Evolution Of The Mental Health System In Georgia
The National Alliance on Mental Illness in Gwinnett is the county’s voice on mental illness. We are part of the grass-roots, non-profit, national NAMI organisation founded in 1979 by family members of people with mental illness. We are also an affiliate of NAMI Georgia.
State concern for mental health goes back a long time. It began when the State Asylum (which later became Central State Hospital) was established in Milledgeville in 1842. But it took a long time for more to occur. Some 80 years later, in 1921, Gracewood State School and Hospital was established in Augusta under the Department of Public Welfare.
The next major step occurred in 1960 when Central State and Gracewood were transferred to the Department of Public Health, and the Division of Mental Health was created. From then on, the mental health system grew more rapidly. During 1960–1963, the division made plans for numerous community mental health centres to be scattered throughout the state. The Georgia Mental Health Institute (GMHI) and the Georgia Retardation Centre were responsible for training professional staff for these community centres.
Between 1968 and 1972, construction of regional state hospitals was completed, and the establishment of community mental health and mental retardation centres began. These centres functioned under local boards of health (public health system).
In 1972, the Department of Human Resources (DHR) was created and included the mental health and mental retardation divisions. Three years later (1975), drug abuse services became a part of DHR, and the division became Mental Health, Mental Retardation, and Substance Abuse (MHMRSA), which remained the division name until 2002.
For about 20 years, the MHMRSA system was a hospital-based system under the division. The community centres were under local boards of health. General Assembly funding to DHR was passed onto the division, which allocated funding to the hospitals and boards of health. The boards of health then funded their respective community centres.
The question is what caused the rebellion by family members, consumers, advocates, professionals, and legislators? This question may be best described by two 1992 quotes. The first is from SB 811, which created a study commission of the MHMRSA service delivery. “The system of service delivery has demonstrated shortcomings and lack of continuity of care over a 20-year history…” The second quote is from the SB 811 commission report in late 1992. “We currently have a system that is not just simply broken. It is so fragmented, so non-responsive, so top-heavy with bureaucracy, and so consumer-unfriendly that we feel strongly that just tinkering with the system would be a waste of time at best and deceiving the public at worst.”
The 811 study commissions identified 14 principles to define what should be expected of a service delivery system. These became known as the organising principles of HB100.
HB100, based on the 811 study, was enacted in 1993 and effective July 1, 1993 (start of fiscal year 1994). To achieve local planning and other organising principles, the system was configured into 19 regions. Each region would have a regional board of volunteers and a regional planning unit of state employees headed by an executive director. This planning unit staff would carry out day-to-day functions as well as assist, advise, and make recommendations to the regional board. The executive director reported to the division, as did the regional board. Regional Boards were responsible for the planning, contracting, and monitoring of services in their region. The state hospitals continued to be a division responsibility.
HB100 also changed the name of local MHMRSA centres to Community Service Boards (CSB) and gave them the option of being a separate entity or staying as part of the Boards of Health. County Commissioners appointed the CSB board members. Originally there were 28 CSBs if Haralson County is included. In recent years the number of CSBs has been reduced by 2; one ceased operation, and a merger combined 2 into 1. CSBs were contracted providers through the regional boards, as were other private providers.
In 1998, the number of regions was reduced from 19 to 13 in a cost-reduction effort. This came with an attached penalty of some dilution in local participation and complications due to a larger geographical area and increased population in those regions affected. CSB areas of responsibility were not changed.
In 2001, two bills were introduced in the Georgia House of Representatives. One was HB498, which would replace HB100 with a different system structure. After a deluge of objections from families and advocates, the bill was changed and passed the House. The Senate did not act on this bill. The second bill was HB332, known as the CSB bill. This bill was rewritten extensively and then passed the House. The Senate did not act on this bill either.
In 2002, the second year of the two-year legislative cycle, the Senate passed a new written version of HB498 and made a new rewritten version of HB332 part of HB498. Also included was a section for creating an Ombudsman Agency. After a joint committee review, HB498 passed in both the House and Senate and became effective on July 1, 2002, although most changes occurred in October and some CSB decisions were targeted later.
Some of the more significant changes as a result of HB 498 are
Even a mini-history such as this creates discussion items. The question most often raised is, “Will HB 498 improve the system? The answer is “nobody knows.” It will take a few years to evaluate, and funding reductions will complicate any evaluation. The “do more with less” theory can only work for a short time. HB 498 does contain obvious good points. It also establishes a structure with agonising and perhaps detrimental possibilities.
Looking back at HB 100 is most interesting. HB 100 absolutely improved the system. Anyone who feels differently has either forgotten or never experienced the system prior to HB 100. Perhaps the best way is to look at occurrences that had nothing to do directly with HB 100 as a system structure but had a significant impact.
Written by Daryl Myers, NAMI Gwinnett Member, at the request of some NAMI Gwinnett members.
State concern for mental health goes back a long time. It began when the State Asylum (which later became Central State Hospital) was established in Milledgeville in 1842. But it took a long time for more to occur. Some 80 years later, in 1921, Gracewood State School and Hospital was established in Augusta under the Department of Public Welfare.
The next major step occurred in 1960 when Central State and Gracewood were transferred to the Department of Public Health, and the Division of Mental Health was created. From then on, the mental health system grew more rapidly. During 1960–1963, the division made plans for numerous community mental health centres to be scattered throughout the state. The Georgia Mental Health Institute (GMHI) and the Georgia Retardation Centre were responsible for training professional staff for these community centres.
Between 1968 and 1972, construction of regional state hospitals was completed, and the establishment of community mental health and mental retardation centres began. These centres functioned under local boards of health (public health system).
In 1972, the Department of Human Resources (DHR) was created and included the mental health and mental retardation divisions. Three years later (1975), drug abuse services became a part of DHR, and the division became Mental Health, Mental Retardation, and Substance Abuse (MHMRSA), which remained the division name until 2002.
For about 20 years, the MHMRSA system was a hospital-based system under the division. The community centres were under local boards of health. General Assembly funding to DHR was passed onto the division, which allocated funding to the hospitals and boards of health. The boards of health then funded their respective community centres.
The question is what caused the rebellion by family members, consumers, advocates, professionals, and legislators? This question may be best described by two 1992 quotes. The first is from SB 811, which created a study commission of the MHMRSA service delivery. “The system of service delivery has demonstrated shortcomings and lack of continuity of care over a 20-year history…” The second quote is from the SB 811 commission report in late 1992. “We currently have a system that is not just simply broken. It is so fragmented, so non-responsive, so top-heavy with bureaucracy, and so consumer-unfriendly that we feel strongly that just tinkering with the system would be a waste of time at best and deceiving the public at worst.”
The 811 study commissions identified 14 principles to define what should be expected of a service delivery system. These became known as the organising principles of HB100.
- Consumer Choice (voice in treatment)
- Quality of Service
- Single Point Of Accountability (fiscal & administrative)
- Separation of Function (planning from service delivery)
- Comprehensive System
- Prevention
- Privatisation (expand provider pool)
- Single Point of Entry
- Local Planning
- Accountability (outcome measurement)
- Adaptive System (handling future changes)
- Qualified Staff (training)
- Most in Need (safety net)
- Funds Follow Clients
HB100, based on the 811 study, was enacted in 1993 and effective July 1, 1993 (start of fiscal year 1994). To achieve local planning and other organising principles, the system was configured into 19 regions. Each region would have a regional board of volunteers and a regional planning unit of state employees headed by an executive director. This planning unit staff would carry out day-to-day functions as well as assist, advise, and make recommendations to the regional board. The executive director reported to the division, as did the regional board. Regional Boards were responsible for the planning, contracting, and monitoring of services in their region. The state hospitals continued to be a division responsibility.
HB100 also changed the name of local MHMRSA centres to Community Service Boards (CSB) and gave them the option of being a separate entity or staying as part of the Boards of Health. County Commissioners appointed the CSB board members. Originally there were 28 CSBs if Haralson County is included. In recent years the number of CSBs has been reduced by 2; one ceased operation, and a merger combined 2 into 1. CSBs were contracted providers through the regional boards, as were other private providers.
In 1998, the number of regions was reduced from 19 to 13 in a cost-reduction effort. This came with an attached penalty of some dilution in local participation and complications due to a larger geographical area and increased population in those regions affected. CSB areas of responsibility were not changed.
In 2001, two bills were introduced in the Georgia House of Representatives. One was HB498, which would replace HB100 with a different system structure. After a deluge of objections from families and advocates, the bill was changed and passed the House. The Senate did not act on this bill. The second bill was HB332, known as the CSB bill. This bill was rewritten extensively and then passed the House. The Senate did not act on this bill either.
In 2002, the second year of the two-year legislative cycle, the Senate passed a new written version of HB498 and made a new rewritten version of HB332 part of HB498. Also included was a section for creating an Ombudsman Agency. After a joint committee review, HB498 passed in both the House and Senate and became effective on July 1, 2002, although most changes occurred in October and some CSB decisions were targeted later.
Some of the more significant changes as a result of HB 498 are
- Changed the division name to Mental Health, Developmental Disabilities, and Addictive Diseases (MHDDAD).
- Reduced the number of regions from 13 to 7 and made a state hospital part of each region.
- Made each region office, headed by a regional coordinator, responsible for local planning, contracting, and monitoring. The regional hospital administrator also reports to the regional coordinator.
- Changed the regional boards to planning boards as an advisory board to the regional coordinator.
- Clarifies and defines the position and role of CSBs in the system structure.
Even a mini-history such as this creates discussion items. The question most often raised is, “Will HB 498 improve the system? The answer is “nobody knows.” It will take a few years to evaluate, and funding reductions will complicate any evaluation. The “do more with less” theory can only work for a short time. HB 498 does contain obvious good points. It also establishes a structure with agonising and perhaps detrimental possibilities.
Looking back at HB 100 is most interesting. HB 100 absolutely improved the system. Anyone who feels differently has either forgotten or never experienced the system prior to HB 100. Perhaps the best way is to look at occurrences that had nothing to do directly with HB 100 as a system structure but had a significant impact.
- HB 100 was not responsible for the flat funding (some say declining) that occurred during the prosperous decade of the 1990s.
- HB 100 was not responsible for the instability of leadership at the DHR commissioner and division director levels, which each changed six times.
- HB 100 was not responsible for regional planning units being understaffed for most of its 9-year life.
- HB 100 was not responsible for allowing a few regional boards to taint the fine performance of the majority.
- HB 100 was not responsible for the lack of addressing the CSB issue and their concerns.
- HB 100 was not responsible for the Revenue Max/Rehab Option initiative, which placed most CSBs in financial stress.
Written by Daryl Myers, NAMI Gwinnett Member, at the request of some NAMI Gwinnett members.
