Arizona’s Mental Health Private System consists of hospitals, emergency rooms, psychiatric intake facilities, ambulance companies, private non-profit organizations, and private insurance providers. All of these service providers are a link in the chain of a system of care in Maricopa County, yet the links are often tangled, looped, and even missing.
The navigation of the mental health system from the consumer side is complex and even when entities like COPA Health provide navigation assistance the system itself, the way that it is structured creates a barrier to access. When people who seek treatment end up abandoning treatment regimes because they experience barriers to treatment simply because of the way the system is organized is called structural non-compliance. This category of patient has been labeled by health professionals as “non-compliant”. We have labeled people as non-compliant as if they do not care enough to adhere to their treatment plan. When in reality there are two factors really at play. Structural barriers to care created by poor systems design and personal barriers created by complex issues surrounding the burden that treatment itself puts on a patient. This burden is called treatment burden, that often leads to a tipping point in which the person does not have the capacity to continue the uphill battle of seeking, navigating, advocating for their own care and gives up. Since mental illness remains an unseen illness (much like hypertension) people can more easily let it go untreated. Much like hypertension, untreated chronic mental illness continues to progress into acute states of crisis. The crisis pathways of our mental health system are the most expensive, ineffective, yet highly used system pathways. Parts of the crisis pathways are managed by public sector entities like ambulance, police and fire EMS sector handing off to private sector entities like hospitals who then hand off to long term follow-up providers.
All of this hand-off adds layers of complexity, especially when the hand offs are not connected under one unified policy. This is where the links in the chain begin to erode. The policies and practices of one service entity (say fire EMS) do not necessarily create a seamless continuum of care. In speaking to front line fire personnel many attest that the system they must operate does not make sense at all. The process flows that dictate when they must take people and how calls are routed prevent inefficient and ineffective care. Leaving people churning in that endless loop of ineffective, expensive treatment. This looping creates a burden to the system and a burden to the person seeking care (treatment burdeon).
There are more than 24,700 providers of mental health and substance abuse providers in Maricopa County. All of which have their own barriers to entry, fee schedules and operating policies.
Local first responders have a burden when navigating which port of entry they can take a person experiencing mental health crisis. The call can be complicated by co-occurring illness states (mental health in addition to a chronic physical illness). In fact 6 in 10 American adults have a chronic disease 4 in 10 have two or more chronic diseases. People over 65 are more likely (1:4) to have chronic comorbidities[3].
While there are local entities like NAMI (National Alliance on Mental Illness) that aim to bring a unified approach to local actors in the system, the system remains complex and each entity has competing priorities that often do not match up in creating a true alliance. In Arizona there are eleven chapters. The Maricopa County chapter stated mission is: NAMI Valley of the Sun is dedicated to improving the quality of life for people with mental illness and their families through support, education, and advocacy.
This mission statement does not speak to the alliance of unifying the varied actors in Maricopa County’s complex mental health system. So, then who is to serve as a unifying source in aligning and coordinating all the complex players in this system with an aim at simplifying and unifying the structure?
I discovered David’s Hope. David’s Hope leads the Arizona Mental Health Criminal Justice Coalition. A mental health criminal justice advocacy non-profit organization with a stated mission to, in part:
Improving Collaboration between Arizona’s Mental Health and Criminal Justice Systems
Summary
- Many Americans live with complex chronic health conditions that each carry their own workload of treatment (Treatment Burden)
- The system of accessing preventative normal follow up care is complex (often times one provider for each separate chronic illness (treatment Burden)
- Leaving people feeling overwhelmed to the tipping point of giving up on the effort it takes to seek treatment (Structural Non-Compliance)
- The system itself is comprised by a myriad of complex public and private actors (Complex Structures)
- Most often the complex actors within the system do not have coordinated policies or processes that allow for coordination in the continuum of care (Complex Structures)
What do you think is needed to fill in the missing links?
https://www.cdc.gov/chronicdisease/resources/infographic/chronic-diseases.htm
Maricopa's Mental Health Freedom Trails 
Great post, I work in behavioral health and I see it everyday. Patient’s constantly report the barriers that they face with being able to obtain access to behavioral health services.
There is enough evidence that supports the need for services, there are millions of Americans with mental illness who are struggling to find services. Roughly about 60 million people living with a mental condition go without treatment, yet many can not access care specially when they need it the most.
As you mentioned in your post, there are multiple reasons as of why individuals are having problems having access to care. There is shortage of providers and many that are available are considered out of network, which leads to higher cost. Some astonishing facts reported by NAMI (2019), was that more than half of respondents who looked for a new mental health provider in the last year contacted psychiatrists who were not accepting new patients (55%) or who did not accept their insurance (56%). A third of respondents (33%) reported difficulty finding any mental health prescriber who would accept their insurance, either in- or out-of-network. This far exceeded the number who had difficulty finding a medical specialist who would accept their insurance (13%) or a primary care provider (9%).
Fortunate for Arizona, we are an independent state, therefor NPs are able to provide services without needing collaborating physicians and it allows for NPs to close the gap in lack of provider shortage.
References:
https://www.nami.org/parityreport
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