substance Abuse & Mental Health 

Services Administration (SAMHSA), U.S. Department of Health and Human Services (DHHS). Deborah Baldwin served as the Government Project Officer. 

Acknowledgments

Disclaimer

The views, opinions, and content of this 

publication are those of the author and 

do not necessarily reflect the views, opinions or policies of SAMHSA or DHHS. 

Public Domain Notice

All material appearing in this report is 

in the public domain and may be reproduced or copied without permission from 

SAMHSA. Citation of the source is appreciated. However, this publication may 

not be reproduced or distributed for a fee 

without the specific, written authorization of the Office of Communications, 

SAMHSA, DHHS. 

Electronic Access 

and Copies of Publication

This publication may be accessed electronically through the following Internet World Wide Web connection: www.

samhsa.gov. For additional free copies 

of this document, please call SAMHSA’s 

National Mental Health Information 

Center at 1-800-789-2647 or 1-800-889-

2647 (TTD).

Recommended Citation

Trends in Mental Health Systems Transformation: The States Respond. DHHS 

Pub. No. (SMA) 05-4115. Rockville, MD: 

Center for Mental Health Services, Substance Abuse and Mental Health Services 

Administration, 2006.

Originating Office

State Planning and Systems Development Branch, Division of State and Community Systems Development, Center 

for Mental Health Services, Substance 

Abuse and Mental Health Services Administration, 1 Choke Cherry Road, 

Rockville, MD 20857

DHHS Publication No. (SMA) 05-4115

Printed 2006
iii Trends in Mental Health System Transformation: The States Respond 2005

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

 Overarching Trends 2005 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

 The Role of Planning Councils in State Systems . . . . . . . . . . . . . . . . . . . . . . . . 5 

 GOAL 1: 10

Americans Understand that Mental Health Is Essential to Overall Health

 Reducing Stigma, Raising Awareness . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11

 Preventing Suicide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14

 Addressing Mental Health with the Same Urgency as Physical Health . . . . . . . . . . 16

 GOAL 2: 18

Mental Health Care Is Consumer and Family Driven

 Person-Centered Planning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .20

 Consumer Input into System Design . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .21

 Consumer Involvement in Service Delivery and Support . . . . . . . . . . . . . . . . . .22 

 Protecting Consumer Rights . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .23

 Housing for Consumers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .24

 Supported Employment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .24

 Mental Health and the Justice System . . . . . . . . . . . . . . . . . . . . . . . . . . . . .25

 Creating a Comprehensive State Mental Health Plan . . . . . . . . . . . . . . . . . . . .26

 Financing Mental Health Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .27

 GOAL 3: 28

Disparities in Mental Health Services Are Eliminated 

 Recognizing Disparities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .29

 Building an Infrastructure to Support Cultural Competence . . . . . . . . . . . . . . . .30

 Addressing Consumer Needs Across Cultures . . . . . . . . . . . . . . . . . . . . . . . . .31

 Reaching Rural Populations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .32

GOAL 4: 34

Early Mental Health Screening, Assessment, and Referral to Services Are Common Practice

 Promoting the Mental Health of Young Children . . . . . . . . . . . . . . . . . . . . . . .35

 Improving and Explaining School Mental Health Programs . . . . . . . . . . . . . . . .39 

 Screening, Assessment, and Referral . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .41 

 Moving Toward Integrated Services for Co-Occurring Disorders . . . . . . . . . . . . . .42 

 Transitioning Youth to Adult Programs . . . . . . . . . . . . . . . . . . . . . . . . . . . . .45

 Providing Mental Health Services to Older Adults . . . . . . . . . . . . . . . . . . . . . .46 

 Linking Mental Health with Primary Care Services . . . . . . . . . . . . . . . . . . . . . . .48 

cont.

 Contents
iv Trends in Mental Health System Transformation: The States Respond 2005

GOAL 5: 50

 Excellent Mental Health Care Is Delivered and Research Is Accelerated

Planning and Guiding State Use of Evidence-Based Practices . . . . . . . . . . . . . . .51

 Promoting Evidence-Based Practices Through Education . . . . . . . . . . . . . . . . . .52 

 Evidence-Based Practices in Action . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .54 

 Promising and Emerging Practices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .57 

 GOAL 6: 58

 Technology Is Used to Access Mental Health Care and Information

Using Telehealth to Improve Access and Coordination of Mental Health Care . . . . . .59

 Developing and Implementing Integrated Electronic Health Records . . . . . . . . . . .60 

 Providing Health Information to Consumers . . . . . . . . . . . . . . . . . . . . . . . . .61 

 State-Developed Resources Available to Others . . . . . . . . . . . . . . . . . . . . . . .63

 Contents
Trends in Mental Health System Transformation: The States Respond 2005 1

The Community Mental Health Services Block Grant, administered by the Center 

for Mental Health Services (CMHS) in the Substance Abuse and Mental Health Services Administration (SAMHSA), U.S. Department of Health and Human Services 

(DHHS), is awarded to States, Territories, and the District of Columbia (collectively 

referred to as States) to establish or expand a community-based system of care for 

adults with serious mental illnesses and children with serious emotional disturbances. States request funds by submitting annual applications (State Plans) that are approved by the Secretary of DHHS to receive Mental Health Block Grant funding. 

In 2005, development of State Plans was guided by several intersecting factors: 1) 

SAMHSA’s National Outcome Measures (NOMS); 2) the Office of Management and 

Budget’s Program Assessment Review Tool (PART) score; 3) the final report of the 

President’s New Freedom Commission on Mental Health; and 4) SAMHSA’s Mental 

Health Transformation Action Agenda. The Commission’s report, entitled Achieving 

the Promise: Transforming Mental Health Care in America, provides clear direction 

in the form of concrete goals and recommendations for achieving the promise of 

community integration that echoes SAMHSA’s vision of “a life in the community for 

everyone.” The Commission recognized that much of the work of system transformation takes place at the State and local level, using Federal resources as a catalyst for 

change. Indeed, States are at the very heart of mental health system transformation; 

their work informed, and is informed by, the work of the President’s Commission. 

In 2005, CMHS focused its mandated review of State Plans on the States’ efforts to 

use Block Grant funds to address the New Freedom Commission’s goals and recommendations. States are using Block Grant dollars—as well as other Federal and State 

funds, local resources, and private contributions—to transform the mental health 

service delivery system in their States from one dictated by outmoded bureaucratic 

and financial incentives to one driven by consumer and family needs that focuses on 

building resilience and facilitating recovery. 

This 2005 report summarizes the activities that States are pursuing within the 

framework of the six goals articulated by the Commission. The report includes the 

following: 

• A brief summary of overarching trends, including challenges States face 

in their transformation efforts;

• An overview of activities of the State Mental Health Planning Councils;

• Activities of the States discussed goalby goal, with 25 State programs 

featured in side-bars to represent accomplishments to date; and

• A table of State-developed resources listed according to goals addressed. 

Introduction
2 Trends in Mental Health System Transformation: The States Respond 2005

Introduction

In addition, a companion CD to this report presents a profile for each of the States 

that captures key transformation activities based on the New Freedom Commission’s 

goals. Profiles on the CD are presented both State by State and as a single comprehensive file. The search function in the comprehensive file helps users locate crossState information, such as all States with supported employment programs.

Information in this report comes from three primary sources:

• 2005 Block Grant applications and 2004 implementation reports;

• Facilitated discussions with Federal reviewers and technical assistance staff; and

• Communication between States and the staff that compiled this report.

It should be noted that where lists of States that employ specific strategies appear, 

these lists are illustrative but not exhaustive. Because all States are involved in multiple activities related to the New Freedom Commission’s six goals, it is impossible to 

catalogue them completely. 

Activities highlighted in this report are funded by Block Grant dollars and by other 

resources. Each State profile articulates the ways that a State uses its Block Grant 

funding. Even though Block Grant funds represent a small percentage of State mental health budgets, State representatives have observed that this funding has an impact disproportionate to its size. In addition to funding State Mental Health Planning 

Councils, which bring diverse stakeholders together to play an often critical role, States 

have used these funds to support peer-operated services, evidence-based practices, 

pilots of promising practices, technical assistance, early intervention and prevention 

activities, suicide prevention, public outreach, family support, and many other crucial 

activities that have made a significant contribution to enhancing service quality.

Different constituents will use this report in different ways. For example, consumers 

and family members can use the report to understand how the goals of the New Freedom Commission report, which stress building resilience and facilitating recovery, can 

become reality in their communities. State mental health administrators, planners, 

and Planning Council members can review the State profiles to find specific evidencebased practices in which they are interested, e.g., Assertive Community Treatment 

(ACT) for a particular population. Local, State, and national legislators can use the 

report to learn more about how Federal resources are used in their States and communities to support mental health system transformation. 

Whatever the specific use, this report will inform SAMHSA staff and technical assistance providers about State activities; educate State agencies, consumer groups, and 

providers; encourage networking among States; increase resource sharing; and aid 

Planning Councils in their advocacy and educational activities. Mental health system 

transformation is challenging work, and this report provides ample evidence that 

States are meeting this challenge in unique and innovative ways. 
Trends in Mental Health System Transformation: The States Respond 2005 3

Each State faces individual legislative, financial, and social constraints and uses different opportunities in its efforts to transform the mental health service delivery system. Yet they all confront similar challenges: shrinking resources, increasing needs, 

and a desire to provide the most effective treatments and services. A review of State 

activities in 2005 reveals these overarching trends: 

• All States are working to move people from State psychiatric hospitals to full and 

productive lives in their communities. They are making progress even though 

in most States the lack of affordable housing is a significant barrier to timely 

discharge;

• The lack of financing for mental health treatment drives States to use a wide 

range of strategies to fund essential services. Advocacy groups lobby State 

legislators; agency staff apply for funding from various sources; State agencies apply for Medicaid waivers to fund specific forms of treatment; some 

States are working with insurance providers to encourage parity for mental 

health treatment; and, most notably, cash-strapped agencies are joining together to try to achieve more through partnership than they can independently;

• State agencies seek to adapt organizational structures, funding mechanisms, 

training, and strategic plans to promote Evidence-based practices (EBPs) as 

rapidly as possible. They struggle to find the balance between fidelity to a 

specific model and the need to address specific populations and funding circumstances. They may meet skepticism and resistance from the field. They 

may debate the point at which a particular strategy has crossed the line from 

“emerging” or “promising” to “evidence-based.” EBPs are being promoted by 

funders, legislators, community members, families, and the research community. Legislators want accountability for public funds; consumers want assurance of quality care; and State systems want to use limited resources as 

efficiently as possible to promote positive outcomes and continued support 

for their efforts;

• The need for effective ways to measure outcomes and share essential information across programs and agencies drives data management efforts that are 

becoming more and more complex. Although the rewards of such initiatives 

are great, the effort required to develop common definitions and to get State 

providers, as well as diverse agencies, working together is immense, consuming scarce staff resources; 

• Most States are addressing serious workforce shortages primarily by cultivating close working relationships with universities and other institutions 

that train providers. Many states also fund internships and offer scholarships;

Overarching Trends 2005 
4 Trends in Mental Health System Transformation: The States Respond 2005

Overarching Trends

• More States are working in partnership with consumers as they plan, deliver, 

and assess mental health care. Asked to identify the most striking transformation underway in their mental health systems, many States pointed to 

the increasing influence of consumer groups in shaping the treatment system. Consumers and their family members influence State legislatures, analyze programs and trends, provide services, review feedback from treatment 

recipients, and enhance system resources by serving as mentors and guides;

• Many States have reorganized human service departments to allow agencies 

with related missions to work more closely together. The silos are coming 

down. In several States, substance abuse and mental health agencies are now 

in the same division, facilitating integrated care for consumers with co-occurring mental and substance use disorders. Statewide interagency task forces 

and high-level coordinating bodies are universal. With resources shrinking, 

agencies have succeeded in setting aside rivalries to provide collaborative 

systems of care, especially for the benefit of children with serious emotional 

disturbances and their families;

• There is widespread awareness and acceptance of New Freedom Commission 

goals in most States. Many Planning Councils find them helpful in their advocacy work and as they set their own priorities. State mental health agencies 

and consumer advocacy groups also use them frequently as touchstones for 

progress. The Commission’s report often is used as a framework for communicating systemic needs and priorities to legislators, lending weight to locally 

driven initiatives;

• States are engaged in developing effective transition programs for youth 

who are ready for adult programs. These efforts include collaboration across 

agency lines to provide job opportunities and essential support;

• States are better able each year to capitalize on the opportunities technology offers to disseminate critical information and expertise to wider audiences more cost effectively. Information about mental illnesses and available 

treatments routinely is disseminated statewide and nationally by means of 

the Internet; and

• States are exploring the use of telemedicine to meet pressing treatment needs. 

Especially common is the practice of making psychiatrists available by teleconference in rural areas that have severe workforce shortages. 
Trends in Mental Health System Transformation: The States Respond 2005 5

State Mental Health Planning Councils are required to conform to certain membership requirements and to perform specified duties. Membership must include representation from principal State agencies, such as Education and Medicaid; other 

public and private entities with mental health-related missions; consumers and 

family members; organizations that represent consumers and family members; and 

advocacy groups. At least half the members must not be either State employees or 

providers of mental health services. 

The Planning Council is required to:

• review State Mental Health Plans and submit recommendations for modification to the State;

• serve as an advocate for adults with serious mental illnesses, children with 

severe emotional disturbances, and other individuals with mental illnesses 

or emotional problems;

• monitor, review, and evaluate the allocation and adequacy of mental health 

services within the State at least once each year; and

• work to improve mental health services within the State.*

Membership

Most Planning Councils include between 20 and 50 members (fewer than 10 Planning Councils have fewer than 20 members and fewer than 5 have more than 50). In 

many States, Planning Council activities are undertaken by subcommittees, which 

can include other interested parties. In Kansas, which is atypical, this structure involves more than 200 people through subcommittees and up to 500 on task forces. 

Often, task forces are formed to address emerging issues. For example, in Maryland, 

members of the Joint Council participated in several ad hoc committees, including a 

committee to review and comment on the State’s proposed restructuring of the system of hospital care and another to comment on Maryland’s Blueprint for Children’s 

Mental Health. 

Many States exceed Block Grant requirements for non-State employee/non-provider 

Council membership. In more than a dozen States this membership on the Planning 

Council exceeds 55 percent. In Wyoming, for example, 71 percent of the 35-member 

Planning Council represents primary consumers, family members, and others who 

are not providers or State employees; among Idaho’s 46 members, the proportion is 

74 percent. 

* See Block Grant application, pp. 21-24; references in Sections 1914(b) and 1914(c) of the Public Health 

Service (PHS) Act.

The Role of Planning Councils 

in State Systems
6 Trends in Mental Health System Transformation: The States Respond 2005

The Role of Planning Councils in State Systems

Many States give special emphasis to ensuring strong consumer voices, especially 

representation for children with serious emotional disturbances, on the Planning 

Council:

• In South Dakota, specific consumer membership “slots” are reserved 

for family members of children with severe emotional disturbances in 

early childhood, elementary school, and high school to ensure that issues 

throughout childhood are addressed;

• Minnesota supports consumer representative members by providing per 

diem and reimbursements for child care and travel costs. A consumer serves 

as the Chair of the Minnesota State Advisory Council on Mental Health;

• The Illinois Mental Health Planning and Advisory Council, which has 31 

consumers, among its 53 members, recruits and selects its own new members—thus ensuring that consumer voices are represented in the composition of the Council as well as in its deliberations; and 

• In Nebraska, New Jersey, Ohio, South Dakota, and Wisconsin, consumers and family members comprise at least 50 percent of Planning Council 

membership. 

Some States have invited young consumers to represent their age group’s interests 

on the Council:

• In Ohio, two youth members are included on the Planning Council;

• A transition-age youth serves on the Planning Council in South Dakota; 

and

• Utah has recently added a youth voice to its Council. 

Other States develop specific strategies to garner youth input. Ohio, for example, is 

planning a youth focus group to solicit input from youth on mental health services 

in the State. 

Shaping Mental Health Services

Planning Councils have assumed a broad and diverse portfolio of responsibilities, 

which include and often exceed mandated roles. Planning Councils throughout the 

United States educate local and State legislators on mental health issues; they also 

advocate for legislation to address those issues. To stay abreast of legislative initiatives and opportunities, Indiana’s Mental Health Planning Council includes legislative updates in each meeting. Many councils work intensively when the State legislature is in session. For example, West Virginia’s Council sponsored a Legislative Day 

with the theme, “Resilience, Recovery, and Rehabilitation.” Information sheets were 

distributed to legislators to inform them of the accomplishments and challenges 
Trends in Mental Health System Transformation: The States Respond 2005 7

faced by the West Virginia system and to educate them on the meaning of these 

key terms.

A council’s advocacy efforts are often influential. In Missouri, for example, the Community Psychiatric Services State Advisory Council was instrumental in the passage 

of parity legislation. In North Dakota, advocacy by the Planning Council helped 

to forestall plans to co-locate a women’s prison within a State psychiatric hospital. 

(The Planning Council felt the association between a prison and a psychiatric hospital would worsen the stigma around mental health care.) Legislative advocacy and 

education efforts in other States addressed a variety of topics, including Medicaid 

capitation and other funding for mental health care, child custody relinquishment, 

housing, and consumer rights. 

In meeting their obligation to monitor, evaluate, and report on mental health services with the State, Planning Councils issue a variety of documents, many of which 

are available to the public:

• The California Mental Health Planning Council prepared a report entitled 

California Mental Health Masterplan: A Vision for California, which is available at www.dmh.ca.gov/MHPC/masterplan.asp; and

• A workgroup formed by Connecticut’s State Mental Health Planning Council has focused specifically on services for transition-aged youth, providing 

recommendations for system improvement and age-appropriate services in 

its Final Report on Transition Services (FY 2004). 

Planning Councils also comment on funding decisions, sometimes participating directly in the dissemination of certain targeted funds: 

• In the Federated States of Micronesia, the Substance Abuse and Mental Health Council reviews and evaluates competitive applications for substance abuse and mental health grants;

• The Nevada Mental Health Planning Advisory Council (MHPAC) supports 

consumer involvement in the mental health system by awarding funds to 

community-based services that benefit consumers directly, including consumer education and training programs. MHPAC also has funded a leadership academy for consumers, a staff exchange program between a mental 

health and primary health care clinic, and a peer recovery program for people with serious mental illnesses who are homeless; and

• In the District of Columbia, a Project Review Committee comprised of 

three State Mental Health Planning Council members and three staff from 

the Department of Mental Health reviews all proposed projects and makes 

recommendations to the Director.
8 Trends in Mental Health System Transformation: The States Respond 2005

The Role of Planning Councils in State Systems

The recommendations of the President’s New Freedom Commission have been directly adopted as a working framework or explicitly addressed by most Planning 

Councils. For example, the Minnesota Mental Health Planning Council has created a 

Mental Health Action Group with the goal of transforming the mental health system 

in the State. (Information on their activities is available at www.citizensleague.net.)

Education and Training

Increasing knowledge and awareness of mental health issues is a priority of many Planning Councils. Activities to educate the general public about mental health, mental health 

services, and/or the CMHS Block Grant were undertaken in Guam, Maine, Washington, and other States. Planning Councils in several States also supported education and 

training activities targeting advocacy groups or providers. Here are some examples:

• Guam’s Council has taken the video Inside Outside (SAMHSA funded 

and produced) “on the road” as part of a community awareness and antistigma campaign;

• Maine’s Council sponsored three regional Block Grant Forums to educate the public, particularly consumers and family members, regarding the 

CMHS Block Grant and to elicit comments and response to both the planning process and the application itself; and

• Maryland’s Joint Council annually cosponsors a seminar with the Mental 

Health Association for individuals who are members of local mental health 

advisory committees to help them review services in their communities and 

advocate for development and modification where needed.

Planning Councils also undertook efforts to further educate their own members 

about mental health issues. Technical assistance and training activities have been undertaken in several States, including American Samoa, Arkansas, Florida, Iowa, 

North Carolina, Ohio, and South Dakota; others, such as Utah, have identified 

the need for training as an important next step in improving the effectiveness and 

function of their Planning Council.

Topics of Concern

The Planning Council of each State plays a central role in identifying and bringing 

attention to topics of concern specific to their State. The following are among specific 

areas of concern highlighted by councils:

• Mental health concerns in the criminal justice system;

• Mental health services for children and youth, including the transition from 

children’s to adult systems of care;

• Co-occurring disorders;
Trends in Mental Health System Transformation: The States Respond 2005 9

• Mental health services for elderly persons;

• Olmstead requirements;

• Cultural competence; and

• Recruitment of mental health professionals.
Americans Understand that Mental 

Health Is Essential to Overall Health

Significant barriers to mental health treatment include the stigma surrounding mental illness and the lack of awareness that effective mental 

health services are available and can make a difference. Overcoming these 

barriers is especially urgent in addressing suicide, the leading cause of violent death worldwide and the 11th leading cause of death among Americans. However, access to mental health care and funding (both public and 

private) for care are also major challenges. 

The New Freedom Commission made two recommendations to address 

these challenges:

1.1 Advance and implement a national campaign to reduce the 

stigma of seeking care and a national strategy for suicide 

prevention.

1.2 Address mental health with the same urgency as physical 

health.

 GOAL 1
Trends in Mental Health System Transformation: The States Respond 2005 11

States are committed to reducing stigma surrounding mental illnesses and

emotional disturbances and raising awareness about the availability and effectiveness of mental health treatment, and they address these issues in a variety of ways. 

Several States have sponsored public education efforts that place mental health 

consumers at the heart of the message. Some have produced documentaries, others use public media campaigns, others reach people through speakers and the 

arts, and still others provide training. In Virginia, Planning Council members report that consumer-run services have contributed to reducing stigma. They have 

helped change attitudes toward mental illness among consumers, providers, and 

the public.

Documentaries 

• In Idaho, mental health consumers collaborated with Idaho Public television to produce a documentary on mental illness called In Your Own Voice. 

This documentary is available for purchase at www.idahoptv/productions/

ownvoice. 

• Hearts and Minds, a documentary on teens and mental illness produced by 

the Idaho Department of Health and Welfare and Idaho Public Television, 

was awarded an International Peabody Award.

• In cooperation with a local film company, the Children, Youth and Families Department of New Mexico’s Department of Health created an Emmy 

Award-winning documentary, See Mommy Cry. Its purpose was to educate 

the public on the nature and scope of domestic violence and its effect on 

families, especially children. The 11⁄2 hour television documentary aired 

during prime time. Related educational videos for “pathway communities” 

(legal, law enforcement, faith, and education) and a 30-minute follow-up 

program to the original documentary were also developed.

• In Our Own Voice: Living with Mental Illness, a program that presents an example of recovery from the point of view of an individual living with mental 

illness, has been presented at numerous community groups in South Dakota as a means of reducing the stigma surrounding mental illness. 

THE STATES RESPOND 

Reducing Stigma, Raising Awareness
12 Trends in Mental Health System Transformation: The States Respond 2005

Goal 1 Americans Understand that Mental Health Is Essential to Overall Health

Public Education and Media Campaigns

• The National Alliance on Mental Illness, the Kim Foundation, Omaha Federation of Advertising, Catholic Charities, Lutheran Family Services, and 

other organizations collaborated in the development and support of Project 

Relate, a public relations effort aimed at reducing the stigma surrounding 

mental illness. They provide a Web-based clearinghouse of resources for 

mental health consumers, their families, and community members. In Nebraska, Project Relate Campaign activities included public service advertisements on television and radio, print ads, brochures, billboards, and posters. 

Information on Project Relate is available at www.projectrelate.org.

• Consumer groups and consumer advocacy groups often are active in promoting anti-stigma campaigns (examples include Kentucky, Maryland, 

Minnesota, North Carolina, Rhode Island, Vermont, and Wyoming). 

The specific groups that take the lead differ from State to State: NAMI chapters are particularly active in these efforts in Virginia and New Mexico, 

while Michigan’s Clubhouse Programs take the lead in that State. Maine, 

Pennsylvania, and South Carolina are among the States that provide 

funding to consumer groups especially for anti-stigma and public education efforts.

• Public education and media campaigns also have been undertaken in Alabama, Alaska, Guam, Louisiana, Michigan, New York, North Carolina, 

and South Carolina. In Puerto Rico and Delaware, radio public service 

announcements were developed to provide public education and increase 

public awareness of mental illness and mental health services. State governments contribute by recognizing Mental Health Awareness Month in 

Kansas, Wisconsin, and Delaware; Mental Illness Awareness Week in 

Kansas; and Children’s Mental Health Awareness Week in Alabama. Some 

States are fortunate to have high-profile support in their efforts: Idaho’s

First Lady participates in public education efforts, as does the First Lady 

of Palau, who is also a member of the International Women Leaders for 

Mental Health.

• To encourage and reward anti-stigma efforts, Washington’s Planning 

Council has instituted “Way to Go” awards to recognize individuals who 

have contributed to reducing stigma for mental illness. Other awards have 

been made to several newspaper reporters for their contribution to reducing stigma about mental illness. Stories have included topics such as promoting insurance parity for mental illness, the need for services for people 

with mental illnesses in jail, and mental health services for children.

Nebraska’s Project Relate 

is a public relations 

effort aimed at reducing 

the stigma surrounding 

mental illness. Posters, 

ads, and brochures are 

used to publicize a Webbased clearinghouse 

of resources.
Trends in Mental Health System Transformation: The States Respond 2005 13

FEATURED PROGRAM

Speakers and the Arts

• Several States have used the arts to reach the public with information about 

mental illness. In Michigan, published consumer success stories and theatre troupes reach the public. South Carolina hosted an Art of Recovery 

showcase of art by people with mental illnesses.

• Kansas supports a Consumer Speakers Bureau on mental health issues.

Training 

Another avenue for defeating stigma and raising awareness is training for service 

providers, especially those who are not mental health professionals. For example, 

the Commonwealth of the Northern Mariana Islands will be undertaking significant training efforts in 2005, targeting first responders (i.e., police officers, 

paramedics, firefighters, and the Community Health Center Emergency Room Department), paraprofessionals, and other health professionals. 

Special Topics, Special Targets 

In several States, public education is targeted to benefit high-risk groups. For 

example, Iowa recognizes the increased stigma that surrounds mental illness in 

many rural communities and funds indigenous workers to conduct outreach in 

rural areas. Massachusetts is focusing on reducing stigma among older adults, 

and Louisiana and New Mexico support special efforts to raise awareness of the 

importance of infant mental health.

Youth are being reached in many ways.

• The Kids on the Block puppet troupe has visited hundreds of thousands of 

school children in Tennessee and Maryland.

• North Carolina hosted a Stomp Out Stigma Youth Rally and is piloting 

anti-stigma campaigns in seven school districts. 

• Tennessee advanced an “Erase the Stigma” campaign for children and 

youth. It also has developed a course for middle and high school students 

along the lines of “Mental Health 101.” 

• South Carolina hosts a Teen Matters Web site (www.teen-matters.com) 

with information for adolescents on stress, depression, suicide, eating disorders, and similar issues. The Web site has had more than 470,000 hits 

since it went online in 2000. 

• In Hawaii, children’s mental health is the topic of education and awareness 

materials developed in four languages for the general population.

After a startling statistic was disclosed by Salt Lake City’s East 

High School’s principal at a Parents, Teachers, and Students Association (PTSA) meeting—the 

school had at least one suicide 

each year for 12 years—the PTSA 

sought help to stop these tragic 

deaths. Funded in part with Block 

Grant funds, the Hope for Tomorrow program (HFT) was developed to help educate students, 

teachers, and families about mental health issues. Now available in 

27 schools, HFT has been presented to more than 33,000 students, 

1,700 teachers, and 3,000 parents, 

with plans to go statewide.

The program’s curriculum educates teachers, administrators, 

parents, and students about 

mood disorders, eating disorders, 

and addictive disorders. Delivery 

methods include in-class assemblies, parent forums, teacher inservices, and a student lunchtime 

forum. 

Paul Hansen, the principal at 

Olympus High School in Salt Lake 

City, has said, “I was not sure what 

to do,” referring to a suicide at his 

school, “but I did know that to do 

nothing was wrong, so we embraced the Hope for Tomorrow 

program and we are grateful we 

did.” 

For more information, contact: 

Vickie Cottrell, NAMI Utah,

 (801) 323-9900, (877) 230-6264 (tollfree), education@namiut.org.

Hope for Tomorrow 

(Utah)
14 Trends in Mental Health System Transformation: The States Respond 2005

Goal 1 Americans Understand that Mental Health Is Essential to Overall Health

Preventing Suicide

Preventing suicide has become priority for many States. A great number of States 

have developed tasks forces or coalitions specifically charged with planning and/

or coordinating suicide prevention initiatives. These States include Alabama, 

Alaska, Colorado, Connecticut, Florida, Georgia, Idaho, Massachusetts, New 

Hampshire, Oklahoma, Tennessee, and Washington. Other States (Arizona,

the Federated States of Micronesia, Minnesota, and Nevada) are just beginning 

their efforts. Colorado has a State Office for Suicide Prevention, and many States 

have State Suicide Prevention Plans in place. Alaska, Mississippi, and South Dakota are developing State plans. 

Some States make a point of encouraging local-level suicide prevention initiatives. 

For example, Alaska’s Community-Based Suicide Prevention Program provides 

support and assistance to communities to help them develop and implement their 

own locally designed projects to reduce self-destructive behavior and suicide and 

to increase individual, family, and community health. Assistance is in the form of 

grants, training, and a support and information network. Ohio operates a similar 

system of locally based efforts.

Hotlines or crisis lines are among the most common interventions for suicide prevention. These support lines operate in most States, including Colorado, Guam, 

Kentucky, Louisiana, Missouri, the Commonwealth of the Northern Mariana 

Islands, and Tennessee. 

West Virginia’s HOTT Coalition seeks to prevent teen suicide by enabling the public 

to recognize symptoms of depression and other precursors of suicide attempts.

Hotlines or crisis lines 

are among the most 

common interventions 

for suicide prevention.

National 

Suicide Prevention Lifeline

1 800 273-TALK (8255)

TTY: 1 800 799-4TTY (4889)
Trends in Mental Health System Transformation: The States Respond 2005 15

FEATURED PROGRAM

Training—for law enforcement personnel, educators, family service workers, 

criminal justice staff, and others—is another important and widely shared intervention. Training programs are planned or underway in Kentucky, the Commonwealth of the Northern Mariana Islands, Puerto Rico, Tennessee, and Washington. The Tennessee Suicide Prevention Network has developed training to help 

providers adopt effective suicide prevention strategies. Applied Suicide Intervention Skills Training (ASIST) is a 2-day, train-the-trainer module, and Question, 

Persuade and Refer is a train-the-trainer module that can be conducted in one day 

or less. 

Public education efforts focused on suicide awareness and prevention are underway in Arizona, Colorado, and Virginia. As with stigma reduction efforts, some 

States have targeted particular audiences for suicide prevention activities. Given 

the dramatic rise in teen suicide, a number of States have focused on youth. These 

include North Carolina, American Samoa, Alaska, Connecticut, Massachusetts, New Hampshire, New Jersey, the Federated States of Micronesia, West 

Virginia, and Utah.

Other States, such as Georgia and Maine, focus their suicide prevention efforts on older 

adults. Florida and Nevada have used the Gatekeeper model for suicide prevention. In 

Oregon, the Department of Human Services’ Public Health Unit has published and distributed The Oregon Plan for Reducing Suicides in Older Adults. This document provides 

a statewide older adult suicide prevention plan and is available for other States to review. 

Contact Sandra.Moreland@state.or.us.

These are some of the resources for suicide prevention that States have developed:

• A training video called Students at Risk for Suicide—Assessment and 

Interview Techniques developed with the help of University of Medicine and 

Dentistry of New Jersey’s Technical Assistance Center, presents realistic 

scenarios between school clinicians/counselors and students at risk. More 

information is available through Val Casey, Division of Children’s Behavioral Health Service, (609) 777-0740, val.casey@dhs.state.nj.us; and

• The Southeast Nebraska Suicide Prevention Curriculum, developed with 

the University of Nebraska, provides suicide awareness and prevention 

training for the general public and key helpers. The core curriculum is available in English and Spanish. Modules designed specifically for law enforcement personnel, health care personnel, clergy, and educators are also available. For more information and to download the curriculum, see www.nebhands.nebraska.edu/Resources.htm#suicide. 

The Suicide Prevention Education 

and Awareness Kit includes information to help everyone understand the frequency and toll of 

suicide, and to discover ways and 

methods to help prevent it. The 

kit provides information about 

suicide and suicide prevention, 

the risk factors and the warning signs, resources about how 

to seek help for oneself or how 

to help others, and a poster. The 

kits include specific information 

about men and depression; women and depression; older adults, 

depression, and suicide; teen depression and suicide; facts about 

suicide; telephone hotlines across 

the State; and other information, 

all of which is accessible from the 

Web site. 

The primary goal of the SPEAK 

education and awareness campaign is to reduce suicide in New 

York State. But the program also 

has the important secondary goal 

of reducing the stigma associated 

with getting help for emotional 

problems or mental illness.

For a free copy of this kit, contact: 

The Office of Mental Health

Community Outreach & 

Public Education Office, 

44 Holland Avenue, 

Albany, NY 12229, 

(866) 270-9857 toll- free. 

Also see the Web site at 

www.omh.state.ny.us/omhweb/speak.

SPEAK: 

A Suicide Prevention Kit 

(New York)
16 Trends in Mental Health System Transformation: The States Respond 2005

Goal 1 Americans Understand that Mental Health Is Essential to Overall Health

Addressing Mental Health with 

the Same Urgency as Physical Health

Two barriers to addressing mental health with the same urgency as physical health 

are the stigma associated with mental illness and mental health treatment, and 

the lack of access to care or funding for that care. 

To decrease the stigma associated with mental health care, Georgia, Puerto Rico, 

Rhode Island, Tennessee, and Washington support integrative or collaborative 

efforts between primary care and mental health care providers. Nevada supports 

staff exchanges between medical and mental health providers. In Washington, 

the Mental Health Division and the Medical Assistance Administration sponsor 

community forums at which mental health and medical providers meet, learn 

about one another’s services, and are encouraged to work together locally on behalf of their clients. 

To promote equality in the treatment of both illnesses, Alabama and Illinois have 

passed legislation to create health insurance coverage. Preliminary data from Alabama, which passed its legislation in 2001, indicate that overall health costs were 

lower for those enrolled in plans with mental health parity than for those enrolled 

in other plans. Iowa also is working on parity legislation. North Dakota is encouraging Blue Cross/Blue Shield to provide parity in its coverage.

Billboards like this one in Palau’s capital city of Koror raised awareness of World 

Mental Health Day and the connections between physical and mental health.

Mental Health Care Is 

Consumer and Family Driven

The New Freedom Commission recognizes that the current mental health 

care delivery system is fragmented and overwhelmingly complex. Adults 

with serious mental illnesses and children with serious emotional disturbances come in contact with many different—and often disparate—systems, including mental health centers and hospitals, criminal and juvenile 

justice facilities, homeless shelters and child protective services, and the 

education system. The New Freedom Commission envisioned a coordinated mental health care delivery system that places consumers at its center. 

At the consumer level, this orientation would be evident in individualized 

plans of care that address the true breadth of any person’s life, including 

the need for stable housing and the desire for employment and educational success. At the programmatic level, a “no wrong door” approach 

would increase the ability of States and systems to meet the needs of citizens, whether they enter the system through a homeless shelter, a welfare 

office, a community-based mental health clinic, a school, or even a jail. At 

the system level, a consumer-centered approach would be manifested in 

funding structures that increase consumer choice and control. Such a system would be infused with a focus on recovery.

In order to develop and implement this vision, the New Freedom Commission made five recommendations:

2.1 Develop an individualized plan of care for every adult with 

a serious mental illness and child with a serious emotional 

disturbance.

2.2 Involve consumers and families fully in orienting the mental health system toward recovery.

2.3 Align relevant Federal programs to improve access and accountability for mental health services.

2.4 Create a Comprehensive State Mental Health Plan.

2.5 Protect and enhance the rights of people with mental illnesses.

 GOAL 2
Trends in Mental Health System Transformation: The States Respond 2005 19

FEATURED PROGRAM

THE STATES RESPOND

The concept of a mental health system with consumers at its center has been embraced in States across the Nation. Adults with serious mental illnesses, youth 

with serious emotional disturbances, and families of children with serious emotional disturbances have been invited into the development, implementation, delivery, and evaluation of mental health care across America through a broad range 

of strategies:

• Person-centered planning; 

• Consumer input into system design; and

• Consumer involvement in service delivery and support.

States protect and promote the rights of mental health consumers through

several strategies:

• Reducing or eliminating the use of seclusion and restraint;

• Providing mental health services in the least restrictive setting through 

development of community-based services, affordable housing, and supported employment; and

• Reducing consumers’ involvement in the criminal justice system

Through Comprehensive State Mental Health Plans, States have been improving 

the coordination and integration of services. Finally, States have been creative in 

identifying new funding sources and finding ways to control costs.

The O.T.H.E.R.S. (Other Teens Help Everybody Respect Self ) have fun 

while fighting stigma. Together, they created a powerful public service 

announcement focused on mental health issues for teens.

Teen recipe for success: introduce 10 really talented, creative, 

and energetic teens to one equally 

talented, popular disc jockey. Mix 

them together and throw in a 

full-day recording session at the 

radio station and the results are the 

creation of a very effective and 

moving public service announcement (PSA) geared toward teens 

struggling with various mental 

health issues in their lives, a PSA 

that won national recognition with 

a SAMHSA ECCO award. 

In 2001, this group of teens officially became the O.T.H.E.R.S. (Other 

Teens Help Everybody Respect 

Self ) Youth Group, a youth-driven 

group of teens that keep themselves busy by having fun while 

fighting stigma. O.T.H.E.R.S. is 

open to any teen, age 13 or older, 

who wants to make a difference 

by raising awareness. The group 

includes teens who are struggling 

with their own mental health 

needs, siblings, and friends. The 

group meets twice a month, with 

the teens generally setting the 

agenda. 

Recently, a “spin-off” has formed: 

two members, a parent, and a social worker have joined together 

to run biweekly meetings for siblings of brothers and sisters with 

mental health needs. Activities, 

crafts, food, and fun provide a safe 

atmosphere to talk about being a 

sibling and all the issues that complicate it. 

For more information, contact: 

Rina Cavallini, (508) 767-9725, 

crcav@msn.com.

O.T.H.E.R.S. Youth Group

(Massachusetts)
20 Trends in Mental Health System Transformation: The States Respond 2005

Goal 2 Mental Health Care Is Consumer and Family Driven

FEATURED PROGRAM

Person-Centered Planning

Several States have mandated person-centered planning in their mental health 

systems. Through contracts with community-based mental health clinics, department regulation, or even State statute, Arkansas, Florida, Indiana, Iowa, North 

Carolina, and Ohio are among the States that require consumers to be involved 

in and at the center of their treatment plans. Twenty-nine other States have either implemented individualized service plans directly or have done so through 

the adoption of Wellness Recovery Action Plans (WRAP) for adults with serious 

mental illnesses and wraparound systems for children with serious emotional disturbances.

Alabama, Connecticut, Illinois, Michigan, and Mississippi are among the States 

that have recently conducted training in person-centered planning. Oregon conducted training for consumers on how to facilitate the development of personcentered planning.

A growing number of States explicitly have identified recovery as the ultimate goal 

and central purpose of treatment, whether through the adoption of WRAP principles and processes or by other means. Colorado, Florida, Georgia, Kentucky, 

Missouri, and Texas are among the States that have fully adopted recovery principles. Arizona, Kansas, Vermont, and Wisconsin are advancing recovery principles through training and conferences. 

Michigan mandates a person-centered planning process for adult 

mental health services and a family-centered planning process for 

children’s mental health services. 

Individuals and families must be 

involved in the development of 

the individual plan of service, and 

their goals must be incorporated 

in that plan. 

The Department of Community 

Health (MDCH) provides training 

to Community Mental Health Services Programs (CMHSPs) on person-centered and family-centered 

planning. A manual, Planning 

for Yourself, was developed with 

national expert Michael Smull and 

is used by several counties. A grant 

from the Robert Wood Johnson 

Foundation allowed four communities to pilot the family-centered 

training across all systems and 

sectors serving children and families; three additional communities 

have piloted the project since. 

CMHSPs are encouraged to focus 

on family-centered planning and 

practice, which is also integrated 

into the protocol used by MDCH 

site review teams. 

For more information, contact: 

Pamela Werner, Consumer-Directed 

Home & Community-Based Services 

Specialist, 

(517) 335-4078, 

wernerp@michigan.gov.

A consumer-run Pilates class is offered as one of a varied menu of Healthy 

Activities provided through Interact of Michigan, a program founded with 

support from the Michigan Department of Community Health. Participants report 

an increased sense of well-being after participating in healthy activities.

Person-Centered and 

Family-Centered Planning 

(Michigan)
Trends in Mental Health System Transformation: The States Respond 2005 21

FEATURED PROGRAM

Consumer Input into System Design

States have moved to engage consumers not just at the level of their own treatment plans, but also in the development of mental health systems. In addition 

to their mandated roles on State Mental Health Planning Councils, consumers 

often serve on a variety of advisory committees and oversight groups where their 

input can have real impact on system design and development. Kentucky, Massachusetts, Montana, Nebraska, New Hampshire, New Mexico, North Carolina, 

Oregon, South Carolina, and Washington are among the States with local, regional, or statewide Consumer Advisory Groups. Alabama, Arkansas, Louisiana, 

Montana, Virginia, and Wyoming are among those that include consumers in 

planning activities. Other States ensure and strengthen consumer input in the 

following ways:

• In South Dakota, consumers serve on mental health program accreditation review teams and participate in provider trainings;

• In Idaho, providers are required to receive annual training from the family 

members of children with serious emotional disturbances;

• Regional Mental Health Boards in Idaho and Virginia include consumer 

representatives;

• Maryland provided consumer training to facilitate consumer participation 

in State and local policymaking. Missouri provided legislative advocacy 

training for consumers;

• More than 10,000 New York State consumers were involved in the development of a white paper: Infusing Recovery-Based Principles into Mental 

Health Services; and

• In Ohio, consumers serve on the Strategic Advisory Committee charged 

with addressing the recommendations of the New Freedom Commission. 

“Consumer and family members bring us back to reality with 

their focus on ‘How are the consumer and family able to access 

appropriate care?’ In 1998, we opened our Medicaid formulary 

to include atypical (anti-psychotic) medications and SSRIs (antidepressants) due to consumer and family pressure. They also 

keep housing on the front burner.”

Mental health planner, Department of Mental Health and Developmental Disabilities 

(Tennessee)

Maine’s Office of Consumer Affairs (OCA) employs three fulltime regional staff members. 

They facilitate consumer input 

in such areas as program development, implementation, and 

evaluation; training; contract 

management; development of 

policy regulations; and system 

advocacy. Specific activities

include:

• Collabortion with the 

Advocacy Initiative Network of Maine to develop 

a statewide WRAP program;

• Sponsorship of 20 scholarships for the WRAP Correspondence Course, a 

prerequisite for facilitator 

training;

• Quarterly networking 

and training meetings for 

WRAP facilitators;

• Quarterly Regional Consumer Forums that offer 

an opportunity for Adult 

Mental Health Services 

staff to hear from consumers. Each forum addresses 

a topic related to quality 

improvement; and

• Bimonthly leadership 

meetings in each region 

that provide an opportunity for information sharing between representatives of consumer-run 

programs and the director/coordinator.

For more information, contact: 

Katharine Storer, OCA, 

(207) 941-4788, 

Katharine.Storer@Maine.gov

Consumer Involvement

in the Mental Health System

(Maine)
22 Trends in Mental Health System Transformation: The States Respond 2005

Goal 2 Mental Health Care Is Consumer and Family Driven

FEATURED PROGRAM

Consumer Involvement in Service Delivery and Support

In a variety of positions and with varying titles (for example, Consumer Service 

Assistants in Nevada, Peer Support Specialists in South Carolina, and Peer Outreach and Engagement Specialists in Connecticut and Georgia), consumers provide mental health services from a peer perspective and help other consumers 

navigate the mental health system. 

Consumers also act as peers, mentors, supports, and role models as they operate 

consumer-run organizations throughout the States. Consumer-run organizations 

fill important roles in the service delivery system in more than 30 States. Many 

States provide funding for these organizations, and a number of States—including 

Kentucky, Maine, Maryland, Texas, Utah, Virginia, and Wyoming—offer training for consumers or for consumer-run organizations. Rhode Island is currently 

collecting outcome data on two peer counseling sites operating in that State. 

In Massachusetts and New Hampshire, innovative and award-winning youth 

leadership and peer groups are promoting mental health for young people.

South Carolina is implementing 

Peer Support, a service based on 

a person-centered model with a 

recovery focus developed by the 

State of Georgia. Consumers are 

certified as Peer Support Specialists and, under the supervision 

of a mental health professional, 

work with clients as specified in 

the client’s individual recovery 

plan. A Peer Support Specialist is 

a self-identified individual with 

a diagnosed mental illness who 

delivers mental health services to 

other adult consumers. The goal 

of this service is to facilitate a person’s recovery by offering hope 

that recovery is possible. Peer 

specialist training was offered in 

State Fiscal Year 2004, and community mental health centers 

(CMHCs) are now beginning to 

offer peer support services. Thus 

far 26 Peer Support Specialists 

have received training and have 

been certified. The 2004 State 

Plan goal was to have peer support services in six CMHCs; this 

goal has been exceeded. To date, 

12 CMHCs have hired 22 of the 

certified Peer Support Specialists 

to offer services. South Carolina is 

the third State in the country to 

have Peer Support as a Medicaidbillable service.

For more information, contact: 

Katherine Roberts, 

Director, Consumer to Consumer

Evaluation Team 

(803) 234-4200, 

KMR50@SCDMH.org. 

Also see :

www.state.sc.us/dmh/consumer_

resources/consumer_resources.htm.

Peer Support Specialists 

(South Carolina)
Trends in Mental Health System Transformation: The States Respond 2005 23

FEATURED PROGRAM

Protecting Consumer Rights

The majority of States have offices of consumer affairs or staff positions dedicated 

to protecting and promoting the rights of mental health care consumers. Palau

and Kentucky developed and distributed brochures to inform consumers about 

their rights within the mental health system. Maryland and North Carolina have 

conducted presentations and trainings for consumers on the mental health system. In Rhode Island, a database of consumer complaints is currently being analyzed, and findings will be used in future planning.

Reducing or eliminating the use of seclusion and restraint is central to any consideration of consumer rights within the mental health care system. Florida, Louisiana, Nevada, New Jersey, Oregon, Palau, and Wisconsin are among the States 

seeking alternatives to seclusion and restraint.

Providing mental health services in the least restrictive setting, another central 

tenet of consumer rights, may require further development of community-based 

services, support for affordable housing to allow consumers to live in the communities where services are provided, or both. California, Guam, South Carolina, 

Virginia, and Washington are among the States seeking to expand communitybased services, especially for those in transition from residential to communitybased care.

Targeted efforts to provide community-based services for children with serious 

emotional disturbances are underway in Colorado and New York, while Wisconsin focuses on providing community-based services to nursing home residents. 

A “foster home” model of Family Care in Colorado supports consumers who are 

ready to leave inpatient care but lack community-based supports.

In 2003, Texas began a unique 

grant program to stimulate and 

support the growth of local consumer-directed, consumer-operated organizations, providing peer 

support and other services to the 

mental health population. The 

Texas Department of State Health 

Services contracts with Texas Mental Health Consumers, a statewide 

consumer-directed, consumer-operated education and advocacy 

organization, to oversee the grant 

program.

The program uses a 5-year, incremental funding methodology. Interested groups must first apply for 

and be granted an establishment 

grant. Once a group has demonstrated it can successfully manage 

this $1,500 grant, it can reapply 

in subsequent years for either a 

$24,000 development grant or a 

$65,000 sustainability grant. Targeted technical assistance at each 

funding level is designed to create 

viable organizations capable of 

managing contracts and producing deliverables.

For more information, contact: 

Mike Halligan, Executive Director, 

Texas Mental Health Consumers,

 (512) 451-3191.

Consumer-Operated 

Services Grant Program 

(Texas)
24 Trends in Mental Health System Transformation: The States Respond 2005

Goal 2 Mental Health Care Is Consumer and Family Driven

FEATURED PROGRAM

Housing for Consumers

To overcome the barrier that housing presents to mental health care, some States 

provide transitional housing directly, as do the Federated States of Micronesia, 

the Commonwealth of the Northern Mariana Islands, West Virginia, and Utah; 

others provide rental assistance or housing subsidies for consumers to live independently, as do Delaware, Minnesota, Nebraska, North Carolina, Oklahoma, 

Tennessee, and Vermont. Alaska, Mississippi, North Dakota, Tennessee, and

Wisconsin are among the States seeking to develop new housing. Indiana, Nebraska, Ohio, and South Carolina have all undertaken efforts to evaluate and 

address the housing crisis in their localities. 

Often, State efforts to assure affordable housing for mental health consumers 

lead to coordinated initiatives with other State agencies that address housing and 

homelessness. Iowa, Michigan, and West Virginia are among the States that have 

convened interagency bodies to address the housing needs of people with serious 

mental illnesses. 

Providing mental health services to people who are homeless is a major challenge 

for many reasons, including the difficulties of outreach and tracking. Wisconsin is among the States that provide training for mental health workers focused 

specifically on providing assistance to people who are homeless. States including 

Hawaii, Maine, and Vermont provide services specifically targeted to youth who 

are homeless or at risk of becoming homeless. Some States, including Georgia, 

Minnesota, and Oklahoma, have undertaken the creation of State plans for the 

elimination of homelessness.

Supported Employment

Adults with serious mental illnesses and youth with serious emotional disturbances may require supported employment programs to allow them to participate fully 

in their communities. The New Freedom Commission noted that vocational rehabilitation services often have failed to serve people with mental illnesses well. In 

addition to the many States that employ consumers in their own offices and programs, American Samoa, Illinois, and Ohio are examples of States undertaking 

staff training to improve and coordinate services between vocational rehabilitation and mental health systems. Illinois is one of several States that seek to coordinate State and Federal work benefits; it also helps consumers understand their 

choices—and the consequences of their choices—in regard to work and benefits. 

Medicaid Buy-In programs, such as the one operating in Indiana, allow working 

people with disabilities to buy in to Medicaid coverage, thus reducing the fear of 

losing health insurance, which is a disincentive to return to work. 

In August 2003, Nevada’s Division 

of Mental Health and Developmental Services (MHDS) began 

working with other agencies and 

stakeholders on an initiative to 

reduce and ultimately eliminate 

the use of seclusion and restraint 

in facilities that currently use 

these techniques when individuals pose a danger to themselves, 

others, or both. This initiative requires staff to develop new policies and procedures, forms, training formats, and data reporting. 

During 2004, MHDS continued 

to work with the National Technical Assistance Center for State 

Mental Health Planning (NTAC) 

to provide statewide and regional training in the reduction 

and elimination of seclusion and 

restraint. In collaboration with 

NTAC, MHDS hosted two Western 

regional meetings in September 

2003 and June 2004 in which 

key program providers and policymakers from seven Western 

States met in Las Vegas to review 

exemplary practices. MHDS data 

indicate a consistent decrease in 

the use of seclusion and restraint 

in Nevada.

For more information, contact: 

Kevin Crowe, Ph.D., 

Chief of Planning and Evaluation, 

(775) 684-5984.

Seclusion and 

Restraint Initiative 

(Nevada)
Trends in Mental Health System Transformation: The States Respond 2005 25

FEATURED PROGRAM

Mental Health and the Justice System

According to the New Freedom Commission, approximately 7 percent of all incarcerated people have a serious mental illness. States recognize the need to provide 

mental health care to people within the criminal justice system, and, when appropriate, divert consumers to mental health systems of care.

Among the States working to ensure or improve the provision of mental health 

services to incarcerated adults and youth are Alaska, the District of Columbia, 

Colorado, Louisiana, Maryland, Michigan, Oklahoma, Nebraska, Pennsylvania, Puerto Rico, and Wisconsin. 

Illinois and Oregon provide Assertive Community Treatment (ACT) services in 

local jails. 

Mental Health Court programs designed to avoid unnecessary incarceration of 

adults with serious mental illnesses operate in States that include Illinois, Indiana, Michigan, Minnesota, North Carolina, Oklahoma, Pennsylvania, South 

Carolina, Tennessee, Texas, and Utah. Similar programs for juveniles are highlighted in Nebraska, Puerto Rico, and Oregon.

In Connecticut, a Youth Violence Prevention Initiative seeks to prevent girls from 

becoming involved with the courts in the first place. Another Connecticut program targets women in the prison system; South Dakota has an outreach program for women in prison with serious mental illnesses. 

Several programs for adults in the criminal justice system seek to reduce recidivism by providing transition planning and other supports. Arizona, the District 

of Columbia, Georgia, Iowa, New Jersey, North Dakota, and South Dakota are 

among the States with transition programs. In Wisconsin, an initiative is underway to more quickly reestablish disability and other benefits for offenders on release, thus reducing their risk of homelessness and recidivism.

In 2000, the Oregon Office of Mental Health and Addiction Services, 

in collaboration with the Oregon 

Judicial Department, was awarded 

Federal funds to implement Integrated Treatment Courts for juveniles and their families. This partnership resulted in an innovative 

statewide pilot project designed 

to address the growing concern 

about juvenile offenders with cooccurring disorders. The Integrated 

Treatment Court model was developed and pilot projects established in seven counties. More 

than 200 youth and families have 

participated in the project. Integrated Treatment Courts combine 

juvenile drug court concepts and 

service integration principles to 

increase accountability, promote 

service coordination across agencies and systems, support the use 

of evidence-based practices, and 

provide individualized behavioral 

health services for youth and families involved in the juvenile justice 

system. Preliminary outcomes 

include greater access to services 

and decreased recidivism.

For more information, contact: 

Bill Bouska, Bill.Bouska@state.or.us

Integrated 

Treatment Courts 

(Oregon)
26 Trends in Mental Health System Transformation: The States Respond 2005

Goal 2 Mental Health Care Is Consumer and Family Driven

FEATURED PROGRAM

Originally begun as a demonstration program, California’s Integrated Services for Homeless 

Adults with Serious Mental Illness 

program was recognized as an exemplary model by the President’s 

New Freedom Commission on 

Mental Health. Individual projects, sometimes referred to as AB 

2034 programs after the legislation that created them, provide 

services that include, but are not 

limited to, outreach, supported 

housing, supported employment, 

mental health and medical treatment, substance abuse treatment, 

benefits assistance, and other 

non-medical services. The programs establish close collaboration at the local level among core 

serve providers, including mental 

health, law enforcement, veterans’ 

services agencies, and other community agencies. The May 2003 

report to the California Legislature 

on the effectiveness of these programs indicates that for individuals enrolled in the programs:

• Homeless days have 

been reduced by 67.3 

percent;

• Psychiatric hospital days 

have been reduced by 

55.8 percent;

• Jail days have been reduced by 72.1 percent; 

and

• 13.3 percent of people 

enrolled are involved in 

some type of employment activity. 

For more information, contact: 

Dee Leemonds, Section Chief, 

Adult & Older Adult Program Policy, 

(916) 654-3001. 

Creating a Comprehensive State Mental Health Plan

The New Freedom Commission called on States to develop Comprehensive State 

Mental Health Plans to address the provision of services across the life span and 

to coordinate and integrate services among multiple State agencies. Many—if not 

most—States are in the process of developing such a plan, and many are participating in efforts to redesign and integrate related services. 

Service- or agency-based coordination efforts are underway in Delaware, where 

crisis staff are co-located in hospital emergency departments; in Illinois, where 

multiple partnerships between State and Federal agencies provide services for 

people with co-occurring disorders; and in other States to address issues of housing, long-term care, domestic violence, and disaster preparedness. Texas and Wisconsin are among the States that have reconfigured mental health and substance 

abuse agencies to facilitate coordination. 

Service integration efforts often have the explicit endorsement of the political establishment, whether mandated by State Government, promoted in a Governor’s 

report or initiative, or—as is the case with Maine’s Children’s Cabinet—chaired 

by the First Lady. This top-down support can be critical to breaking down barriers 

between State agencies and working through regulatory and bureaucratic differences.

Wisconsin’s Redesign Initiative moves the State’s adult system 

of mental health care delivery toward realization of the goals of 

the President’s New Freedom Commission. The implementation 

of Comprehensive Community Services will support the 

creation of a flexible, consumer-oriented psychosocial recovery 

system for adults and children.

Integrated Services

for Homeless Adults 

(California)
Trends in Mental Health System Transformation: The States Respond 2005 27

FEATURED PROGRAM

Financing Mental Health Services

Increasing Medicaid revenue has been a priority in many States. In Illinois, a System Restructuring Initiative was undertaken that had the specific goal of increasing revenue for services billed to Medicaid. These funds will be used to support a 

system of recovery-based care. Other States sought and received reimbursement 

for home-based care; peer support services; and integrated medical, chemical dependency, mental health, and long-term care services.

States also have accessed other sources of funding for essential treatment for 

mental health disorders:

• Real Choice Systems Change Grants provided several States—including 

Mississippi, Nebraska, Oregon, and Vermont—with support to move 

forward in advancing recovery-oriented, consumer-based care; 

• In Michigan, an Independence Plus grant helped advance consumer selfdetermination;

• In Puerto Rico, a $1 billion perpetual trust supports services to impoverished communities; and

• A State appropriation in West Virginia helped expand the number of 

adults with serious mental illnesses and children with serious emotional 

disturbances who are eligible for services.

In addition to identifying revenue, States have worked to control costs: 

• Wisconsin launched a psychiatrist-education initiative to advance the use 

of generic medications;

• Colorado recruits licensed mental health professionals to provide probono 

health care for people who are homeless; and

• Florida’s self-directed care program allows the funding to follow the client, 

expanding client choice and control over services.

In Colorado’s Pro Bono Mental 

Health Program, licensed and/or 

certified mental health professionals volunteer at more than 

30 community agencies where 

people are already receiving 

non-mental health services. They 

provide free mental health services in the form of individual, group, 

and family psychotherapy, as well 

as psychological and psychiatric 

evaluations to low-income youth, 

families, older adults, and people 

who are homeless. The volunteers 

also benefit clients indirectly by 

providing case consultation, program consultation, and staff training to the host agency staff. The 

volunteers help these staff to recognize the symptoms of and treatments for mental illnesses and to 

better understand the needs of 

their clients with mental illnesses. Since 1986, more than $7.5 

million worth of services have 

been provided to the community 

for free.

For more information, contact: 

Susie Street, Director of 

Community Services, 

Mental Health Association of Colorado, 

(303) 377-3040.

Pro Bono 

Mental Health Program 

(Colorado)
Disparities in Mental Health 

Services Are Eliminated

The New Freedom Commission recognized that access to quality mental health care is not equal across all segments of the American population. Racial and ethnic minorities, as well as rural populations, may face 

more significant barriers to care than others do; some also find recovery 

impeded by the lack of culturally appropriate care. In addition to these 

systemic failings, individuals in rural areas and from some cultural groups 

may struggle with increased stigma associated with mental illnesses and 

mental health treatment.

In an effort to better understand and address these issues, the New Freedom Commission made two recommendations:

3.1 Improve access to quality care that is culturally competent.

3.2 Improve access to quality care in rural and geographically 

remote areas.

 GOAL 3
Trends in Mental Health System Transformation: The States Respond 2005 29

THE STATES RESPOND

Recognizing Disparities 

The Nation as a whole is experiencing significant demographic and cultural population shifts. These changes come at different speeds and in different forms. Rhode 

Island and Delaware have seen growth and shifts in their Hispanic populations. 

Minnesota officials recently traveled to Thailand to meet with and assess the 

needs of Hmong refugees who are likely to immigrate to Ramsay County, which 

already has a large Hmong population. In other States, a growing awareness of 

disparities or increasing understanding of cultural barriers to care drives efforts 

to adapt elements of the mental health system to better meet the needs of specific 

subgroups.

Developing a greater understanding of the disparities that exist within a State and 

the related cultural competence challenges faced by care providers is a critical step 

in advancing quality care for all citizens. To refine their understanding, Massachusetts and Connecticut are both engaged in an assessment of their States’ ability to capture and analyze data on various cultural groups, their use of services, 

and their treatment outcomes. California, Oregon, South Carolina, Ohio, and 

Arizona also are planning assessment activities. 

Building an Infrastructure to Support Cultural Competence

A number of States have developed councils, committees, work groups, task forces, and similar entities and charged them with identifying strategies to advance 

culturally competent care in the mental health system (e.g., Alabama, California, Colorado, Delaware, Hawaii, Idaho, Massachusetts, Mississippi, Missouri, 

North Carolina, New York and Washington). 

In some States, specific offices or staff are designated to address issues of cultural 

competence or to support the delivery of quality care to cultural minority populations (e.g., Arizona, Connecticut, Idaho, Kansas, Louisiana, Massachusetts, 

Nebraska, North Carolina, Oklahoma, Texas, and Washington). 

States also seek to enhance quality of care by hiring staff who reflect the culture of the target population and partnering with organizations that represent 

these populations. For example, New York’s Office of Mental Health enhances its 

outreach efforts through partnerships with the Association of Hispanic Mental 

Health Professionals, Black Psychiatrists of Greater New York, and the Coalition 

for Asian American Mental Health.

Often, the councils, task forces, offices, or staff are charged with providing training in cultural competence to mental health providers in their States. Training also is provided through other avenues. More than 20 States have pro-
30 Trends in Mental Health System Transformation: The States Respond 2005

Goal 3 Disparities in Mental Health Services Are Eliminated

FEATURED PROGRAM

vided some level of cultural competence training to mental health providers. 

Examples include the following:

• In Ohio, mental health providers are trained in the use of the Consolidated 

Culturalogical Assessment Tool (C-CAT), which enables them to assess their 

own cultural competence;

• In the District of Columbia, training provided by the Department of Mental Health Training Institute addresses not only traditionally recognized 

cultures such as that of the Latino community, but also gang cultures and 

the culture of commercial sex workers;

• In Massachusetts, the Department of Mental Health collaborated with the 

Massachusetts Office for Refugees and Immigrants to promote mental 

health in diverse racial, ethnic, and minority communities. In all, about 25 

community forums were held and more than 90 primary care practitioners 

were trained; and

• New York has presented a training program—Cultural Competence: Maintaining an Asking Stance—to provider agencies, trade associations, social 

work education programs, and community groups throughout the State.

Addressing Consumer Needs Across Cultures

In some cases, cultural affinities are related to specific barriers to care for consumers. In American Samoa, the Federated States of Micronesia, and the Commonwealth of the Northern Mariana Islands, outreach, education, and empathy 

all are needed to address differing beliefs about the causes of and treatments for 

mental illness. 

Massachusetts and New Hampshire are undertaking efforts to address stigma 

within the deaf and hard-of-hearing community. Alabama, Guam, Kentucky, 

Maine, Massachusetts, North Carolina, and Virginia also are undertaking outreach to deaf and hard-of-hearing communities.

Sometimes, language is the primary barrier to care. Efforts to address language 

and translation needs are underway in many States:

• To educate mental health consumers, family members, service providers, and the general public, California provides a multicultural mental 

health brochure series that is available through the Web at www.cimh.org/

projects/translation.cfm;

• Alabama maintains a statewide funding pool to support translation services;

• Minnesota recently has validated a transcultural assessment tool; and

Pennsylvania has used Block Grant 

funds to foster cultural competence, selecting participating 

counties by inviting competitive 

concept papers. The pilots include 

the following initiatives:

• Allegheny County Department 

of Human Services is collaborating with Mayview State Hospital 

and Mercy Behavioral Health to 

address the over representation 

of African Americans in the hospital. The project will emphasize 

community supports for discharged patients;

• Bucks County will do outreach to 

providers with Latino consumers 

to inform them of the services 

Pan American Behavioral Health, 

Inc., can offer to the Latino population;

• The Northampton County Colonial Intermediate Unit 20, in collaboration with Touchstone Theater and RESOLVE, designed a 

psychoeducation project to create a dialogue among students 

of diverse cultural/ethnic backgrounds, teachers, and mental 

health professionals. This nonstigma/non-threatening (experiential) process will use students’ 

cultural resilience while developing problem-solving skills around 

prejudice/discrimination; and

• Community Action Southwest, 

in Washington County, will be 

doing outreach to a rural population that traditionally does not 

seek mental health services. Outreach efforts will be integrated 

with services in the community. 

For more information, contact: 

Maria del Carmen, 

Cultural Competence Coordinator, 

(717) 705-8240, 

c-mperez@state.pa.uis. 

See also 

www.dmhas.state.ct.us/multicultural.htm.

Local Pilots for 

Cultural Competence 

(Pennsylvania)
Trends in Mental Health System Transformation: The States Respond 2005 31

FEATURED PROGRAM

• Guam and Palau translate materials into local languages to reach all segments of the population. For example, in Guam, pamphlets are translated 

into the Tagalog, Chuukese, and Palauan languages. 

States provide a variety of programs to benefit specific cultural or ethnic populations identified as underserved or at-risk: 

• Minnesota dedicates 25 percent of State Block Grant funds to meet the 

mental health needs of the Native American nations in the State;

• A Latino Mental Health Roundtable was formed to achieve accountability 

in meeting the behavioral health needs of Colorado’s diverse Latino community;

• Nebraska is developing a transitional program specifically targeted to African American males involved in the juvenile justice system;

• Washington State commissioned a report on the mental health needs of 

American Indians in Washington State: www1.dshs.wa.gov/pdf/hrsa/mh/

amindiansmhneeds.pdf. Using Block Grant funds, the State also has developed a best practices guide for vulnerable populations, including Alaska Native/American Indian children and ethnic minorities: www1.dshs.wa.gov/

mentalhealth/bestpracticesguide.shtml;

• Rural boards in Ohio receive support to implement evidence-based practices to ensure that quality services are available to Ohio’s Appalachian and 

Amish communities; and

• In Texas, the Mental Health Interpreter project will deliver linguistically 

and culturally competent mental health services to people who are deaf and 

hearing impaired. 

Reaching Rural Populations

Providing services to populations in rural and geographically remote areas is a 

challenge to many States. In Oregon, Delaware, Illinois, Michigan, and Wisconsin, the availability of mental health services throughout the jurisdiction is 

mandated by contract or legislation. Across the States, a variety of strategies have 

been adopted to extend mental health services to rural areas. These are some examples:

• Providing transportation or subsidies for transportation to enable providers to reach their more distant mental health clients, or to make it easier 

for clients to reach providers (e.g., Alabama, American Samoa, Arizona, 

Idaho, Kentucky, Massachusetts, Mississippi, the Federated States of 

Micronesia, North Carolina, Oregon, Puerto Rico, Rhode Island, Tennessee, and Vermont);

Cost-free, confidential mental 

health counseling for rural residents is provided through a voucher program Nebraska residents access through the Nebraska Farm 

Hotline. Rural residents calling the 

toll-free Nebraska Farm Hotline 

who seem to be in need of professional mental health treatment 

are informed of the voucher program. Eligible individuals include 

those who derive their livelihood 

from the rural economy and who 

often face the stress of low prices, increased costs, and drought. 

These include farmers, farm family members, those employed in 

agriculture-related businesses, 

small town businesses dependent 

on the agricultural economy, and 

others. Those who are eligible may 

request a voucher for outpatient 

mental health counseling. They 

also receive a list with contact information for all participating mental health providers in their area. 

Callers have 30 days to redeem the 

voucher and may request up to 

five additional vouchers through 

the hotline. Currently, 189 providers have signed up to participate 

in the voucher program. As of June 

30, 2004, 68 providers were active. Many of these providers have 

strong farm backgrounds and a 

clear understanding of rural culture.

For more information, contact: 

James Harvey, 

Quality Improvement Coordinator, 

(402) 479-5125, jim.harvey@hhss.ne.gov.

Rural Mental 

Health Vouchers 

(Nebraska)
32 Trends in Mental Health System Transformation: The States Respond 2005

Goal 3 Disparities in Mental Health Services Are Eliminated

FEATURED PROGRAM

• Providing services through rural networks or satellite offices (e.g., American Samoa, Arizona, Idaho, Mississippi, North Carolina, Oregon, Palau, Pennsylvania, Puerto Rico, Vermont, and West Virginia); and

• Using telemedicine to provide mental health services (e.g., Alaska, Arizona, California, Idaho, Illinois, Iowa, Kansas, Kentucky, Louisiana, 

Michigan, New Mexico, New York, Oklahoma, Oregon, Virginia, West 

Virginia, Wisconsin, and Wyoming). Telemedicine is being piloted in Nevada and South Dakota.

States have developed a variety of creative outreach strategies, sometimes including home-based services. For example—

• The Commonwealth of the Northern Mariana Islands provides training 

for nurses and social workers on remote islands so they can monitor adults 

with serious mental illnesses. Monthly home visits also support adults receiving treatment;

• Treatment Foster Care is used in Oregon to better serve rural children who 

might otherwise be placed in more restrictive settings;

• South Carolina has developed Rural Assertive Community Treatment 

(ACT) teams, an initiative it hopes to expand statewide; and

• The Utah Frontier Project provides wraparound services to children and 

their families in rural and frontier communities. 

In addition to these efforts to extend existing services to rural populations, States 

also are working to increase the availability of mental health care in rural areas by 

increasing the number of qualified workers in those areas. Many States specifically train, certify, and provide incentives for providers to deliver services in rural 

areas:

• Utah uses a State-funded Rural Mental Health grant to support the educational expenses of mental health staff working on clinical licensure in exchange for a commitment to work in an underserved rural area; and

• Efforts to increase the number and capacity of rural mental health workers 

are also underway in Alaska, American Samoa, Arizona, Georgia, Kentucky, Minnesota, New Mexico, North Dakota, the Commonwealth of 

the Northern Mariana Islands, and Oklahoma.

The Behavioral Health Disparities Initiative of the Connecticut 

Department of Mental Health and 

Addiction Services (DMHAS) is a 

multilevel, multidimensional, systematic effort to identify, reduce, 

and ultimately eliminate behavioral 

health disparities within the public 

sector State system. It is based on 

collaboration among DMHAS and 

academic partners (Yale University 

and the University of Connecticut), 

consumers and people in recovery, 

community leaders, providers, and 

other stakeholders. Component 

programs include

• the Health Disparities Forum—a 

periodic meeting of researchers 

and policymakers to discuss new 

findings and directions;

• the Health Disparities Research 

and Data Analysis Project—to 

identify health disparities 

through analysis of administrative databases and identify crucial components of culturally 

competent care;

• the Culturally Specific Programs 

Initiative—a cluster of programs 

serving the needs of specific 

racial or cultural groups; and

• Health Disparities Consultation 

Support—technical assistance 

provided by postdoctoral fellows 

from the Yale University School 

of Medicine.

For more information, contact: 

Wayne Dailey, 

(860) 418-6899, 

Wayne.Dailey@po.state.ct.us. 

See also 

www.dmhas.state.ct.us/multicultural.htm.

Healthcare Disparties

Initiative 

(Connecticut)
Trends in Mental Health System Transformation: The States Respond 2005 33

FEATURED PROGRAM

States have shown resourcefulness in meeting the challenge of funding rural services:

• The Alabama Rural Coalition for the Homeless was created to access U.S. 

Department of Housing and Urban Development funds to help provide a 

continuum of care for people with severe mental illnesses who are homeless; Tobacco Settlement Funds are used to advance services to children and 

adolescents in rural parts of the State;

• South Dakota has established a rural reimbursement rate that is 20 percent higher than the regular rate. This rural rate can be charged when mental health care providers must travel more than 20 miles from their office to 

provide care; and

• An additional barrier in rural West Virginia is the high poverty rate. However, only 25 percent of people living in rural areas qualify for Medicaid, 

compared to 43 percent of those who are poor and living in urban areas. The 

West Virginia Children’s Health Insurance Program covers mental health 

and substance abuse treatment for more than 20,000 children who otherwise would be ineligible to receive these services.

States also have opened new avenues to care:

• Utah views Clubhouse programs as integral to rural outreach efforts;

• Oregon established Treatment Foster Care in order to avoid residential 

placement for youth from rural areas;

• In Illinois, the Farm Resource Center provides crisis services to rural families; and

• Mental health vouchers are available to Nebraskans through the Farm Hotline. 

Such approaches also may help offset any stigma surrounding mental illnesses 

and mental health treatment in rural areas.

The Rural Human Services System 

Project (RHSSP) was designed to 

correct identified problems with 

the delivery of human services, 

particularly mental health and 

substance abuse services, in rural 

Alaska. RHSSP links the Division of 

Behavioral Health, regional mental 

health and substance abuse programs, and the University of Alaska 

to train, employ, and supervise village-based human service providers. Village residents are employed 

and supervised by the regional 

programs. The University of Alaska, 

College of Rural Alaska, offers a 

30-hour certificate in Rural Human 

Services at five campuses across 

the State. The certificate program 

emphasizes community development, a holistic model of human 

functioning, and the integration 

of Native and Western counseling 

techniques. For every 5 to 10 village-based positions, the RHSSP 

provides funds to train and employ 

one master’s level supervisor. 

For more information, contact: 

L. Diane Castro, Manager, 

Prevention and Early 

Intervention Services, 

(907) 465-3033, 

diane_castro@health.state.ak.us.

Rural Human Services 

System Project

 (Alaska)
Early Mental Health Screening, 

Assessment, and Referral to Services 

Are Common Practice

The New Freedom Commission recognized that early detection, assessment, and linkage with treatment and supports can lessen the long-term 

effects of some mental illnesses. They saw a clear need to identify people 

who can benefit from interventions and help them access the resources 

they need to recover before poor life outcomes accumulate. In particular, the Commission pinpointed the critical needs of children, for whom 

early detection, assessment, and links with treatment can prevent mental 

health problems from worsening. The Commission also noted that people 

with co-occurring mental and substance use disorders often are caught 

between the mental health and substance abuse systems, unable to access effective, integrated care. To address these challenges, the Commission made the following recommendations:

4.1 Promote the mental health of young children.

4.2 Improve and expand school mental health programs.

4.3 Screen for co-occurring mental and substance use disorders 

and link with integrated treatment strategies.

4.4 Screen for mental disorders in primary health care, across the 

life span, and connect to treatment and supports.

 GOAL 4
Trends in Mental Health System Transformation: The States Respond 2005 35

THE STATES RESPOND

Promoting the Mental Health of Young Children 

In State after State, traditional boundaries are erased or crossed regularly as State 

agencies and their partners forge alliances to support children and families coping with serious emotional disturbances, who frequently must navigate multiple 

systems to receive the treatment and services they need. Together, these agencies 

are planning, sponsoring training, and implementing wraparound care programs 

that provide a wide variety of support.

These are some examples of alliances driven by top-down directives or legislative 

mandates: 

• Arizona’s Governor issued an Executive Order creating a Children’s Cabinet to ensure cross-system coordination;

• The Governor’s KidsFirst Initiative, unveiled in Spring 2004, seeks to coordinate all systems that serve children in Wisconsin;

• Nebraska’s Governor appointed an Early Childhood Interagency Coordinating Council to establish a planning structure and process that engages 

the full spectrum of early childhood stakeholders;

• In Missouri, the Children’s Mental Health Act of 2004 recognized that to 

adequately meet the mental health needs of children, multiple State agencies must be involved and coordinated leadership and funding is required. 

A Comprehensive System Management Team and a Stakeholder Advisory 

Committee will guide the integration effort; and

• The Wyoming Legislature mandated the Children and Families Initiative, 

which requires the Department of Family Services to develop a comprehensive, collaborative plan to improve the lives and futures of all children and 

families in Wyoming.

States’ initiatives in behavioral health for children and their families involve an 

ever-expanding range of partners. The following examples are illustrative but far 

from exhaustive:

• Arizona’s 300 Kids Project has become a statewide effort to develop, demonstrate, and disseminate a child and family team approach to assessment, 

service planning, and delivery;

• Delaware has a continuum of care that consists of Clinical Services Management Teams with a coordinator assigned to each client and more than 

40 agencies providing a wide array of mental health and substance abuse 

services for children and adolescents;

• In Florida, a Multi-Agency Network for Students with Emotional Disturbance works at both State and local levels;
36 Trends in Mental Health System Transformation: The States Respond 2005

Goal 4 Early Mental Health Screening, Assessment, and Referral to Services Are Common Practice

FEATURED PROGRAM

• In Guam, an Inter-Agency Case Review Committee made up of representatives from various youth-serving agencies reviews multi-agency cases for 

children who have needs that tend to overwhelm the local system of care 

and who often are considered for off-island treatment;

• In Illinois, the Screening Assessment Support Services Initiative supports 

an integrated network of individualized services for children with serious 

emotional disturbances. Case management services employ a strengthsbased, wraparound approach (p.57);

• Massachusetts reports positive results with supported child care, a strategy in which a clinical social worker is hired through a community health 

center and assigned to a local child care center to identify and support children who need intensive services;

• In New York, a multi-year training program in Functional Family Therapy 

is being delivered to 21 teams who represent a variety of mental health, 

juvenile justice, and social service agencies. Functional Family Therapy is a 

multi-systemic, family-based prevention program with an encouraging record of success; and

• Rhode Island’s Local Coordinating Councils, located in eight catchment 

areas, meet regularly to review problematic child or adolescent cases and 

engage in joint problem solving. 

Many States are striving to reach very young children with preventive, collaborative care. 

• Vermont’s CUPS (Children’s Upstream Services) seeks to reduce the number and rate of children who enter kindergarten without the emotional and 

social skills necessary to be active learners. This program targets children 

from birth to age 6 who are experiencing (or are at risk of experiencing) 

serious emotional disturbances. Interagency collaborators at State and regional levels include representatives of families, early care and education 

providers, and health and mental health providers. Services include outreach, information and referral, consultation, and training. Initially grantfunded, the program is now sustained by State funds.

• In Colorado, Jefferson Center’s Early Intervention Services teaches the 

building blocks of good parenting to parents who struggle with mental health 

issues in the family. This initiative provides timely and accessible mental 

health services to at-risk children from birth to age 8 and their families.

• In Connecticut, the Partnership Resources and Infrastructure Support 

Monies initiative implements prevention models for children (kindergarten 

through grade 5) and assesses them for improved skills, behaviors, family 

relations, and a reduction in violence and mental health problems. The iniThe Child and Adolescent Service 

System Program (CASSP) was established in Arkansas in 1991. CASSP 

is based on the concept developed 

by the National Institute of Mental 

Health regarding the need for interagency collaboration and coordination in delivering services 

to seriously emotionally disturbed 

children. CASSP service teams are 

available throughout the State to 

develop multi-agency plans of care 

for individual children and adolescents with serious emotional 

disturbances when the current 

system is not adequately meeting 

their needs. 

The goal is to provide an integrated 

system of care. Families participate 

in treatment planning and other 

meetings. Priorities include 

early childhood, the Head Start 

population, and discharge planning for those in hospitals or 

moving into the adult system. The 

CASSP Coordinating Council promotes the early childhood mental 

health initiative. 

For more information, contact: 

Anne Wells,

Assistant Director for Children’s Services, 

(501) 686-9489, 

anne.wells@arkansas.gov.

CASSP

(Child and Adolescent Service System Program)

Service Teams 

(Arkansas) 
Trends in Mental Health System Transformation: The States Respond 2005 37

tiative features an evidence-based bullying prevention program and interventions to strengthen families.

States also are working to provide appropriate care and support for youth with 

serious emotional disturbances, including those involved with the criminal justice 

system. 

• Delaware’s Individual Residential Treatment Services program (IRT) provides appropriate alternatives for youth ready to leave residential treatment 

but unable to live with their families. As of July 2004, the Division of Child 

Mental Health Services had five providers under contract (three of whom 

are operating on a statewide basis), and 42 clients had been served through 

the IRT initiative.

• In the Federated States of Micronesia, a broad range of sports, counseling, and awareness programs help youth and their families address mental 

health and substance abuse issues. 

• With new funding received in 2004, Mississippi’s Department of Mental 

Health opened a Specialized Treatment Facility for Youth with Emotional 

Disturbance, with priority given to youth referred through the court system. 

• North Dakota’s mental health system collaborated with the child welfare 

and juvenile justice systems to develop a wraparound certification (p.57) 

process with a Single Plan of Care.

• Several of West Virginia’s behavioral health centers have developed volunteer-based youth mentoring programs for children with serious emotional 

disturbances who are 7 to 17 years old. 

Participants in Puerto Rico’s system of care program enjoyed a family retreat in which 

children express themselves through art and painting. All family members of the children 

receiving treatment participated in this activity, which was held in Vista Mar Resort (2003).
38 Trends in Mental Health System Transformation: The States Respond 2005

Goal 4 Early Mental Health Screening, Assessment, and Referral to Services Are Common Practice

• In Palau, the Ministry of Health’s Children’s High Risk Clinic targets children ages birth to 21 with high-risk conditions. A multidisciplinary team 

provides assessment, diagnosis, treatment planning, and follow-up.

• In Alabama, law enforcement officials and emergency health services providers receive training to help them handle children and adolescents with 

serious emotional disturbances. 

• A grant from the Federal Office of Juvenile Justice and Delinquency Prevention to the South Dakota Council of Mental Health Centers is supporting enhanced services to youth who live in rural regions of the State who are 

involved with—or at risk for involvement with—the State’s juvenile justice 

system. Services provided through the grant include wraparound services 

(p.57) for youth and families, school-based/linked mental health services, 

community development/coordination, and professional training and development for service providers in rural and frontier areas.

States are seeking ways to support children and youth experiencing a crisis.

• Louisiana has developed a Child and Adolescent Response Team mobile 

crisis program.

• Oklahoma will establish the State’s first Children’s Crisis Stabilization Center in Fiscal Year 2005, offering new alternatives to hospitalization for children and allowing more immediate resolution of crises.

• Ohio’s TEENLINE, a toll-free hotline, provides assistance to teens in crisis 

and refers adolescents to the nearest treatment provider. 

• New Jersey’s Department of Mental Health Services has dedicated 

$500,000 annually in Block Grant funds to develop Traumatic Loss Coalitions in each of the State’s 21 counties. A key purpose is to identify and 

train a network of professionals in each county to address issues related to 

mental health emergencies for youth subsequent to trauma.

States strive to reduce out-of-State placements for children and adolescents, often 

by providing the strongest possible support for the family. 

Nebraska has the highest number of children per capita who are wards of the State. 

The National Association of State Mental Health Program Directors (NASMHPD) 

supported Nebraska’s Department of Health and Human Services (DHHS) in efforts to address the issue of parents relinquishing custody of their children to access mental health services. In five of Nebraska’s six behavioral health regions, 

Integrated Care Coordination Units work cooperatively with local family organizations and DHHS to provide wraparound services (p.57) for children who are at high 

risk for out-of-home placement and their families.
Trends in Mental Health System Transformation: The States Respond 2005 39

Many States are actively exploring new funding possibilities that will enable them 

to provide essential services.

• In California, the Children’s System of Care Initiative will benefit from 

funds generated by the Mental Health Services Act, which pays for expanded mental health programs through a 1 percent surcharge on the income of 

all Californians who earn more than $1 million per year. 

• In Fiscal Year 2005, Maine’s Children’s Services will seek to expand the 

range of services available to children with mental retardation and autism 

by applying for a Home and Community-Based Medicaid waiver. 

• Maryland is studying the feasibility of bringing child and adolescent respite care into the Medicaid benefit package on a limited basis. 

• In New Jersey, resources from child welfare, mental health, and Medicaid 

agencies will be pooled to enable the system to meet the needs of children 

with emotional and behavioral disturbances and their families more effectively. 

• In Ohio, Intensive Home and Community Based Services for Children are 

being developed as a distinct Medicaid service.

• In 2003, the Oregon Legislature passed a Budget Note (a resolution regarding the use of public funding) requiring the children’s public mental health 

system to fully integrate Medicaid-covered services into managed care organizations. 

Improving and Explaining School Mental Health Programs 

States are working with schools in a wide variety of ways. Many, if not most, States 

offer interventions and referrals through schools. 

• In Hawaii, children and youth who have educational disabilities receive 

school-level supports and services through their home school. 

• Idaho’s Department of Health and Welfare and its Departmnt of Education 

have an interdepartmental agreement to jointly develop and implement 

school-based programs for children with serious emotional disturbances in 

all regions of the State. These programs blend mental health, education, and 

local school district funds to support a range of services from traditional 

day treatment models to intensive school-based services.

• Illinois uses school consultation teams and offers psychiatric expertise.

• Vermont’s Success Beyond Six program provides mental health staff who 

work in partnership with the schools to link children and their families with 

an array of mental health and other community-based services.
40 Trends in Mental Health System Transformation: The States Respond 2005

Goal 4 Early Mental Health Screening, Assessment, and Referral to Services Are Common Practice

FEATURED PROGRAM

• New Hampshire’s Positive Behavioral Interventions and Supports program 

helps schools approach children with intensive needs from a strengthsbased perspective. 

• In the Commonwealth of the Northern Mariana Islands, the Division of 

Public Health collaborated with the public school system to open an Adolescent Health Clinic at the Marianas High School campus. Services offered 

on-site include mental health and substance abuse counseling with support 

groups on topics such as anger management and grief recovery.

• In Kansas, Rock Creek School District credited the regular presence of case 

managers in their schools with a greatly reduced need to contact the mental 

health center for assistance with crisis response.

Training teachers and staff to respond appropriately to behavioral health needs is 

done in a variety of ways.

• In Kansas, Olathe Special Services adopted the Behavioral Intervention 

Support Team model (based on how teachers and staff respond to students’ 

behaviors) to train staff. Regular classroom teachers are now attending the 

training as well.

• In Missouri, the Department of Mental Health and the University of Missouri-Columbia collaborate on the Center for the Advancement of Mental 

Health Practice in Schools. The Center helps ensure that university-trained 

teachers and school administrators are apprised of best practices in public 

mental health awareness and prevention initiatives, early identification and 

intervention efforts, and treatment services and supports in the school setting.

• Pennsylvania’s Commonwealth Student Assistance Program (SAP) places 

SAP core teams, which include school staff and liaisons from the mental 

health and drug and alcohol systems, in the high schools and middle schools 

of each school district.

• Minnesota’s Local Children’s Mental Health Collaboratives and Family 

Services Collaboratives provide technical assistance and training to help 

educators address mental health issues in school settings. 

Screening, Assessment, and Referral

States are developing screening tools and procedures for a variety of ages and venues. Many are seeking to identify children who need help as early as possible. 

• In American Samoa, infants and toddlers served through the “Part C” program at the LBJ Tropical Medical Center benefit from early intervention, 

screening, identification, assessment, information, and referral services.

A prevention program developed by the Mental Health Association of Summit County in concert with the Ohio Department 

of Mental Health, Red Flags helps 

students, parents, and school staff 

recognize and respond to signs of 

depression and related mental illnesses. The program includes an 

in-service training for school personnel, a video-based curriculum 

for students called Claire’s Story: 

A Child’s Perspective of Childhood 

Depression, and a seminar for parents, students, and the community. Red Flags is available at more 

than 600 schools.

For more information, contact: 

www.redflags.org 

or 

Victoria Doepker, 

Associate Director, 

Mental Health Association 

of Summit County 

(800) 991-1311,

(800) 991-1311 (toll-free). 

The Red Flags Program 

(Ohio)
Trends in Mental Health System Transformation: The States Respond 2005 41

FEATURED PROGRAM

• In the Federated States of Micronesia, screening and diagnostic services 

for emotional problems are incorporated with routine pediatric care. Mental health staff also identify students with potential emotional disturbances 

through teacher interviews, review of school records, and student testing. 

• In Hawaii, staff of the State mental health agency provide training for families, child care providers, and preschool staff to help them identify and support children with emotional and behavioral challenges.

• Through Georgetown University’s National Technical Assistance Center, 

Indiana is receiving help in developing an Early Identification and Intervention plan. When the plan is fully implemented, all children entering the 

child welfare system will be screened for mental health and addiction issues. 

• Iowa’s Medicaid Early Periodic Screening, Diagnosis, and Treatment Program has received a grant to develop early screening and assessment of 

children’s mental development from birth to age 3.

• In Palau, the Chief of the Behavioral Health Division and the social worker 

assigned to children visited each Head Start Center in Palau to screen the 

children who attend using the Temperament & Atypical Behavior Screen 

(TABS). Of 262 children who were screened, 10 percent scored high and 

were referred for further assessment.

Screening strategies for older children and adults, and for special circumstances, 

also are being developed and refined. 

• Ohio is piloting Teen Screen, a computer-based mental health screening 

program.

• Puerto Rico’s 12 centers of prevention and promotion help citizens and 

teachers identify emotional disorders in children and adolescents.

• South Carolina has selected screening tools to assess trauma in children 

under age 9 and children age 9 and older. Guided by a Trauma Initiative 

Task Force, the State will continue testing the tool at seven trauma screening/treatment pilot sites.

• In Texas, the Adult-TRAG makes it possible for clinicians at each local authority to assess mental health consumers on nine dimensions. (i.e., risk of 

harm, support needs, psychiatric hospitalizations, functional impairment, 

employment problems, housing stability, co-occurring substance use, criminal justice involvement, and response to medications). Along with principal 

diagnosis, the Adult-TRAG provides a methodology to facilitate rapid and 

consistent levels of care recommendations.

(Arizona)

In evaluating people seeking behavioral health services in Arizona, 

the Arizona Department of Health 

Services, Division of Behavioral 

Health Services, found that most 

of the assessments were assessing parts of the person, but 

not collecting a comprehensive 

picture that included the person’s mental health, substance 

abuse, culture, and related factors in one coherent process. In 

an effort to devise a more holistic approach to clinical assessment, a workgroup comprised of 

stakeholders and Division staff 

developed a streamlined and 

standardized assessment tool, 

in English and Spanish, to gather 

more comprehensive information. 

In addition to a core assessment 

component, the tool also includes 

a behavioral health and medical 

questionnaire and a provision 

for additional individual information to be gathered.

Division staff trained Regional Behavioral Health Authorities and 

providers on the new process, and 

implemented the tool statewide 

on January 1, 2004. An instructor’s guide and training materials 

on the assessment are available 

as resources on Arizona’s Web 

site (www.azdhs.gov/bhs/assess_

process.htm#assessment). 

For more information, contact: 

Dr. Michael Franczak, 

Clinical Services Director, 

ADHS/DBHS, 

150 North 18th Avenue, Suite 220, 

Phoenix, Arizona 85007, 

(602) 364-4626, 

FRANCZM@azdhs.gov.

Clinical Assessment 

Tool and Process 
42 Trends in Mental Health System Transformation: The States Respond 2005

Goal 4 Early Mental Health Screening, Assessment, and Referral to Services Are Common Practice

Moving Toward Integrated Services for Co-Occurring Disorders

States are working to screen, refer, and treat people with co-occurring mental and 

substance use disorders more effectively. These are examples of State-sponsored 

training efforts to help mental health and substance abuse clinicians coordinate 

care and use appropriate screening procedures.

• American Samoa and Nevada cross-train mental health and substance 

abuse providers to promote integrated treatment.

• In Alabama, the Department of Mental Health/Mental Retardation teamed 

with the Southern Coast Addiction Technology Transfer Center (ATTC) to 

train 900 mental health and substance abuse professionals in co-occurring 

disorders. 

• In Guam, the Department of Mental Health and Substance Abuse conducts twice-yearly mental health training for drug and alcohol counselors 

and substance abuse training for mental health clinicians/social workers to 

increase awareness of co-occurring disorders.

• Kentucky provides training on co-occurring disorders for case managers, 

consumers, family members, and providers.

States are cognizant of the driving role played by licensure and State requirements 

in establishing competencies to address co-occurring disorders. 

• In Texas, an administrative rule on co-occurring psychiatric and substance 

abuse disorders outlines competencies that mental health providers serving 

children with substance use/abuse disorders must have, beginning with assessment skills. The Texas Commission on Alcohol and Drug Abuse developed a similar rule regarding the competencies needed by substance abuse 

providers serving children with mental disorders. 

• Florida’s Common Licensure Standards now require training on assessment and treatment for co-occurring disorders. 

• In Rhode Island, all eight community mental health centers are licensed to 

provide substance abuse services.

Many States are promoting screening of co-occurring mental and substance use 

disorders and linkages with integrated treatment strategies (e.g., Alabama, Arkansas, Florida, Georgia, Mississippi, Nebraska, North Carolina, Minnesota, 

Montana, and Tennessee). Some also have developed tools to meet their needs.

• Alaska’s Department of Behavioral Health developed the Alaska Screening 

Tool to promote identification and service referrals for co-occurring mental 

health, substance use, traumatic brain injury, and fetal alcohol spectrum 
Trends in Mental Health System Transformation: The States Respond 2005 43

disorders. Implementation of the tool is scheduled for 2005. A copy of this 

tool is available at http://health.hss.state.ak.us/dbh/providers/doc/ToolsInstructions.doc.

• Delaware is developing a customer satisfaction tool specifically for co-occurring disorders.

A significant number of States are particularly concerned with youth and young 

adults who have co-occurring disorders, including at-risk youth or those involved 

with the criminal justice system.

• Alabama has worked with juvenile courts to use a standardized screening 

test to identify youths who need treatment. Jefferson County will train case 

managers, probation officers, and Family Court staff on co-occurring disorders. 

• Colorado developed a pilot program for young people ages 16 to 21 with 

severe emotional disturbances, focusing on youth with co-occurring disorders. 

• In Kentucky, a Co-Occurring Workgroup focuses specifically on youth with 

co-occurring disorders in the juvenile justice system.

• In Massachusetts, a Substance Abuse Task Force is focusing on the issue of 

access to care for adolescents who have co-occurring disorders.

• Oklahoma provides integrated outpatient treatment for adolescents with 

co-occurring disorders.

• In order to screen for co-occurring mental and substance use disorders and 

provide linkages with integrated treatment strategies, Puerto Rico has four 

interdisciplinary teams for children and adolescents with co-occurring disorders.

Many States are benefiting from SAMHSA’s Co-Occurring Disorders State Incentive Grants (COSIG) and from its National Policy Academy for Co-Occurring Disorders, both intended to foster major changes in infrastructure to provide essential screening, referral, and treatment. States actively working toward integrated 

care that are engaged in comprehensive planning to address co-occurring disorders, either with or without Federal assistance, include Connecticut, the District 

of Columbia, Hawaii, Louisiana, South Carolina, and Washington. To inform 

its planning efforts, New Jersey has distributed a survey to 400 mental health 

and substance abuse agencies to collect information on best practice techniques. 
44 Trends in Mental Health System Transformation: The States Respond 2005

Goal 4 Early Mental Health Screening, Assessment, and Referral to Services Are Common Practice

Other examples of support for integrated treatment include the following:

• California’s Department of Mental Health annually sets aside $8 million of 

its Block Grant funds to support county efforts to provide integrated treatment services for adults with co-occurring disorders.

• In Delaware, integrated treatment is now available in three counties.

• In Indiana, integrated treatment for children and youth with co-occurring 

disorders is delivered through the Division of Family and Community Services.

• North Dakota’s Off Main program offers comprehensive services to people 

with co-occurring disorders. 

• In cooperation with the Division of Alcohol and Drug Abuse, South Carolina’s Department of Mental Health supports a residential treatment program for individuals with co-occurring disorders.

• Tennessee funds Foundation Associates to develop integrated services for 

adults with co-occurring disorders at agencies around the State. Also, the 

Co-Occurrence Project supports a resource center, self-help groups, vocational services, and provider education.

• In Oklahoma, integrated treatment is available in four residential and five 

outpatient settings. 

• In West Virginia, integrated treatment is available at jointly funded crisis 

stabilization units.

In Michigan, grandparents are being taught to recognize signs 

of substance abuse by playing “substance abuse bingo.” 
Trends in Mental Health System Transformation: The States Respond 2005 45

Transitioning Youth to Adult Programs

A key challenge identified by States is the need to help adolescents with serious 

mental illness transition into the adult system. 

Several States have been working on systemic issues in order to make a more 

seamless transition. 

• Alabama’s Child and Adolescent Task Force is addressing the issues.

• Illinois has developed a transitional protocol that specifies the responsibilities of all who must play a role in the process. 

• Maine’s Partnership for Youth in Transition also seeks to identify and resolve systemic barriers; two pilot sites are now testing a service model. 

• Missouri has established a work group to study the issue and develop best 

practice guidelines. 

Some States have developed specific strategies to assist youth during this transition.

• Noting an inadequate supply of age-appropriate services for transition-age 

youth, Massachusetts’ Department of Mental Health is using Block Grant 

funds to contract with M* Power, a consumer-run organization, to create a 

peer mentoring project to assist youth in transition.

• Michigan has developed a mental health youth-to-adult transition services 

project that requires significant revisions to the local mental health services 

structure.

• In New Mexico, an Adolescent Transition Group involves representatives 

from both the adult and children’s service systems in an analysis of service 

system issues and barriers. The group developed a checklist to document all 

the systems a young person must navigate in order to obtain the services he 

or she will need as an adult.

• Oklahoma uses Block Grant funds to provide a comprehensive array of services for youth ages 16 to 25 with serious emotional disturbances. 

• In Pennsylvania, the Office of Vocational Rehabilitation (OVR) partners 

with Child and Adolescent Service System Programs to provide transition 

and pre-employment services for adolescents with physical and mental disabilities. The 14 OVR district administrators promote outreach and have 

been active supporters and participants in planning for adolescents at the 

local level. 
46 Trends in Mental Health System Transformation: The States Respond 2005

Goal 4 Early Mental Health Screening, Assessment, and Referral to Services Are Common Practice

FEATURED PROGRAM

Providing Mental Health Services to Older Adults

States clearly recognize the special mental health needs of older adults. 

Several States are in the process of planning or demonstrating models that address ways of providing mental health services for these citizens.

• California’s Department of Mental Health has awarded Block Grant funds 

to four counties to implement Older Adult System of Care demonstration 

projects. 

• In Illinois, a GeroPsych Specialist Initiative, now in the pilot stage, supports 

the development of local mental health and aging coalitions, and provides 

training and education on older adult mental health issues to Department 

of Mental Health and Department on Aging staff.

• Iowa is developing a best practice model for mental health outreach and 

treatment for older adults through partnerships between three community 

mental health providers and primary care physicians. 

• In North Dakota, which faces a rapidly aging population, the Division of 

Mental Health and Substance Abuse Services has entered into an agreement with the Mental Health Association in North Dakota to identify existing mental health services for older individuals, develop an understanding of those services and collaborations among agencies, identify future service needs, and raise public awareness of the mental health needs of older 

adults.

• New Hampshire, the Referral, Education, Assistance, and Prevention 

(REAP) program, a substance abuse/mental health early intervention program, continues to expand outreach to older adults in low-income senior 

housing, senior centers, Service Link sites, and individuals’ homes. The program is a collaborative effort among the New Hampshire Housing Finance 

Authority, the Bureau of Behavioral Health, the Bureau of Developmental 

Services, the Bureau of Elderly and Adult Services, and the Division of Drug 

and Alcohol Prevention and Recovery.

Many States have coordinating committees that play a role in providing comprehensive systems of care to older adults. 

• The Older Adult System of Care Committee of the California Mental Health 

Directors Association provides a link between the Department of Mental 

Health and local efforts to create systems of care for older adults.

• An Advisory Committee on Geriatric Services coordinated by the Department of Mental Health with the Illinois Department on Aging provides 

training, consultation, and technical assistance in the area of mental health 

and aging.

In North Carolina, the Division 

of Mental Health, Developmental Disabilities, and Substance Abuse Services funds 

20 community-based geriatric mental health specialty teams to provide consultation, training, and support 

to long-term care facilities 

and caregivers throughout 

the State. The teams were 

developed in response to the 

number of elderly individuals 

who are inappropriately admitted to State psychiatric 

hospitals. The teams help 

older adults with mental illnesses live in their communities by training staff in nursing homes, adult care homes, 

other agencies, and caregivers that serve older adults 

who have mental health 

treatment needs and who 

may be at risk of psychiatric 

hospitalization. The teams 

also educate other agencies 

that serve elderly individuals, 

such as senior centers and 

primary medical providers, 

on issues of mental illness 

and its effects on people as 

they age. 

For more information, contact: 

Debbie Webster,

Best Practice Team, 

Community Program Coordinator, 

(919) 715-2774, 

debbie.webster@ncmail.net.

Geriatric Mental Health 

Specialty Teams

(North Carolina)
Trends in Mental Health System Transformation: The States Respond 2005 47

• The Kentucky Mental Health and Aging Coalition reviews, advises, and advocates in concert with regional staff who represent older adults. 

• Virginia has a Gero-Psychiatric Workgroup that advises and monitors 

screening efforts among older Virginians. 

• In Michigan, a Geriatric Community Mental Health Team functions at the 

local level. 

States also work to publicize the unique issues around mental health care for older 

adults. 

• The Department of Mental Health for Illinois works with the State’s Department on Aging to coordinate an annual Mental Health and Aging Conference.

• Kansas produced and distributed a publication titled A Mental Health Guide 

For Older Kansans and Their Families.

• In Pennsylvania, in recognition of Older American’s Month and Mental 

Awareness Week, the Joint Committee on the Mental Health of Older Persons collaborated with the central region’s Mental Health and Aging Coalition to coordinate a Web-based training series focused on mental health 

issues facing older Pennsylvanians and innovative treatment and recovery 

options available. 

• In South Dakota, a diverse workgroup developed a Geriatric Resource 

Guide that lists trainings, conferences, and educational opportunities for 

mental health care providers. 

Many States are working with models that train “gatekeepers” to identify older 

adults in need of assistance with mental health problems. 

• Massachusetts’s Department of Mental Health is collaborating with the 

Boston Department of Elder Affairs, the Boston Housing Authority, and an 

elder advocacy organization to develop a training module for janitors, security guards, facility service workers, and others who work in public elderly 

housing developments to help them identify elders with mental health and 

substance abuse problems and bring them to the attention of appropriate 

housing authority staff so that referrals and interventions can be made. 

• In Michigan, Gatekeeper programs help community members identify 

elders at risk of suicide or in need of other mental health services. Also, 

Serving Elders at Risk in the Community and at Home (SEARCH) provides 

outreach to identify older adults in need of services, develops linkages with 

primary care physicians, and supports the empowerment of seniors to fully 

participate in health care decisions. 
48 Trends in Mental Health System Transformation: The States Respond 2005

Goal 4 Early Mental Health Screening, Assessment, and Referral to Services Are Common Practice

FEATURED PROGRAM

• As part of Nevada’s Senior Mental Health Outreach Program, the program 

director trains community members and service providers to recognize and 

treat depression in older adults, address problem gambling, prevent suicide, 

and maintain good mental health later in life.

States also are working to screen older adults through more traditional forms of 

outreach. 

In Pennsylvania, the State Hospital system volunteered the assistance of clinical 

personnel to do geriatric depression and alcohol abuse screenings at community 

health fairs and senior centers during May 2004. County mental health programs 

and Area Agencies on Aging were provided with detailed information and screening tools to use with older adults in their communities. 

Linking Mental Health with Primary Care Services

States are working in a variety of ways to improve access to behavioral health care 

through primary care settings.

• Idaho, in conjunction with the Western Interstate Commission for Higher 

Education (WICHE), funded a training program for primary care physicians 

on the use of psychotropic medications. Training materials are available at 

http://WICHE.edu/mentalhealth/grand_rounds/primary_care.htm. 

• Louisiana has two interagency initiatives related to screening for mental 

disorders in primary health care: the Adolescent School-Based Health Initiative and the Nurse Family Partnership Program. 

• In Texas, an action plan to improve access and integration of primary care 

and behavioral health focuses on three areas: a seamless system of care, 

workforce training and development, and partnerships and collaboration. 

Also in Texas, the Texas Adolescent Mental Health in Primary Care Initiative is developing surveillance and assessment tools that can be used in 

primary care settings. 

• As part of a movement to further integrate mental health services with primary care and allied health providers in communities, Wyoming successfully has piloted collaborative programs with primary care physicians and 

public health nurses at two sites.

• To help promote early mental health screening of adults and children, 

Guam’s Department of Mental Health and Substance Abuse is working 

with the Guam Medical Society to educate primary care physicians about 

the need to screen for mental disorders and to make referrals where appropriate. 

A grant from the Commonwealth Foundation supported the 

development of the Great Start 

Minnesota Project, which promotes strategic improvements in 

services to young children whose 

mental development is at risk. 

Great Start initiatives include:

• Co-location of children’s mental health 

clinicians in primary 

care clinics;

• Implementation of DC03, an innovative set of 

diagnostic criteria for 

young children that 

identifies preschoolers’ 

mental health needs and 

appropriate Medicaid 

coverage;

• Efforts to develop a 

State consensus on 

screening tools, symptom measures, functionality measures, and 

level of care determination;

• Training to primary care 

clinics and public health 

nurses on the identification and referral of children with mental health 

needs; and

• Mental health screening during public health 

home visits that include 

children and parents 

and focus on maternal 

depression and appropriate development of 

the mother-child dyad.

For more information, contact: 

Gary Cox, 

(651) 296-5882, Gary.Cox@state.mn.us.

Great Start 

Minnesota
Trends in Mental Health System Transformation: The States Respond 2005 49

• Ohio’s Medical Director is currently developing a plan to increase mental 

health screening in the primary care setting. 

States also are exploring a variety of strategies to raise awareness of mental health 

issues among primary care providers and to make these services more readily 

available in primary care settings. 

• Virginia offers Continuing Medical Education credits in mental health 

care to physicians. 

• Idaho supports physician training on mental health care, including training on children’s mental health, to primary care doctors. 

• South Carolina places primary care doctors in mental health clinics. 

• In Texas, mental health providers are placed in Federally Qualified Health 

Clinics. 

• In Oregon, a workgroup of Department of Human Services’ staff and key 

stakeholders developed recommendations for linking and integrating behavioral health and primary care. The group’s report is available online at 

www.dhs.state.or.us/mentalhealth/rec-int-hlth-pricare.pdf.

Wyoming’s Department of Family Services is guiding a statewide collaboration to 

create policy direction, a strategic plan, and legislative initiatives to improve the 

lives of families. The plan will examine causes of the most serious problems facing 

children and families, including poverty, mental health needs, and violence.
Excellent Mental Health Care 

Is Delivered and Research Is Accelerated

Concerned about the length of time it takes for research that produces 

useful treatments to reach the field, members of the New Freedom Commission called for aggressive steps to publicize evidence-based practices, 

train providers to use them, and make them available to those who could 

benefit from them. The Commission also encouraged the use of emerging 

best practices, which are promising but have less thorough documentation of their efficacy.

Currently, SAMHSA recognizes six strategies as evidence-based: supported 

employment, integrated treatment for co-occurring disorders, Assertive 

Community Treatment (ACT), illness management and recovery, medication management, and family psychoeducation. Examples of emerging 

practices include wraparound services, jail diversion and community reentry programs, and therapeutic foster care. 

The Commission made four recommendations for Goal 5:

5.1 Accelerate research to promote recovery and resilience, and 

ultimately to cure and prevent mental illnesses.

5.2 Advance evidence-based practices using dissemination and 

demonstration projects and create a public-private partnership to guide their implementation.

5.3 Improve and expand the workforce providing evidencebased mental health services and supports.

5.4 Develop the knowledge base in four understudied areas: 

mental health disparities, long-term effects of medications, 

trauma, and acute care.

 GOAL 5
Trends in Mental Health System Transformation: The States Respond 2005 51

THE STATES RESPOND

Planning and Guiding State Use of Evidence-Based Practices

States report a growing consensus on the importance of evidence-based practices. Pressure to ensure their use as widely as possible comes from legislatures and 

funders concerned about making the best use of limited dollars, consumer and 

advocacy groups who want to ensure proven methods of care, and provider groups 

and researchers who are aware of emerging practices. 

Some States have passed legislation endorsing the use of evidence-based practices. 

During 2003, the Oregon Legislature passed a bill endorsing the use of evidencebased practices in the public mental health system. The requirement for phased 

implementation ends with full implementation in 2009, when at least 75 percent 

of State and Federal treatment resources must be used to purchase services from 

programs that are confirmed to be evidence-based. A similar bill being drafted in 

Kentucky would require all mental health services in the State to be evidencebased practices within 6 to 8 years. The Iowa legislature specifically mandated 

that, as of July 1, 2004, 70 percent of Block Grant funds must be used to promote 

the use of evidence-based practices in the mental health care system, or for emergency services. 

Many States are involving stakeholder groups to plan and oversee the use of evidence-based practices. For example, the Connecticut Coalition for the Advancement of Prevention, community-based organizations, and State agencies collaborate to develop comprehensive strategies to implement and evaluate evidencebased programs to promote mental health and prevent violence and substance 

abuse among Connecticut’s children. A Preferred Practices Initiative identifies 

and implements evidence-based practices throughout the State system, while the 

Recovery Institute provides training on recovery-oriented practices. Hawaii has 

established a child- and youth-focused Evidence-Based Service Committee. Other 

States using this approach include Illinois, New Mexico, Vermont, and Washington. Many States also host conferences and sponsor training on evidence-based 

practices.

Some State mental health agencies are moving to integrate requirements for evidence-based practices into their arrangements with providers and regional entities. For instance, Delaware’s Department of Substance Abuse and Mental Health, 

observing a growing consensus among behavioral health providers at all levels of 

government that publicly funded programs must promote the acquisition and 

use of evidence-based practices, has begun to incorporate these practices into its 

contractual relationships, State-managed systems of care, workforce development 

efforts, and program evaluation and performance outcomes. Also, in Minnesota, 

provision of integrated treatment for co-occurring disorders will be required of 

ACT teams, adult residential treatment centers, and hospitals with contracts to 

provide extended inpatient psychiatric services. 
52 Trends in Mental Health System Transformation: The States Respond 2005

Goal 5 Excellent Mental Health Care Is Delivered and Research Is Accelerated

FEATURED PROGRAM

Promoting Evidence-Based Practices Through Education

States are using conferences, the Internet, regular meetings, training, and technical assisstance resources to spread knowledge and use of evidence-based practices. 

• In Maine, a recent statewide symposium provided an opportunity for providers, consumers, and other stakeholders to learn from national and local 

experts on evidence-based practices. 

• In North Dakota, the State has implemented monthly evidence-based 

practices forums with regional Human Service Centers. These forums help 

to assess organizational readiness, increase provider knowledge and behavior, build consensus, increase access, and identify ongoing needs. 

• Minnesota provides statewide monthly core trainings on adult evidencebased practices via videoconferencing. Between 200 and 400 individuals 

participate.

• The annual NAMI-VT provider conference focuses on innovative practices 

for treating individuals with severe mental illnesses in Vermont.

• A new institute for substance abuse and mental health staff and stakeholders hosts statewide unveilings of new plans or evidence-based models of 

treatment adapted for Wyoming.

• Virginia’s Department of Mental Health, Mental Retardation, and Substance Abuse Services issues regular guidance bulletins to Community 

Services Boards regarding best practices in substance abuse treatment and 

other services. 

To refine and promote evidence-based practices, many States are establishing centers specifically for this purpose, often with links to universities. Examples include 

a Center of Excellence in Utah, the Hawaii Center for Evidence-Based Practice, 

University of Maryland Evidence-Based Practice and Systems Evaluation Centers, 

Coordinating Centers for Excellence and Networks in Ohio, and Iowa’s Technical 

Assistance Center for Evidence-Based Practices. 

Some States also have established technical assistance centers to help them implement particular evidence-based practices, such as the ACT Technical Assistance 

Centers of Indiana.

The University of Iowa’s Iowa Consortium of Mental Health (ICMH) 

was provided funding to develop 

and deliver a statewide training 

on evidence-based practices. This 

7-week, 10.5 hour training was 

broadcast over the Iowa Communications Network to more than 

900 registrants in dozens of locations throughout the State. Information about the series, including 

PowerPoint slides and streaming 

video, can be found at the ICMH 

Web site: www.icmentalhealth.

org. 

For more information, contact: 

Dr. Michael Flaum, 

Iowa Consortium for Mental Health, 

Michael-flaum@uiowa.edu.

Teletraining on 

Evidence-Based Practices

(Iowa)
Trends in Mental Health System Transformation: The States Respond 2005 53

Many States are producing resources to guide the implementation of evidencepractices.

• Washington used Block Grant funds to contract with the Washington

Institute for Mental Illness Research and Training, which produced a 

resource guide, A Summary of Best and Promising Mental Health Practices. 

• Virginia’s interagency State Commission on Youth disseminated a collection of Evidence-Based Treatment Modalities for Children and Adolescents 

with Mental Health Treatment Needs. (See the Resource section at the end 

of this report for more information on these resources.) 

• New York, the State Mental Health Association established a Web site 

to promote the use of evidence-based practices; the site allows visitors 

to search a database or programs and treatments. The site’s address is 

www.mhanys.org/ebpdb.

Most State mental health agencies have forged close relationships with local universities and research centers to inform and support their use of evidence-based 

practices. Often, they sponsor targeted research through these institutions and 

look to them as a source of expert trainers. 

Many States also have established scholarships and internship programs through 

these institutions to address workforce shortages. 

• Maryland’s Mental Hygiene Administration has established academic 

linkages with Coppin University, Georgetown University, the University 

of Maryland, and the Johns Hopkins University to help infuse evidencebased treatments into everyday practices. 

• Kentucky sponsors research on recovery and works regularly with the 

University of Louisville and the University of Kentucky to adapt evidencebased practices for use by the State and providers.

A primary role of the Mental Health Block Grant program in 

Wyoming is to develop specific projects and pilots that show 

promise for statewide implementation.
54 Trends in Mental Health System Transformation: The States Respond 2005

Goal 5 Excellent Mental Health Care Is Delivered and Research Is Accelerated

FEATURED PROGRAM

Evidence-Based Practices in Action

States use all SAMHSA-recognized evidence-based practices in varying degrees. 

ACT, supported employment, and integrated treatment for co-occurring disorders 

were mentioned most frequently in Block Grant applications, followed by illness 

management and recovery, medication management, and family psychoeducation. 

Programs for Assertive Community Treatment (PACT) and ACT teams have been 

promoted for many years and are now widely used. Some States have used 

SAMHSA toolkits or research centers to ensure model fidelity, and others 

have adapted the model to serve specific audiences, meet identified needs, or 

add essential components. 

• In four areas of South Dakota, Individualized and Mobile Programs of Assertive Community Treatment (IMPACT) have been developed. An IMPACT 

Step-Down Program has been developed for individuals currently receiving 

IMPACT services who require a less intense level of service. The Step-Down 

Program is operated with an open door for people who may later require 

more intensive intervention or support.

• Maine and Louisiana have modified ACT programs to serve children.

• In North Carolina, some ACT teams participate in jail diversion programs.

• Hawaii emphasizes the need to adapt ACT protocols to fit the unique cultural needs of its communities.

• Certified Community Support Programs are Wisconsin’s version of Assertive Community Treatment programs, which operate in 62 of 72 counties.

• Utah’s Assertive Community Outreach Treatment is specifically designed 

to meet the needs of consumers living in rural areas.

Two outstanding supported 

employment programs in Wyoming have received national 

recognition. One operates in a urban environment and the other 

in a more rural environment. 

Thus, they are different in how 

they approach a “place and train,” 

client-led model of supported 

employment. 

Employment statistics for the 

urban program indicate that 54 

percent of 160 clients are employed, with length of employment ranging from a few months 

to more than 8 years. The program 

credits a collaborative buy-in 

from core team members, who 

include a primary therapist, 

a job coach, and a vocational 

rehabilitation counselor, along 

with the client and employer (if 

the client is placed). Together, 

they develop a job plan and provide intensive on-site supervision 

for the client. One outcome has 

been a noticeable change in the 

attitude of clients and their families about work. 

In the rural settings, not 

enough jobs are available, 

so mental health innovators 

started their own company. 

Washakie Works is a vocational 

program operating as a freestanding business. Its services 

include yard and garden work, 

household moving, painting, 

and miscellaneous small jobs. 

As client workers became skilled 

at carpentry, they began remodeling an apartment complex and 

building duplexes for purchase 

Supported Independence 

Projects 

(Wyoming) 

continued on next page

In New Hampshire, a Dollars and Sense pilot project 

supported individual career accounts where 

consumers design and fund their own work 

readiness and transitional employment programs.
Trends in Mental Health System Transformation: The States Respond 2005 55

FEATURED PROGRAM

Supported employment programs are varied, with many successful examples. Programs that report successful outcomes generally involve close alliances with key 

agencies and prospective employers. 

• In Vermont (one of three original recipients of Supported Employment 

grants from the Johnson and Johnson Foundation), the Division of Mental Health has partnered with Vocational Rehabilitation, the Department 

of Corrections, and Child Welfare and Youth Justice to offer supported 

employment programs and intensive case management to transition-aged 

youth in JOBS programs throughout the State. 

• Ohio is developing an Employment Network to further disseminate evidence-based supported employment practices.

• In New Hampshire, supported employment has in large part replaced partial hospitalization programs. The Individual Placement and Support model 

has been enhanced through flexible supports, including support in mastering work-related skills and behaviors in integrated work settings. 

• In South Dakota, Block Grant dollars augment Extended Employment Services for adults with serious mental illnesses. Employment coaching, job 

shadowing, and assistance with locating and maintaining employment are 

provided by private agencies through contracts with the State.

as their own residences. Now licensed as a building contractor 

with crews supervised by professional job coaches to ensure quality work, Washakie Works provides 

construction/remodeling services at competitive prices and 

often will be the low bidder for 

small jobs that are not profitable 

for larger commercial companies. 

The project is self-supporting and 

takes advantage of available job 

training funds. 

For more information, contact: 

Urban model – 

Michael Huston, Director, 

and 

Paul Demple, Program Manager, 

Psychiatric Rehabilitation Program, 

Central Wyoming Counseling Center, 

Casper, Wyoming, (307) 237-9583. 

Rural/frontier model – 

Lonnie Gerherter, Interim Director, 

and 

Lew Markley, Adult Program Manager, 

Washakie Mental Health Center, 

Worland, Wyoming, (307) 347-6165. 

Supported Independence 

Projects 

(Wyoming) 

continued from previous page 

In Virginia, ACT teams reduced hospitalizations, 

increased stability, and reduced involvement with 

police among recipients. 
56 Trends in Mental Health System Transformation: The States Respond 2005

Goal 5 Excellent Mental Health Care Is Delivered and Research Is Accelerated

FEATURED PROGRAM

Most States are promoting integrated treatment for co-occurring disorders; many 

have pilots, planning committees, and task forces in place to promote the use of 

this evidence-based practice. A summary of their work in this area is contained 

under Goal 4 of this report.

Illness management and recovery is taught in many States. One proponent of this 

practice is New Jersey’s Division of Mental Health Services, which contracted 

with the Center of Excellence in Psychiatry to pilot Team Solutions, a program 

shown to have positive results in improving overall physical and mental status 

using illness self-management and self-directed care techniques. The program is 

being provided in all adult State psychiatric hospitals and in selected community 

mental health settings. 

Medication management has become increasingly widespread, with many States 

promoting SAMHSA’s medication management toolkit. Key elements include: use 

of a systematic plan for medication management, objective outcome measures, 

clean and thorough documentation, and consumer and provider involvement in 

decision-making. The New Freedom Commission highlighted the Texas Medication Algorithm Project as an example of an evidence-based practice that “results 

in better consumer outcomes, including reduced symptoms, fewer and less severe 

side effects, and improved functioning” (p. 68). Similar efforts are underway in 

Florida, Kentucky, Michigan, New Jersey, Oregon, and Pennsylvania. 

A joint effort by the Division of 

Disability and Elder Services, 

Bureau of Mental Health and 

Substance Abuse Services, and 

the Department of Workforce 

Development, Division of Vocational Rehabilitation, Pathways to 

Independence is a research and 

development project that seeks 

to develop and test innovative 

policy and service strategies to 

reduce employment barriers for 

people with severe disabilities. 

A collaborative effort between 

Federal, State, and county governments, Pathways provides 

comprehensive, integrated, 

team-based, consumer-centered 

vocational services. 

In order to facilitate an informed 

decision regarding employment, 

Pathways staff provide consumers with an analysis of the impact 

of potential earnings and asset accumulation on continued cash, 

health care, transportation, and 

housing supports. Programs that 

reduce work disincentives have 

been integrated in the array of 

services available through Pathways. Such programs include 

Federal earnings waivers and the 

Wisconsin Medicaid Purchase 

Plan, which allows individuals to 

buy into Medicaid services.

For more information, contact: 

John Reiser, 

Director, 

(608) 266-3062,

http://dhfs.wisconsin.gov/WIpathways.

A Peer Support Advocate helps a consumer rate symptoms and side effects—

an illness teaching and monitoring activity conducted during a medication 

visit. Michigan consumers were hired and trained to serve as Peer Support 

Advocates in the Michigan Assertive Community Treatment (ACT) program.

Pathways to Independence 

(Wisconsin)
Trends in Mental Health System Transformation: The States Respond 2005 57

Family psychoeducation also is used in a number of States. However, States did not 

provide details on how this model is used. 

Promising and Emerging Practices

One of the most frequently mentioned promising or emerging practices is therapeutic foster care, which is identified as widespread in Arkansas, Colorado, Hawaii, Kentucky, Mississippi, Puerto Rico, and Vermont. This strategy is sometimes cited as an alternative to out-of-State placements, which most States are 

striving to avoid. 

Supportive housing strategies are common, though States are struggling to find adequate funding to meet the need. These are some notable examples:

• North Carolina has several supportive housing projects, usually in cooperation with local public housing authorities, nonprofit organizations, and 

the U.S. Department of Housing and Urban Development. Efforts are being 

made to expand Shelter Plus Care rental assistance and to increase permanent and transitional units for people with mental illnesses who are homeless;

• The PILOTS program, a supportive housing initiative for people who are 

homeless, is a public/private collaborative effort in Connecticut that fosters the development of solutions for long-term housing and service needs 

of individuals and families coping with psychiatric disabilities and/or chemical dependency. The PILOTS program consists of transitional and/or permanent housing subsidies with funding for supportive services; and

• California’s Supportive Housing Initiative Act has awarded $48.2 million 

in State General Fund dollars to 46 supportive housing projects serving approximately 8,300 low-income individuals throughout California, including 

people with mental disorders.

Another cited strategy is wraparound services for children and adolescents (see 

Goal 4 (p.36 approach,37 certification,38 services) for further discussion of children’s services). 
Technology Is Used to Access 

Mental Health Care and Information

The New Freedom Commission recognized the application of information 

technology to health care as “perhaps the most important medical advance 

of the 21st century” (p. 79). The Commission envisioned the development 

of two critical components for a national health information infrastructure 

to support quality mental health care delivery, especially in rural and other 

underserved areas, and made these two recommendations:

6.1 Use health technology and telehealth to improve access 

and coordination of mental health care, especially for Americans in remote areas or in underserved populations.

6.2 Develop and implement integrated electronic health record 

and personal health information systems.

 GOAL 6
Trends in Mental Health System Transformation: The States Respond 2005 59

THE STATES RESPOND

Using Telehealth to Improve Access and 

Coordination of Mental Health Care

Telecommunications technologies using computers, video cameras, telephones, 

and the Internet to relay information have created a new tool for health care—

telehealth. Telehealth systems can be used to provide long-distance clinical care 

and consultation, patient and professional health-related education, and public 

health and health administration. 

A large number of States use telehealth technology, most often to provide direct 

access for consumers to mental health care providers via teleconference. Assessment, consultation, development of treatment plans, medication management, 

and commitment hearings have been held via teleconference. States with large 

rural populations have taken the lead in using these technologies to serve their 

populations. 

Most of the Mountain States (including Arizona, Colorado, Montana, Nevada, 

and New Mexico) and Appalachian States (including Kentucky, North Carolina, 

Tennessee, Virginia, and West Virginia) have developed telehealth systems. 

Telehealth systems are used in Illinois, Iowa, Oregon, Texas, and Wisconsin. 

Consumer satisfaction with the services has been high in those States where it 

has been measured.

As an alternative to direct service provision via teleconferencing, the technology 

is used in California, Hawaii, and North Dakota to link specialists to other providers. In Oklahoma and Tennessee, commitment hearings can be held via teleconference. A number of States including Arizona, Colorado, Iowa, Minnesota, 

and Oklahoma also use teleconferencing to provide training to mental health 

care providers—yet another strategy for increasing service availability in rural 

regions.

The States below have found other innovative uses of teleconferencing technology 

to advance mental health services and systems.

• Maine frequently uses teleconferences to glean feedback from consumers 

and family members.

• Ohio held forums on the New Freedom Commission via teleconference.

• In Virginia, families can use teleconference technology to “visit” relatives 

in distant hospitals and facilities and to participate in therapy.

• Alabama and North Carolina use teleconferencing to provide American 

Sign Language translation to consumers who are deaf or hard of hearing.
60 Trends in Mental Health System Transformation: The States Respond 2005

Goal 6 Technology Is Used to Access Mental Health Care and Information

FEATURED PROGRAM

The States’ commitment to telehealth is demonstrated in the development of 

comprehensive infrastructure to support and enhance its use. 

• In Mississippi, new adult crisis centers are equipped for telemedicine. 

• In Louisiana, 90 percent of all community mental health centers have direct access to telemedicine and teleconferencing. 

• Kentucky has begun billing Medicaid for telemedicine services, 

• Alabama is in the process of developing billing codes and procedures for 

telemedicine services.

Developing and Implementing Integrated 

Electronic Health Records 

A number of States are improving their data collection and management and implementing electronic health records. A wide variety of technology and approaches are being used. 

• Alabama is using Data Infrastructure Grant funding to develop a uniform 

health record to link hospital and community service records.

• Florida’s new electronic medical records system tracks residential files and 

assists in treatment decisions.

• Maryland has contracted with APS Healthcare to institute a Web-based 

system for the registration and authorization of mental health services.

• The Enterprise Information System integrates services and billing information in Maine.

• Puerto Rico and Palau have begun to explore integrated record keeping for 

children’s mental health services.

• Nevada has adopted the AVATAR software, which will allow for client billing, assessment, medical records, and treatment planning to be maintained 

in a single Master Patient Index.

• Utah is implementing E-charting.

Initial implementation of Kansas’ interactive telepsychiatry 

network, begun in 1988, created one of the largest televideo 

systems in the world for the delivery of mental health services. 

It has now grown to 80 video units across 27 community mental 

health centers.

Geographic distance can be a 

significant impediment to receiving appropriate and timely 

mental health treatment. Community mental health centers in 

two regions in Idaho are addressing this barrier by offering medication monitoring follow-up services to consumers who are willing 

to use this technology. Physicians 

located in the central office can 

serve consumers in a satellite office with the aid of an 8x8 set-top 

videophone connected through 

the regular phone line and the use 

of speaker phones. 

In Region 1, an average of 5 to 10 

consumers a month use the service, and consumer satisfaction is 

reported to be high because this 

service eliminates the 45-minute 

travel time between offices, the 

need to miss time from work or 

school to attend appointments, 

and the need to arrange child 

care. Consumers who do not like 

the system are accommodated 

with face-to-face appointments in 

the central office. Telemedicine 

contacts are used for medication 

follow-up appointments only; all 

initial psychiatric assessments are 

conducted in person. Medicaid 

reimbursement for telemedicine 

services is available for pharmacological management and psychotherapy with medical evaluation.

For more information, contact: 

Anne Bloxham, (208) 334-5716, 

bloxhama@idhw.state.id.us. 

Also, see 

Telehealth Idaho at 

http://telida.isu.edu/telida/index.php.

Medication Management 

by Telemedicine 

(Idaho)
Trends in Mental Health System Transformation: The States Respond 2005 61

FEATURED PROGRAM

• Texas is implementing WebCARE, a Web-based system for registration, diagnosis, and assessment, as well as workflow and data management reporting.

• Alaska has modified a SAMHSA-provided data collection tool called WITS 

(Web Infrastructure for Treatment Services) to reflect both mental health 

and substance abuse treatment services.

• Florida uses Web-based technologies to share community needs assessments and better place individuals in less restrictive settings. 

• New Jersey’s new management information system enhances the quality 

and efficiency of the State’s supported employment system. 

• In Florida, Hawaii, Missouri, and New York, decision-support technologies help health care providers develop evidence-based treatment plans. 

Providing Health Information to Consumers

A number of States use information technology to link service providers or to 

link mental health service providers to others who encounter people with mental 

illnesses. Most States provide consumer information via their department Web 

pages.

• Connecticut maintains a clearinghouse of behavioral health information for 

consumers and providers at www.ctclearinghouse.org. 

• In Virginia, a Web-based program called WorkWORLDTM helps people with 

disabilities make decisions regarding paid employment, work incentives, 

and government benefits.

Network of Care, an individualized mental health resource 

Web site that was identified as a model program by the New 

Freedom Commission, is used in California, Maryland, New York, 

Ohio, and Virginia.

Extensive use of sophisticated 

information technology is a core 

component of the Vermont Division of Mental Health’s CMHSfunded Performance Indicator 

Project (PIP). In-house information 

resources include an integrated 

database that stores extensive 

data describing communitybased service recipients and the 

services they receive. Data are 

provided directly by community 

providers using a Web-based reporting system. All of these components are integrated with fiscal 

data and person-level staffing data 

by means of cost center codes and 

staff ID numbers. These data 

provide the basis for a variety 

of standard reports as well as focused studies. 

The PIP also makes extensive use 

of these internal data in conjunction with administrative 

databases from a wide range of 

government agencies and private-sector service providers 

for mental health services research and program evaluation. 

The core objective of the PIP is 

to support rational data-based 

thinking and decision making 

within systems of care in Vermont 

by producing and electronically 

distributing brief data reports 

to more than 250 service providers, consumers, administrators, advocates, and others on 

a weekly basis. All PIP reports 

are available online at www.

state.vt.us/dmh/docs/pips/

pips-by-date.html.

For more information, contact: 

John A. Pandiani, Chief, 

Research and Statistics, 

Vermont Department of Health, 

The Performance 

Indicator Project 

(Vermont)

Trends in Mental Health System Transformation: The States Respond 2005 63

GOAL 1: Americans Understand that Mental Health Is Essential to Overall Health

State Resource Where Available

AK Alaska Suicide Prevention Plan

Alaska Division of Behavioral Health

3601 C St., Suite 878

Anchorage, AK 99503

(907) 269-3600

CO Population in Need Report www.cdhs.state.co.us/ohr/mhs/Reporting%

20and%20Evaluation%20Folder/Index.htm

CT Juvenile Justice Programming

Ann Macintyre –Lahner

Program Director

(860) 723-7202

Ann.Macintyre-Lahner@po.state.ct.us

CT Managed Service Systems and

Enhanced Care Coordination

Ann Adams

Program Director

(860) 550-6327

ann.adams@po.state.ct.us

CT

Youth Suicide Prevention Packet;

Youth Suicide Advisory Board; 

K-12 Mental Health Initiative

Deanna Paugas-Lia 

Director of Prevention

(860) 550-6637

Deanna.paugas@po.state.ct.us

FL

Preventing Suicide in Florida: A 

Strategy Paper by the Florida Task 

Force on Suicide Prevention

www.myflorida.com/myflorida/

government/governorinitiatives/

drugcontrol/suiide_prev.doc

FSM1 Suicide: Finding a Better Way Out 

video

www.micsem.org/cvideo/videotapes.htm

ID

Hearts and Minds: Teens 

and Mental Illness video

Ross Edmunds

(208) 334-5726

edmundsr@idhw.state.id.us

ID

In Our Own Voice consumer 

documentary

www.idahoptv.org/productions/ownvoice

ID Idaho’s Suicide Prevention Plan www.spanidaho.org

ID

Training program for primary 

care physicians on the use of 

psychotropic medications

http://WICHE.edu/mentalhealth/

grand_rounds/primary_care.htm

KY Preventing Suicide in Kentucky: 

Progress Report – June 2004 

http://mhmr.ky.gov/mhsas/html/PDFs/

Final%20June%202004%20KSPPG%2

0Progress%20Report%20web.pdf

NE Project Relate (anti-stigma 

media campaign) www.projectrelate.org

State-Developed Resources 

Available to Others

1

 Federated States of Micronesia
64 Trends in Mental Health System Transformation: The States Respond 2005

State-Developed Resources Available to Others

GOAL 1: Americans Understand that Mental Health Is Essential to Overall Health

State Resource Where Available

NE

Southeast Nebraska Suicide 

Prevention Curriculum

www.nebhands.nebraska.edu/

Resource%20Information/Suicide%2

0Prevention%20Info%20Link.htm

NJ

Students at Risk for Suicide—

Assessment and Interview 

Techniques training video

Val Casey

Division of Children’s Behavioral Health Service

(609) 777-0740

val.casey@dhs.state.nj.us

NM See Mommy Cry documentary

Matt Dillman 

mdillman@cyfd.state.nm.us

OK Online publications www.odmhsas.org/publications.htm

OR

Recommendations for linking 

and integrating behavioral 

health and primary care

www.dhs.state.or.us/mentalhealth/

rec-int-hlth-pricare.pdf

OR The Oregon Plan for Reducing 

Suicides in Older Adults Sandra.Moreland@state.or.us

SC Teen Matters Web site www.teen-matters.com
Trends in Mental Health System Transformation: The States Respond 2005 65

GOAL 2: Mental Health Care Is Consumer and Family Driven

State Resource Where Available

AL

Information on the State 

plan to consolidate and close 

mental health facilities

www.mh.state.al.us/Commissioner/

ConsolidationPlans2003.asp

AL

Information on the Wyatt case and 

settlement, which established minimum 

standards for providing treatment and 

habilitation in State mental health 

and mental retardation facilities

www.mh.state.al.us/admin/

downloads/wyatt.html

AZ

A Sourcebook for Families Coping with 

Mental Illness – A Guide for Preventing 

the Other Shoe from Dropping

Community Partnership of 

Southern Arizona (CPSA)

4575 East Broadway

Tucson, AZ 85711

(520) 325-4268

CA

California Mental Health Master 

Plan: A Vision for California www.dmh.ca.gov/MHPC/masterplan.asp

CA

Effectiveness of Integrated Services for 

Homeless Adults with Serious Mental 

Illness (AB 2034) legislative report

http://www.dmh.ca.gov/AOAPP/Int_

Services/docs/AB2034_may2003.pdf

FL Florida guide to supportive housing and 

strategic plan for supportive housing www.state.fl.us/cf_web

FL Florida’s Elimination of Barriers Initiative www.dcf.state.fl.us/mentalhealth/

ebi/index.shtml

GA

A Mental Health Consumer’s Guide 

for Participation in and Development 

of Medicaid Reimbursable 

Peer Support Services.

http://mhddad.dhr.georgia.

gov/DHR-MHDDAD/DHRMHDDAD_CommonFiles/

16618139ConsumerManual403.pdf

GA Georgia Certified Peer Specialist Project www.gacps.org/Home.html

GA

Information and Application to Become 

a Provider of Medicaid Reimbursed 

Mental Health and Addictive Diseases 

Rehabilitation Option Services

http://mhddad.dhr.georgia.

gov/DHR-MHDDAD/DHRMHDDAD_CommonFiles/

14874954medprovapman.pdf

IA

Reports from the Iowa Mental 

Health, Mental Retardation, 

Developmental Disabilities and Brain 

Injury Commission on the State’s 

Mental Health System Redesign

www.dhs.state.ia.us/publications.asp
66 Trends in Mental Health System Transformation: The States Respond 2005

State-Developed Resources Available to Others

KS Pathways to Recovery: A Strengths 

Recovery Self-Help Workbook

Rebecca Rinehart, State Planner 

Kansas Mental Health Authority

(785) 296-3471

RCXR@srskansas.org

GOAL 2: Mental Health Care Is Consumer and Family Driven 

State Resource Where Available

KY Kentucky Partnership for 

Families and Children www.kypartnership.org

KY Opportunities for Family Leadership http://mhmr.ky.gov/mhsas/

OFL%20Trainings.asp?sub6

LA

Project Legacy: Transforming Mental 

Health Services in Louisiana (State report 

on transformation that aligns Louisiana 

goals with New Freedom Initiative)

www.dhh.louisiana.gov/

offices/publications/pubs153/project%20legacy.pdf

LA The Louisiana Mental Health Planning 

Council: goals and operations summary

www.dhh.louisiana.gov/offices/?ID=153

MS Case Management brochure www.dmh.state.ms.us/pdf/CaseM

anagementBrochureBinder.pdf

MS Office of Constituency Services brochure www.dmh.state.ms.us/

pdf/OCSBinder.pdf

NC Hospital downsizing initiative

Laura White, Program Manager 

State Operated Services Team

(919) 733-3654

laura.white@ncmail.net

NC

North Carolina Jail Diversion 

Report: 2003-2004

www.dhhs.state.nc.us/mhddsas/justice/

jaildiversion/ncjaildiv03-04report.pdf

NE Psychological First Aid for disasters www.disastermh.nebraska.edu

NM Smart Money

Michael Basarab

(505) 281-5402

Basarab@earthlink.net

PR Training materials in Spanish

Edwin Montañez

Director of the Training Institute

(787) 767-9415

edwinm@assmca.gobierno.pr

SC Peer Support www.state.sc.us/dmh/consumer_

resources/consumer_resources.htm

SC Recovery for Life/consumer 

empowerment

SCShare@bellsouth.net

TN

Criminal Justice and Mental 

Health Services reports, training 

curriculum, and manuals 

www.state.tn.us/mental/cj/cj1.html

TN Housing Within Reach, a consumer 

housing resource system www.housingwithinreach.org
Trends in Mental Health System Transformation: The States Respond 2005 67

TX

State Action Plan to End 

Chronic Homelessness 

www.tich.state.tx.us

VA

Training audiotapes and PowerPoint 

presentations on human rights 

protection and advocacy 

www.dmhmrsas.virginia.

gov/OHR-Training.htm

GOAL 3: Disparities in Mental Health Services Are Eliminated.

State Resource Where Available

AR Cultural Competence training materials

Vanessa Davis

Assistant Director for Minority Affairs

(501) 686-1693

vanessa.davis@arkansas.gov

CA

Multicultural Mental Health Brochure 

Series/Interactive CDs

www.cimh.org/projects/

translation.cfm

CO

Colorado Mental Health Services 

Cultural Competency Plan

www.cdhs.state.co.us/ohr/

mhs/Cultural%20Competen

cy%20Folder/Index.htm

CT Cultural Competency (assessment, 

workforce development, plans)

William Rivera, Director

Division of Multicultural Affairs

(860) 550-6569

William.rivera@po.state.ct.us

CT

Family Advocacy Services;

Behavioral Health Data System; 

Multiculturalism Subcommittee; 

Multiculturally Competent Contract 

Management Guidance

Susan R. Smith, Program Supervisor

Contracts and Information Systems

(860) 550-6695

susan.smith@po.state.ct.us

CT Health Advocacy Program

Aurele Kamm

Health Program Supervisor

(860) 723-7217

Aurele.Kamm@po.state.ct.us

CT Services and Programs for Girls

Gayle Brooks

Program Director

(860) 550-6540

Gayle.Brooks@po.state.ct.us

MN Tools for translation/transculturation www.dhs.state.mn.us

NC Interim Report on Geriatric Mental 

Health Specialty Teams, 2004

www.dhhs.state.nc.us/

mhddsas/manuals/reports/

leg10-1-04interimreport.pdf
68 Trends in Mental Health System Transformation: The States Respond 2005

State-Developed Resources Available to Others

GOAL 3: Disparities in Mental Health Services Are Eliminated.

State Resource Where Available

TN The Strategic Plan for Cultural Competence; 

includes training curriculum for interpreters

Lygia Williams

(615) 253-5078

Lygia.Williams@state.tn.us

WA

The Mental Health Needs of American 

Indians in Washington State

www1.dshs.wa.gov/pdf/hrsa/

mh/amindiansmhneeds.pdf

GOAL 4: Early Mental Health Screening, Assessment, and 

Referral to Services Are Common Practice.

State Resource Where Available

AK Alaska Screening Tool http://health.hss.state.ak.us/dbh/

resources/publications.htm

AR

The Child and Adolescent Service 

System Program (CASSP) brochure

www.state.ar.us/dhs/dmhs/

cassp_brochure.htm

CA Final Report of the Co-Occurring 

Disorders Workgroup

www.dmh.ca.gov/AOAPP/

Co_Occuring/docs/COD%20Wor

kgroup%20Final%20Report.pdf

CO Colorado System of Care Collaborative http://cosystemofcare.org

CT

Connecticut Community KidCare;

Partnership for Kids (PARK) Project;

Administrative Service Organization

Karen Andersson

Director of KidCare

(860) 550-6683

Karen.Andersson@po.state.ct.us

CT Early Childhood Consultation Partnership

Mary-Ann Dayton Fitzgerald, 

Program Supervisor

Infant and Early Childhood 

Mental Health

(860) 560-5070

Maryann.DaytonFitzgerald@po.state.ct.us

CT Transitional Youth and Young Adult Services

Sara A. Lourie

Program Director

(860) 560-5096

sara.lourie@po.state.ct.us

KS

A Mental Health Guide For Older 

Kansans and Their Families

Leslie Huss, Program Manager

Kansas Mental Health Authority

(785) 296-3471

LXXH@srskansas.org

MO Practice Guidelines Initiative www.dmh.mo.gov/cps/

issues/pracguide.htm

2

 Republic of the Marshall Islands
Trends in Mental Health System Transformation: The States Respond 2005 69

GOAL 4: Early Mental Health Screening, Assessment, and 

Referral to Services Are Common Practice.

State Resource Where Available

MO

Screening Children & Adolescents 

for Substance Abuse, Developmental 

Disability and Mental Illness 

www.dmh.mo.gov/cps/

issues/screenchild.pdf

RMI2 Report on peer outreach program 

Youth to Youth in Health

www.spc.int/youth/Best_Practice/

youth_to_youth_in_health.htm

TX Children’s Mental Health Toolkit

www.dshs.state.

tx.us/mhprograms/

RDMChildResources.shtm

WY The Future of Wyoming’s Children Search 

Conference Report, April 7-8, 2003

http://mhd.state.wy.us/initiatives/

wy_search_conf_0403.pdf

GOAL 5: Excellent Mental Health Care Is Delivered and Research Is Accelerated.

State Resource Where Available

AR Training materials for law enforcement 

regarding mental illness

Billy Burris

Assistant Director for 

Forensic Services

(501) 686-9174

billy.burris@arkansas.gov

CO Colorado Work Group for Evidence Based 

Mental Health Practices Final Report

www.cdhs.state.co.us/

ohr/mhs/index.html

CT

Connecticut Center for Effective Practice; 

Training for Community Service Providers; 

Evaluation of Evidence-Based Practices RFA

Michael Schultz

Director of Research

(860) 550-5034

Michael.Schultz@po.state.ct.us

CT Consumer Perception of Care Surveys

Joan Twiggs

Statistician

(860) 560-5091

joan.twigs@po.state.ct.us

CT Hartford Youth Project (HYP)

Reginald Simmons

Program Supervisor

(860) 560-5087

Reginald.Simmons@po.state.ct.us

CT

Intensive In-Home Services

(IICAPS, MDFT, Family Support 

Teams, FFT); Care Coordination; 

Community-Based Services

Robert Plant, Director

Division of CommunityBased Services

(860) 560-5035

Robert.plant@po.state.ct.us

CT Multi-Systemic Therapy and

Substance Abuse Treatment

Peter Panzarella, Director

Substance Abuse Division

(860) 550-6527

Peter.Panzarella@po.state.ct.us

FL Employment guidebook www.state.fl.us/cf_web
70 Trends in Mental Health System Transformation: The States Respond 2005

State-Developed Resources Available to Others

GOAL 5: Excellent Mental Health Care Is Delivered and Research Is Accelerated.

State Resource Where Available

HI Hawaii Center for Evidence-Based Practice www.amhd.org/cebp

IA Teletraining on evidence-based practices www.icmentalhealth.org

ID ACT Team Standards

Jerry Anderson

(208) 334-5527

anderso6@idhw.state.id.us

KS

Kansas Planning Grids for the 

President’s New Freedom Commission 

and Evidence-Based Practices

Rebecca Rinehart, State Planner

Kansas Mental Health Authority

(785) 296-3471

RCXR@srskansas.org

UT Preferred Practice Manual www.dsamh.utah.gov

VA

Virginia Commission on Youth: Collection 

of Evidence-Based Treatment Modalities 

for Children and Adolescents with 

Mental Health Treatment Needs

http://coy.state.va.us/docs/

ModalitiesSection1.pdf

WA A Summary of Best and Promising 

Mental Health Practices

www1.dshs.wa.gov/mentalhealth/

bestpracticesguide.shtml

GOAL 6: Technology Is Used to Access Mental Health Care and Information.

State Resource Where Available

CA MD NY 

OH VA

Network of Care for Mental Health Internet resource http://networkofcare.

org/home.cfm

NC Data warehousing project

Deborah Merrill

Information Systems Team Leader

(919) 715-7774

Deborah.Merrill@ncmail.net

Federal Resources.

Resource Where Available

FED Transforming Mental Health Care in America 

- The Federal Action Agenda: First Steps www.samhsa.gov. 

FED

The President’s New Freedom Commission 

on Mental Health – Achieving the Promise: 

Transforming Mental Health Care in America

www.samhsa.gov. 

FED National Mental Health Information Center

www.store.mentalhealth.org. 

(800) 789-2647 (toll free)

(866) 889-2647 (TDD)