Each year, nearly 2.3 million Ohioans (20 percent of the population) experience a mental health condition, a mental health condition, with 575,000 experiencing severe symptoms. Ten to 15 percent of Ohioans or 1.15 million to 1.75 million individuals have a life history of a substance use disorder (alcoholism or another drug addiction). While these figures are consequential, it is encouraging that treatment for individuals with mental illness, addiction -- or both -- is effective, and that with sustained treatment, most individuals do recover to lead active, productive, and satisfying lives. In fact, recovery rates for individuals with mental health or substance use conditions are as good as those for other physical conditions, such as diabetes, asthma, and high blood pressure.
As with other diseases and disorders, mental illness and substance use disorders impact everyone. Ohio must continue to work hard to ensure that all strategies addressing mental illness and substance use disorders includes effective approaches to address the needs of all Ohioans and that services and supports in institutions and community programs provide equitable access and clinical approaches that effectively meet the needs of Ohio’s minority populations.
To organize the RecoveryOhio Advisory Council’s recommendations for treatment, this section is grouped into four categories: Early Intervention, Crisis Services, Treatment, and Recovery Supports.
From birth to adulthood, Ohioans deserve our best efforts to support their wellness. Left unidentified and untreated, a serious mental health condition or substance use disorder can cause significant functional impairments at home, at school, and with peers. Throughout a person’s life, there are opportunities to provide intervention to change the trajectory of his or her well-being.
Screening, brief intervention, and referral to treatment (SBIRT) was originally developed as a public health model designed to provide universal screening, secondary prevention (detecting risky or hazardous substance use before the onset of abuse or dependence), early intervention, and treatment for people who have problematic or hazardous alcohol disorders within primary and other health care settings.5 Based on the SAMHSA model, SBIRT is unique in its universal screening of all patients regardless of an identified disorder, allowing health care professionals to address the spectrum of such mental health and addiction conditions even when the patient is not actively seeking an intervention or treatment for his or her condition. SBIRT is also cost-effective, especially when individuals are identified early
Through early identification and intervention, individuals of all ages can achieve success in school, in work, and in family life.
To support this work, the RecoveryOhio Advisory Council recommends:
33. Enhancing Early Intervention Training
Provide statewide screening trainings to health care providers, employers, school health professionals and criminal justice settings to promote mental health and substance use screenings for Ohioans across the lifespan from prenatal to older adults.
34. Increasing the Use of Standardized Screening Tools for Early Identification and Intervention
Require the use of standardized screening processes, such as SBIRT (Screening, Brief Intervention and Referral to Treatment) and tools such as the PHQ-9 (Patient Health Questionnaire) to ensure the quality and consistency of early intervention strategies. Provide incentives for the use of technology in the delivery of screenings to improve access. Support the development of referral processes to facilitate care for those demonstrating need. Investigate third-party reimbursement payment for screenings in all settings, by all qualified providers and for mental illness and substance use disorders.
In all Ohio counties, establish and expand quality programs that emphasize intervention with the whole family, such as OhioSTART (Sobriety, Treatment, and Reducing Trauma). Such programs can help parents maintain custody of their children while receiving the necessary structure and support for their recovery from addiction and/or mental illness and promotes the overall health of the family.
Individuals of all ages (children, adolescents, adults, and the elderly) and their families are seeking care for substance use and mental health conditions in record numbers. Frequently, these individuals are exhibiting severe symptoms, such as psychosis, suicidal thoughts, and agitation and aggression and/ or are exhibiting symptoms of substance withdrawal or the toxic effects of substance ingestion. In many communities, these individuals arrive in emergency departments, which may lack the full-spectrum of resources to adequately assess, stabilize, and integrate them back into the community.
Additionally, law enforcement is frequently called upon to respond to a mental health or addiction crisis. Sometimes, the commission of a crime necessitates the arrest of the person experiencing the crisis. The person may then be jailed – which creates a difficult situation for both the person and the staff of the jail. The environments of emergency departments and jails are not conducive to the resolution of a psychiatric health emergency and, therefore, an undue burden is placed on those facilities and on those experiencing a crisis related to mental illness or a substance use disorder. Such facilities should be evaluated and better equipped to handle these situations as part of the optimization of the overall continuum.
Crisis services are part of a continuum focused on managing individuals’ mental health, addiction, and medical needs and should be integrated whenever possible. They are cost-effective and result in high client satisfaction rates. These services provide comprehensive evaluation and treatment approaches that are specifically designed to stabilize individuals in crisis and promptly link clients to community treatment, frequently avoiding the need for inpatient treatment. Many such efforts are already in place in parts of Ohio and were expanded as a result allocated funding granted by the General Assembly in the fiscal year 2018-19 budget.
These services include transitional housing, quick response teams, crisis stabilization units, and mobile crisis teams to name only a few. While there are numerous models and settings for provision of crisis services, Ohioans of all ages and their families could greatly benefit from a coordinated mental health and addiction crisis system that is integrated with the broader community behavioral health care and medical care system and is readily accessible throughout the state. Such services should be funded in a sustainable way and have facility-based and community-based options available.
To address the crisis services needs in Ohio, the RecoveryOhio Advisory Council recommends:
36. Exploring Crisis Infrastructure Models
Investigate promising crisis service models from across Ohio and in other states, such as Arizona and Vermont. Build a crisis infrastructure that works to assist all Ohioans at all ages by incorporating crisis services into a continuum focused on managing patients’ medical, psychological, and social needs in an integrated fashion. Ensure flexibility in regulations and financing to allow for facility-based and community-based options determined by the availability of local resources and partnerships. Create a sustainable financing model for the development and ongoing operations of these crisis services, including block-grants to local governments and third-party payments to support ongoing service delivery.
37. Hospital Engagement
Support hospitals in their efforts to connect individuals experiencing mental illness and substance use disorders and their families to treatment and recovery support. Strategies should be developed for patients receiving care in emergency departments and in outpatient and inpatient settings.
38. A Review of Civil Commitment
Review and expand the civil commitment process and the role of involuntary treatment in helping individuals and families experiencing mental health and addiction crises to access services. Educate professionals on the full definition and processes and provide community education on accessing emergency services, including the use of medication assisted outpatient treatment.
39. Streamlining Information Sharing to Ease Collaboration and Improve Care
Develop trainings and tools that help collaborative partners share information for care coordination while maintaining compliance with federal privacy and confidentiality laws related to mental illness and substance use disorders.
Treatment can take many forms and occur in many different settings, including outpatient treatment centers, clinician offices, hospitals, residential settings, and increasingly, in schools and community settings. There is no single “best” treatment that applies to all individuals affected by a mental health or substance use disorder, although preferred or “evidence-based” treatments do exist and provide the highest likelihood of treatment success. For some individuals, medication is a critical part of recovery. For others, psychotherapy and other “talking” treatments are preferred. For many, the combination of medication and therapy, along with recovery supports, yields the best results. In all cases, it is important that treatment is tailored to the specific characteristics and preferences of the person experiencing the behavioral health condition while following the best-known evidence.
Mental illness and substance use disorders are frequently life-long and chronic diseases. It is important for communities to have a coordinated network of community-based services and supports that help individuals throughout their life span. A strong system of care also gives individuals in recovery a voice in the recovery system and helps individuals in need of treatment for mental health and/or substance use disorders drive their own recovery journey.
A recovery-oriented system of care will ensure that treatment for mental illness and substance use disorders includes several factors to yield the best chances of success. The care should be:
- Evidence-based: Not all treatments are created equal. “Evidence-based” treatments are those that have undergone scientific scrutiny and demonstrate effectiveness for specific conditions. While not all individuals will respond to any single evidence-based treatment, these approaches do give the best opportunity for a successful treatment outcome. Medications, therapies, and even recovery supports may be evidence-based. Nationally, there are still many practitioners who do not consistently use evidence-based treatments, leading to some individuals not achieving the treatment outcomes they should.
- Culturally competent: Treatments should consider the individual’s culture and preferences that may exist within that culture. Treatment should consider cultural factors that may impact access and barriers to treatment and engagement. These may include language, communication preference, and historical mistrust of the health care system. Cultural factors may also impact response and the sustainment of long-term engagement. Cultural factors should be identified and considered from assessment and throughout the continuum of care.
- Patient and family-centered: The person receiving treatment and, in many circumstances, the individual’s family, should be involved in making treatment plans using a “shared decision- making” process. They should be presented with diagnostic information, treatment options, and the risks and benefits of each option and likelihood of treatment success with each option. This serves to build the treatment alliance and enhance treatment adherence, which is essential for a successful outcome.
- Age appropriate: Treatments are effective for individuals of all ages and cultures. Physiology, medical issues, life experiences, and life challenges differ among age groups. The treatments required for individuals in each life stage need to consider these factors among others for clinical safety and good treatment results.
- Trauma-informed: Many individuals experiencing mental illness or a substance use disorder experience early life trauma. Many others are victimized later in life. In a great number of these individuals the trauma itself is a contributor to the symptoms they experience, so all treatment approaches, including medication and therapy, should consider the trauma context, avoid re- traumatization, and assure that the trauma is addressed.
- Integrated and collaborative: Treatment providers should coordinate efforts to ensure that an individual’s needs are comprehensively met. This includes collaboration among prescribers, therapists, and providers of other medical care, as well as with schools, housing providers, and others outside of the traditional health care system to have complete information, avoid gaps and redundancies, and achieve best outcomes.
- Outcome-driven: The goal of treatment is to produce positive results, which may include a decrease of symptomology and improved life- skill functioning. Positive outcomes may include retention in treatment, sustaining employment, completion of education, and being a productive community participant. Treatment that does not achieve these goals in the expected time frame should be re-evaluated for effectiveness.
- Sustainable: Many mental health and substance use disorders are chronic and require sustained treatment for continuing success. Treatments should be viewed through this lens. Treatments must be affordable and tolerable to the individual, so treatment does not terminate prematurely.
To address the gaps in treatment, the RecoveryOhio Advisory Council recommends:
40. A Focus on Diversity
Convene a focus group connected to RecoveryOhio to review the impact of Ohio’s mental illness and addiction crisis on citizens of racial, ethnic, geographic and socio-economic differences to ensure that all Ohioans have equal access to the treatment and recovery support services they need to live healthy and fulfilling lives.
41. Supporting a Full Continuum of Care
Review the continuum of mental health and addiction treatment services available in communities across Ohio to determine gaps and create strategies to improve access to services and the geographical accessibility of mental health and addiction treatment services. Recognizing addiction and mental illnesses are chronic diseases, the continuum of treatment services should include outpatient, intensive community- based treatment services, residential treatment, and when necessary, inpatient treatment options that allow individuals to access the right services at the right time. Review reimbursement models across all payers (Medicaid, Medicare, commercial insurance) to identify gaps and challenges and develop strategies to support payment for services across the full continuum of care.
42. Promoting Levels of Care Determination and Treatment Recommendations
Ensure that each patient’s needs and treatment recommendations are determined by a qualified clinical professional. Promote insurance coverage of medically-necessary services identified by qualified clinical care providers. Offer training and practice support to clinicians on the American Society of Addiction Medicine (ASAM) levels of care and the most effective methods of treatment continuation between levels of care for people with substance use disorders. Provide similar training for best practices in diagnosis and treatment planning for people with mental illness.
Expand access to telemedicine to Ohioans in underserved parts of the state, including remote and rural areas and in metropolitan areas where transportation and distance are barriers to ready access to specialty care.
44. Using Medication to Treat Addiction
Provide training and ongoing technical assistance to increase the number of medical professionals who can provide comprehensive medication assisted treatment (MAT) services for all MAT options and promote acceptable clinical standards of care that include linking patients to mental health and substance use treatment providers so that MAT is provided in conjunction with psychosocial treatment and supports.
45. Improved Access to Medication to Treat Mental Illness and Addiction
Ensure people with mental illness and addiction have rapid and continued access to prescribers and medications in community and institutional settings.
46. Alternative Pain Therapies
Educate patients and prescribers about effective nonopioid pain management strategies including both nonopioid pain medications and nonpharmacological treatments for pain.
The adoption of recovery by mental health and addiction treatment systems in recent years has signaled a dramatic shift in the expectation for positive outcomes for individuals who experience mental health and/or substance use disorders. The value of recovery and recovery-oriented systems of care is widely accepted by states, communities, health care providers, peers, families, researchers, and advocates.
The process of recovery and wellness maintenance is personal and occurs via many pathways. It may include clinical treatment, medications, faith-based approaches, peer support, family support, self-care, and other approaches. Recovery supports promote individual, program, and system-level approaches that foster health and resilience (including helping individuals with behavioral health needs to “be well,” manage symptoms, and achieve and maintain abstinence); increase housing to support recovery; reduce barriers to employment, education, and other life goals; transition individuals from institutional settings to community living; and connect to necessary social supports in their chosen community. Focus areas for recovery and wellness maintenance:
- Housing and homelessness: A lack of safe housing is a huge challenge to the recovery and wellness of individuals with mental illness or addiction. This is often due to a lack of work history or gaps in employment, a criminal background, or a negative credit history. Supportive housing can provide the stable environment people need to successfully work toward positive goals. Appropriate housing also is a key to rebalancing Ohio’s long-term care options, saving taxpayer dollars, and increasing independence for people who do not require institutional care. Such housing should allow and align with evidence-based treatment plans (including medications) when indicated.
- Employment and benefit planning: Not only does meaningful employment help pay the bills, but can also provide a person with a sense of pride and belonging. It offers opportunities to connect with others socially. Unfortunately, the current rate of employment among people with behavioral health conditions is low despite research that strongly supports the critical impact that work plays in enhancing an individual’s recovery. The factors that lead to low rates of employment in individuals with behavioral health conditions parallel those which create problems to those trying to obtain safe and stable housing. In addition, cash and medical assistance benefits provide essential support for many people with behavioral health needs who are unable to achieve competitive full-time employment.
- Peer support and peer-run organizations: Through the promotion of sharing personal experience and knowledge, individuals engaged in peer support play an active and vital role in laying the foundations for sustained recovery. Peers are an important part of Ohio’s behavioral health workforce. “Peer recovery supporter” is an all-inclusive term consisting of peer specialists, recovery coaches, and peer supporters. As individuals with lived experience, peers offer a unique type of support for people in treatment, recovery, or those working to manage their illness. Consumer-operated services (also known as peer recovery organizations) and recovery community organizations provide services or activities that are planned, developed, administered, delivered, and evaluated by people, a majority of whom have a direct lived experience of a mental health and/or substance use disorder. The peer-run organizations have a primary goal of enhancing the quantity and quality of support available to individuals seeking recovery from mental health or substance use disorders.
To address recovery support gaps, the RecoveryOhio Advisory Council recommends:
47. A Housing Plan
Review and create a comprehensive plan for safe, affordable, and quality housing that will meet the needs of individuals with mental health and substance use disorders so they can fully participate in community and family life. The plan will include supported housing options, transitional housing, recovery housing, adult care facilities, and short-term stabilization options to provide housing stability and choice. The plan will recognize that housing for people with mental health and substance use disorders will allow for and coordinate with treatment providers to ensure alignment of individuals’ treatment plans, including medications. This plan must consider the housing barriers faced by people who have criminal records and evaluate options for individuals who may not be able to live independently to provide the highest quality of life possible.
48. Recovery-Friendly Communities and Workplaces
Support the development of recovery-friendly environments in all sectors, schools, communities and workplaces to promote and sustain health and wellness goals. Put resources toward peer recovery organizations, recovery community organizations, recovery high schools, collegiate recovery communities, and alternative peer groups.
49. Focusing on Employment
Provide incentives and risk management strategies to support employers and business owners in hiring employees recovering from mental illness and addiction and in supporting these employees in their ongoing success in the workplace. Coordinate federal and state resources to expand supported employment services models for people with mental illness and addiction. Reduce barriers to employment for people with criminal histories.
50. Engaging the Faith Community
Work with the Governor’s Office of Faith- Based and Community Initiatives to uncover and leverage current community faith-based recovery support alternatives to augment existing community recovery support programs.
51. Reducing Transportation Barriers
Examine transportation barriers and find ways to reduce them to permit consistent participation in treatment and recovery support and consider technological solutions to these barriers that may be more effective and efficient.
52. Greater Mental Health Advocacy
Support the re-establishment of a statewide mental health peer-run organization led by individuals with lived experience, that, at a minimum, includes advocacy and speakers’ bureau training.
53. Strategies for Human Trafficking Survivors
Work with the Department of Public Safety, the Ohio Human Trafficking Commission, the Governor’s Human Trafficking Task Force, local coalitions and faith-based providers to develop trauma-informed intervention recovery and support strategies and programs for victims of human trafficking.
54. Support for Families
Link families affected by mental illness and substance use disorders to trainings, grief and trauma support groups, and other resources.