Dr. Michael Hogan, the court-appointed Monitor for the U.S. v. Mississippi mental health lawsuit, posted his first monitoring report on Friday, March 4. He divided his report into these sections:
- In the Introduction, he laid out a helpful background of the lawsuit.
- In the “Focus of the Initial Report” section, he clarifies what the report covers, including his activities during the period, preliminary observations and next steps.
- In the “Activities of the Monitor” section, he details what he’s been doing: legal proceedings; meetings and visits in the healthcare system; the staff he hired; the approach he’s developing toward monitoring; his preliminary observations and his planned next steps.
On page 5, he describes his team’s approach to data review. They reviewed a sample of records from the state hospital and then reviewed community records for those same people. (Some of the records were not available, in part due to COVID-related scheduling changes.) He writes: “The review confirms progress by the State but is not sufficient to determine whether people who are at serious risk of hospitalization are receiving the services needed to continue their recovery while avoiding institutionalization.”
The report goes on to say, “Our review … finds that this effort has led to improvements in the discharge transition process, but that continued work is needed to achieve compliance with all related elements of the Order.”
The team noted several strengths but sometimes described challenges associated with these strengths. For example:
- “We found that follow-up appointments at the CMHC were consistently arranged prior to discharge.”
- “We consistently saw Hospital assessments started promptly on admission, leading to [the] development of treatment plans to inform treatment and discharge planning. (This was done in a very timely way at SMSH and within about a week at MSH and EMSH.) While we observed prompt initiation of assessments and treatments, we did not see much documentation that discharge planning specifically starts within 24 hours of admission.”
- “It appears that Hospital social workers are aware of Core Services and the benefit they may offer. Therefore, they check relevant boxes on the Discharge Transition Record (e.g., for PACT, ICORT or ICSS). However, checking the box does not necessarily mean that eligibility has been established or that a referral for the service has been made.”
- “The effort to reach out and engage people in care was substantial and commendable. Clearly the transition to a new CMHC in the former Region 13 was challenging, and despite best efforts there were almost certainly lapses in care. This suggests the need for improved processes within DMH to monitor, and assist or if necessary replace, potentially failing CMHC’s.”
- “Given the impact of hospitalization, we expected to see documentation of efforts to follow up with individuals who miss the first aftercare appointment, or if they drop out of treatment services shortly after discharge. Evidence was mixed.”
- “As we have indicated above, we found some clear signals of improvement resulting from DMH efforts to improve discharge planning were observed. What is generally missing, from review of those State Hospital and CMHC records seen to date, is sharper individualization of the assessment, treatment and discharge planning procedures specifically to address reasons for community crises and hospital admissions or readmissions.”
The team noted these challenges:
- “Reviewing the CMHC records proved challenging due to the wide variability in record keeping systems.”
- “There were persons committed to State Hospitals who when assessed at the Hospital did not have SMI (serious mental illness) …….Of the 29 CMHC records reviewed, Hospital discharge diagnoses were captured on 25. Of those 25 individuals, 8 (32%) were discharged without a SMI diagnosis. Discharge diagnoses included dementia, substance use disorders, antisocial personality disorders, intellectual/developmental disabilities and malingering….. We note the sample is too small to make definitive conclusions, but the large percentage of people admitted to State Hospitals without a primary psychiatric diagnosis does raise concerns about the appropriateness of their care, and contributes to delays in accessing hospital care for individuals with SMI…..In some of these cases, the CMHC had recommended against hospitalization because the person did not meet hospitalization criteria (since their difficulties were not the result of an SMI), but the court opted to commit the person nonetheless.”
- “Documentation of intakes to, or initiating treatment planning by the CMHC prior to the person’s discharge from the State Hospitals was generally not evident throughout the Hospital chart reviews.”
- “Assessment of the need for (more) intensive services, where this is needed to prevent readmission, generally needs improvement.”
- “In a substantial percentage of cases where information was available in the record regarding where people were held pending admissions, we found delays in access, and that a number of people were held in jails…….These patterns appear to differ by Region (although the small samples make generalization unreliable), with a high proportion of people admitted from Regions 12, 13 and 14 held in jail. We do not know if statewide data on this is reviewed by DMH.”
Dr. Hogan ends his report with these conclusions: “In this first and preliminary report, it is not yet possible to make definitive findings on most aspects of compliance. Additionally, some of the data that is intended to be provided to facilitate compliance is not due to be posted on a regular basis until the end of FY22, and the State is currently developing its ability to produce the required reports.”
He noted that the “overall patterns of compliance” are:
- The State has provided funds to CMHC’s to support all the Core community services required by the Order, except those subject to the stay. However, not all the programs are yet operational, and the Monitor has not yet been able to review the State’s oversight of these programs and whether they are functioning adequately. Therefore, compliance ratings for the Core Services generally find Partial Compliance (since funding has been provided), with monitoring to date Incomplete.
- The Monitor reviewed practices for continuity of care and discharge planning at most (but not all) State Hospitals, with about half the CMHC’s. Therefore, we make detailed observations about Discharge Planning and to some extent about Diversion from State Hospitals, but a complete statewide rating of compliance is not yet possible.
- For most other requirements of the Order, monitoring is just beginning, and findings of compliance are generally Incomplete.
The report concludes with: “By the next Report the Monitor and team will have completed introductory visits and some record reviews at all Hospitals and CMHC’s. Record reviews in this cycle emphasized discharge planning; we may be able to evaluate hospital diversion activities in more depth in the next report. Additionally, we expect to begin to review the State’s own oversight activities.”
Dr. Hogan shares additional information in an appendix, “The context of care and compliance in Mississippi” beginning on page 32.
