Highlight on Nevada: Behavioral Health System; Taking Steps to Improve Services

Nevada’s publicly supported behavioral health services have been undergoing significant change over the past several years as a result of challenges it faced related to the operations of these services and the Patient Protection and Affordable Care Act. In 2013, upon enactment of state legislation, Nevada’s Mental Health and Developmental Services Division merged with the State Health Division to become the Division of Public and Behavioral Health ((DPBH). In addition to integrating its public health and behavioral health Divisions, the state has taken several other steps to address and improve its behavioral health services including commissioning an outside company to evaluate and report on the state’s services and operations, developing a behavioral health strategic plan, and establishing a Council on Behavioral Health & Wellness that reports directly to Governor Brian Sandoval.

Analysis of Nevada’s Behavioral Health Services

The report titled, Behavioral Health Services System in the State of Nevada, provides a history of the state’s behavioral health services and details of the state’s efforts to improve publicly supported behavioral health services by implementing an integrated public and behavioral health system of care. The report, which was prepared in 2013 by Social Entrepreneurs, Inc. under contract by the Nevada’s Department of Health and Human Services’ Primary Care Office in the DPBH, was written while the state’s behavioral system was “facing significant scrutiny and yet, in the process of reform.” The DPBH staff edited the report and new data was incorporated for the final report issued in 2014. According to the report, the state’s publicly supported behavioral health services faced allegations of improper discharge practices, excessively long waiting times for consumers at the state-operated forensic facility, and infractions within state psychiatric facilities that could jeopardize the state’s CMS certification. These allegations resulted in multiple investigations and examinations requested by the state.

The state’s current program consists of “federal, state and local resources with a variety of funding sources, priorities and mandates.” Medicaid expenditures make up more than half of the state behavioral health funding, but the DPBH is the most significant primary provider for adult public behavioral health services. The DPBH relies on state general fund revenue with contributions from grants and Medicaid insurance coverage to finance behavioral health services. The state has four service delivery systems, each of which “has its own budget established within the state system, creating inflexibility to meet the needs of the system as a whole,” the report stated. Moreover, there is a lack of sufficient resources to meet behavioral health needs across the state, the report found.

The report noted three problems originally identified in 1979 that continued to exist within Nevada’s behavioral health system during the time the report was being written. The three characteristics are (1) marked fluctuations in service capacity; (2) a lack of public supervision or independent professional review of mental health programs; and (3) absence of long-term planning. The report also explained that because services throughout the state differ based on target population, geographic region, and funding source, persons seeking behavioral health assistance often face different challenges based on what services are available and where they are seeking services. The report concluded that “the current behavioral health crisis leaves the Division in a difficult position as it implements the integration of behavioral health into a public health model of care and the Affordable Care Act (ACA) in 2014;” but noted, however, that the state has taken steps described below that could positively impact the state’s behavioral health services.

Steps Taken to Improve the Behavioral Health System

The passage of Assembly Bill 488, provided for the Mental Health and Developmental Services (MHDS) Division to merge with the State Health Division (public health) to become the Division of Public and Behavioral Health (DPBH). The mission of the DPBH is to develop and operate programs that assist individuals who have mental illness or a history of substance abuse to live as independently as possible.

MHDS issued a Behavioral Health Strategic Plan (Strategic Plan) for the period of July 13, 2013, through June 30, 2015, that sets forth the planning unit, Division administration, and upcoming activities and priorities as wells as goals, objectives, and strategies. The Strategic Plan noted that “the ACA has made significant changes to mental health and substance abuse services delivery in Nevada. […] This reform will bring significant changes and opportunities to Nevada’s mental health and substance abuse service delivery systems.” According to the Strategic Plan, behavioral health services in Nevada is moving in the direction of public health, to be data-driven, population-based, and community-focused. It is adopting the public health model by looking at and examining the behavioral health needs of special populations, including persons with behavioral health needs who are homeless, have co-occurring disorders, are older, are Native Americans, and have interactions with criminal justice and law enforcement agencies. Moreover, the Strategic Plan stated that the behavioral health program will develop a population-based mental health promotion/substance abuse community plan, which will include specific special populations.

Subsequent to the release of the DHHS analysis, Governor Sandoval established the Behavioral Health & Wellness Council(Council) in December of 2013 to develop ways to improve and strengthen the systems of support and delivery of services to those living with behavioral health conditions in Nevada. An analysis of Nevada’s mental health system, which began in May,  also will be evaluated by the Council.  The Council submitted its first recommendations addressing identified emergent issues in Southern Nevada to the Governor on May 31, 2014.  Its recommendations addressed the overcrowding of emergency rooms including unnecessary or inappropriate admissions to emergency departments, jails, and inpatient beds; children’s mental health services; and access to mental health services. The Council also specifically identified other problems that it will be addressing in the future.