Participants:

Medical Directors
Tom Hester, M.D., Chair (Georgia)
Joseph Parks, M.D. (Missouri)
Steve Shon, M.D.(Texas)
Larry Miller, M.D. (Arkansas)
Michael Flound, M.D. (Iowa)

NASMHPD staff
Bob Glover, Ph.D., Executive Director
Brandy Tomhave, Project Director
Bill Emmet, Project Director

I. Review and Changes to draft October 24, 2000 Meeting Minutes

The Medical Directors Council reviewed the draft minutes from its previous business meeting. The minutes were accepted with the two following amendments.

Action: Amend the Action step under the 2001 Best Practices Symposium section to read: "NASMHPD and the Medical Directors Council will continue to seek unrestricted education grants from pharmaceutical companies to support its meetings and technical reports. Further, the Medical Directors Council will identify which events and sessions within the Best Practices Symposium will be determined to be closed to visitors and guests."

Add to the sixth paragraph on page one: "The Medical Directors Council agreed to continue requesting unrestricted education grants to pharmaceutical funding to support future technical reports and Best Practices Symposiums."

II. Criminal Justice/Mental Health Initiatives

Brandy Tomhave provided an update on a recent NASMHPD project, a mental health/criminal justice initiative sponsored by the Council of State Governments (CSG). Ms Tomhave serves as the project director for the 18- month national project which will bring together professionals and non-professionals from law enforcement, courts and mental health to identify promising practices for people with mental illness in justice system. Ultimately, the project will produce a tangible product that outlines nonpartisan recommendations on collaboration and other promising strategies. Several Commissioners are involved with the effort: Barry Kast (Oregon) is the mental health representative to the law enforcement track; Jim Stone (New York) is the representative on the corrections track, and Meredith Alden (Utah) serves on the mental health track.

Dr. Glover also announced that NASMHPD President Meredith Alden will establish a NASMHPD President's Task Force on criminal justice and mental health. Several Medical Directors described criminal justice/mental health initiatives in their states.

Dr. Hester reported on a productive collaboration occurring between criminal justice and mental health in Georgia. The state has established a case management program for persons coming out of prison who have mental illness or substance abuse disorders. This effort started as a pilot and went state-wide in 1999. Some other cross-system issues that still need to be addressed include the differences in formularies used by state hospitals and prisons, which affects patients as they transition between the facilities, and prisoners on death row who are sent to a maximum security facility in order to be restored for eventual execution.

Dr. Parks described the large amount of interaction that occurs between the state mental health agency and the prisons, (e.g., the state provides mental health training to jails and police officers) in Missouri. The state still needs to address linking and prioritizing people on probation/parole into mental health services. Currently, the referral occurs but the individual may not make the priority cut for mental health services.

In Arkansas, the prisons run their own mental health units and have their own staff. Occasionally, the prisons will consult with the state mental agency on difficult cases, but little ongoing collaboration occurs. A growing cross- system concern is the number of juveniles being sent to state hospitals because judges have no other options for placing the youth.

Texas has unique structure for addressing the mental health needs of its corrections population. About five years ago, all prison health care dollars were carved out and given to two university-run managed care organizations. Texas Tech and University of Texas serve the eastern and western half of the state's prisons respectively. The system has worked well, thus far, with university faculty available for consultation and good access to medications. The Corrections system also contracts with the state mental health agency to track people while they're on parole. Within the Texas jail system, the SMHA has a pilot project which trains and certifies forensic examiners to conduct assessments for competency.

Finally, Bill Emmet described another new NASMHPD initiative. Funded by the Center for Mental Health Services, NASMHPD is the prime contractor of a $1.4 million contract to provide targeted technical assistance on policy issues to all stakeholders. NAMI, Federation for Families, NMHA and the Bazelon Center are project partners. The project, for which Mr. Emmet serves as director, will produce 25 written technical assistance documents and conduct 45 on-site visits per year. Each organization did a needs assessment to determine the technical assistance issues to be addressed by the project. Issues identified by NASMHPD included best practices for people with co-occurring disorders, criminal justice interface, and the role of HPPA.

III. NASMHPD Position Statement on Restoration of State Hospital Cemeteries

The Medical Directors received a handout, The Georgia Story: How to Successfully Restore a State Hospital Cemetery. The document included a moving speech given by Dr. Hester to a consumer meeting in Georgia apologizing for the neglect and ruin of state hospital cemeteries. Dr. Hester also wrote up a position statement on this issue, which is being considered and reviewed by the NASMHPD Board. In March, Dr. Hester and Dr. Pat Deegan and Larry Fricks will co-present on this issue at the Superintendents' National Summit.

Dr. Glover reported that the National Association of County Behavioral Health Directors and Charles Ray's group will meet with the NASMHPD Board to discuss the cemetery issue at the county-level. Medical Directors present at the meeting acknowledged Dr. Hester for his leadership on this topic.

IV. Report and Follow-up from the "NASMHPD Medical Directors Council and State Medicaid Directors Technical Report Meeting on Psychiatric Medications"

Drs. Hester and Glover described the joint meeting between the NASMHPD Medical Directors Council and the State Medicaid Medical Directors as a very positive session. During the November 2000 meeting, the group was able to reach consensus on a number of principles, including the economics of good clinical practice, the importance of collaboration and the positive impact of quality improvement processes. A technical writer will prepare a report on the discussion and agreement, which will serve as one of the Council's technical reports for 2000.

Medical Directors who attended the meeting reported the exchange was helpful and gave a better understanding about their respective jobs, including the pressures involved with each of their systems. Given the favorable reaction to the first joint meeting, it is likely that the two groups will meet again in the future.

V. Review of the Medical Directors 2001 Best Practice Symposium

The Medical Directors' Council 2001 Best Practice Symposium will occur in October 2001 in Orlando. The Council reviewed the agenda topics which were selected by the full membership at the 2000 Symposium. The sessions include:

NRI's Performance Measurement System Update. This session will be closed to outside guests and visitors. The presenters will provide the latest data (possibly including risk adjustment and new seclusion and restraint data) and pragmatic examples of how states use the data to make quality improvement and funding decisions. Dan Luchins, M.D. is the Section Chair.

Children Psychopharmacy Issues. The group expressed an interest in having this session address ADHD and the psychopharmacological and diagnostic issues, given the intense public dialogue around this topic. Brian Hepburn, M.D. and Penny Knapp, M.D. are Section Chairs.

Continuity of Care from the Hospital to the Community (Successes and Failures). Alan Radke, M.D. is the Section Chair.

Update on practice guidelines including changes by APA and modifications by the tri-universities. Dr. Shon, the Section Chair, reported that this session will focus on the differences in the practice guidelines approaches and implementation of the guidelines.

VI. Update on 2000 Medical Directors Technical Reports

The Council discussed the status of its 2000 Technical Reports. A draft of Seclusion and Restraint II has been circulated to participants for comments and the final report will be released formally at the Superintendents' Summit in March 2001. Dr. Parks described the report as a reaffirmation and extension of the original technical report; the updated report also addresses seclusion and restraint issues use with elderly consumers, people with co-existing substance abuse disorders, and people with co-existing mental retardation. Rupert Goetz, M.D. has served as Chief Editor.

The second technical reports on psychiatric medications will be the product of the joint Medicaid and NASMHPD Medical Directors Meeting. Consequently, the Medicaid Medical Directors also will be part of the editorial review process for this technical report. Dan Luchins, M.D. serves as the report's Chief Editor. A draft of the report will circulate among attendees shortly.

VII. Children's Health Act of 2000

Dr. Parks directed the Council's attention to the implications of the Children's Health Act of 2000, as outlined in NASMHPD's October 5, 2000 Information Alert. According to the Alert, "the bill places significant new responsibility on states to regulate who may impose restraints or seclusion in non-medical, community-based residential facilities for children and the adequacy of their training."

The law requires that federal regulations be promulgated within 6 months and require states that license non-medical community-based residential facilities for children to develop rules and monitoring requirements; one requirement is that the state provide appropriate staff training and certification regarding the prevention and use of physical restraint and seclusion. These state licensing rules and monitoring requirements must be developed and implemented within one year of publications of the federal regulations. The NASMHPD Alert states, "It is not clear how these provisions in the bill will affect states that do not license some or all of non-medical community-based residential facilities operating in their state, or how it may affect non-residential settings." Until a state has developed a process for training and certifying staff, facilities are required to develop interim procedures to ensure that supervisory or senior staff become involved when seclusion and restraint is used. Additional questions about this provision can be directed to Dr. Glover at (703) 739-9333 x29 or Jenifer Urff, NASMHPD's Senior Policy Analyst at (413) 587-2418.

Dr. Parks discussed how the NASMHPD Medical Directors might play a role in helping states meet this new requirement by providing technical assistance. Some possibilities include the Council 1) creating a checklist of important components that states should look for in training program before certifying them and 2) doing an inventory of existing training programs, perhaps compiling a list of training programs recognized by state authorities.

Action: The Medical Directors Council extended an offer to work in conjunction with the NASMHPD Children's Division and help states comply with the Children's Health Act by outlining the states' responsibilities for certification and how states can meet those responsibilities.

VIII. NASMHPD Information Distribution

As follow-up to the discussion on the Children's Health Act and the Information Alert issued by NASMHPD, several Medical Directors stated they do not regularly receive the information sent out by NASMHPD which is relevant to their roles as Medical Directors.

Action: Request that NASMHPD staff put Medical Directors on its distribution list for all information sent to Commissioners, except information designated as for 'Director's Eyes' only.

IX. Discuss 2001 Medical Directors Technical Reports

The NASMHPD Executive Committee has reviewed and approved the proposed technical report topics for 2001. As planned, the Medical Directors Council will produce a report on outpatient commitment (Chief Editor is Brian Hepburn, M.D.) and poly-pharmacy (Chief Editor is Joe Parks, M.D.). Dr. Hester noted the growing involvement of more Medical Directors with the Council's projects. As new Directors become involved, Dr. Hester will make sure Medical Directors who have gone through the process previously will be available to assist.

X. Follow-up on Memorandum of Understanding with the American Academy of Community Psychiatrists

Dr. Parks has produced a draft Memorandum of Understanding, which Dr. Glover has reviewed. Dr. Parks will forward the draft to AACP for their response.

XI. Superintendents National Summit in March 2001

The Medical Directors discussed how the Superintendents' Summit is a unique opportunity to network and exchange information. Several Medical Directors urged that a Council representative participate in the planning for the March meeting. Medical Directors were interested in several follow-up items from the previous Superintendent's Meeting, namely the formation of superintendent regional networks and updates on state hospital beds (current numbers, trends affecting demand, downsizing efforts, etc.).

Action: Request that a Medical Director be involved with the planning of the Superintendents' Meeting in March.

XII. Next Meeting

The next Medical Directors business meeting will occur in New Orleans in May 2001, in conjunction with the APA's meeting. Roy Praschil is still working on the meeting's logistic details.