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Moving Forward: Comprehensive Integrated Mental Health Plan, 2006-2011 

IV. Examples of Current Initiatives, Projects, and Activities That Fill Service Gaps

DHSS Priority Area: Health and Wellness

Alaska Suicide Prevention Initiatives

According to a 2006 national study of suicides in the United States, Alaska ranks second among states with the highest suicide rate in the country. Alaska had approximately 167 suicides in 2008.  Suicide is the second leading cause of death among Alaskans under age 50. According to the 2009 Youth Risk Behavior Survey, approximately nine percent of high school students had attempted suicide in the past 12 months. Historically, the majority of suicides are occurring among our young people ages 20-29 years and are equally represented among both rural and urban communities. During 2008, there was also a high number of suicides among veterans, accounting for 27 deaths. (VDRS – verify and add references)

The distribution of suicide by ethnicity shows Alaska Natives comprise 16% of the population, however they have accounted for 39% of the suicides. The highest rate of suicide in Alaska is among Alaska Native male teens and young adults 15 – 29 years of age.  Older adults and gay, lesbian and transgender youth are also at an increased risk as well as those with chronic medical illness, trauma, past sexual abuse, substance abuse and mental illness most commonly, depression.

Recent Accomplishments

  • Rural Suicide Prevention Planning Grant Project. The Alaska Department of Health and Social Services Division of Behavioral Health received a one-time FY09 state general fund allocation of $200,000 for suicide prevention planning in rural areas with high rates of suicide. Areas awarded grants included Nome, Kotzebue, Dillingham, Bristol Bay and Lake and Peninsula, and Akiachak and surrounding villages of Tuluksak, Kwethluk and Akiak. Those regions are continuing to plan and implement key strategies including use of evidence-based and other best practices to address suicide in their villages, communities and regions.
  • Alaska Youth Suicide Prevention Project. The Alaska Department of Health and Social Services awarded three $339,000 regional grants as part of the Alaska Youth Suicide Prevention Project. This project carries the message to communities that youth suicide is preventable, and targets high-risk youth for prevention, intervention and follow-up. Grants were awarded to regional agencies to develop suicide prevention teams that will be responsible for building a strategic plan tailored to their region. The plans include steps to  1) prevent youth suicide by promoting positive activities, 2) intervene by identifying youth at risk and referring them to help, and 3) follow up in the wake of a suicide attempt. Plans are required to include Gatekeeper training, a “first responder” training that teaches paraprofessionals and community members how to identify risk factors and warning signs associated with suicide and how to connect youth at risk to community supports and professional resources. Other components of the plan are decided by each region. The Division of Behavioral Health, Prevention and Early Intervention Services section is coordinating the awards.
  • Comprehensive Behavioral Health Prevention and Early Intervention Services Grant. The Division of Behavioral Health, Prevention and Early Intervention Services section also is coordinating the Comprehensive Behavioral Health Prevention and Early Intervention Services Grant program which includes Alaska Careline, 24/7 crisis hotline and community-based suicide prevention projects and grant programs in both urban and rural/remote communities throughout the state. The section also coordinates  the Alaska Gatekeeper Suicide Prevention Training Program which trains instructors in the delivery of a suicide prevention awareness, education and intervention models to a  wide variety of both professional and community based health providers, youth serving organizations, Tribal organizations, educators, clergy, first responders as well as community members or laypersons.

Recent Challenges

  • Challenges facing these initiatives and strategies are how to balance identified needs and resources with the understanding that 1) suicide prevention requires a multi-faceted approach, integrated into Alaska’s continuum of care; 2) efforts must be targeted simultaneously at the community, family and individual level; and 3) for any of these efforts to be successful, there must be community involvement. That may require an assessment of readiness to address suicide prevention at the community level. Through capacity development at both the community and regional level, we can expect that suicide prevention strategies that utilize effective practices will be both culturally responsive and sustainable in the long term.
  • A key challenge is identifying and developing effective and accurate methods of data surveillance in the State in order to learn more about potential areas for improvement within the various systems of health care.  Local and community data could also help us understand community based processes that may rely on informal supports or services that often bridge the gap between medical models based on disease prevention and community prevention efforts that may rely more on public health models and the advancement or promotion of health and wellness. This is especially key in areas of the state that experience high rates of suicides and have little access to formal systems of care.

Alaska Tuberculosis (TB) Program

The Alaska Tuberculosis (TB) Program provides TB screening activities throughout the state. In rural Alaska the TB Program partners with regional Public Health Nurses and Community Health Aides to place TB skin tests and collect sputum samples. Villages where active tuberculosis has recently been detected are the highest priority communities.

Persons at highest risk for TB and latent TB infection are those with a history of substance abuse, mental health problems and those who are homeless. Some individuals face all three of these life challenges. The Alaska TB Program provides screening and any recommended treatment free of charge. Treatment for TB is delivered using directly observed therapy (DOT) where each dose of medication is observed by a DOT aide.  This service is also free of charge.

In Anchorage, the Alaska TB Program partners with the Municipality of Anchorage Department of Health and Human Services (MOA DHHS) to screen homeless persons. An outbreak of TB among homeless people began in 2006 and has involved persons with alcoholism and mental health diagnoses. The Alaska TB Program and the MOA DHHS have provided housing, TB medications, and DOT services free of charge.

Recent Accomplishments
 

  • The statewide TB rate remained stable in 2008.

Recent Challenges

  • Providing screening and treatment in rural and remote Alaska requires dedicated personnel and considerable funds.
  • It is sometimes difficult to find adequate mental health services for individuals, both those who are beneficiaries of the IHS system and non-beneficiaries who do not have insurance.
  • Persons who suffer from substance abuse and mental health problems can be non-compliant with screening and treatment recommendations.

Outcome Data

Summary information about tuberculosis in Alaska: 2004-2008

2004

2005

2006

2007

2008

No. of TB cases

43

59

70

50

50

No. of cases associated with outbreaks

0

0

28

9

6

Alaska population

656,834

663,253

670,053

676,987

676,987

Alaska case rate (per 100,000)

6.6

8.9

10.4

7.4

7.4

USA case rate (per 100,000)

4.9

4.8

4.6

4.4

4.2

Alaska population 0-14 years

160,722

160,376

160,168

161,576

161,576

No. 0-14 yrs old (% total)
(cases/100,000)

6 (14%)
(3.7)

7 (12%)
(4.4)

7 (10%)
(4.4)

4 ( 8%)
(2.5)

4 ( 8%)
(2.5)

No. foreign born (% total)

9 (21%)

17 (29%)

12 (17%)

8 (16%)

12 (24%)

No. homeless in Anchorage
(cases/100,000)

0
( 0)

1
( 25)

28
(650)

9
(225)

6
(150)

No. with isoniazid-resistant TB

2

2

2

0

1

No. with multiple drug resistant TB (MDR-TB)*

0

0

1

0

0

No. offered HIV testing (% of total)

33 (77%)

46 (78%)

51 (73%)

36 (71%)

31 (62%)

No. TB cases infected with HIV

2

0

1

1

1

No. drug use (IV & non-IV) (% total)

4 ( 9%)

2 ( 3%)

2 ( 3%)

6 (12%)

4 (8%)

No. excessive alcohol use (% total)

12 (28%)

8 (14%)

30 (43%)

20 (39%)

16 (32%)

Autism Initiative

The prevalence of autism spectrum disorders has increased dramatically in recent years.  A recent study by the Centers for Disease Control and Prevention suggests that 1 in 150 children have an autism spectrum disorder. 10

The Governor’s Council on Disabilities & Special Education formed an Ad Hoc Committee to develop recommendations for the administration and the legislature related to autism spectrum disorders.  This group identified and prioritized needs, developed recommendations for meeting high priority needs, discussed numerous issues related to identification, screening, and services for autism, and developed a strategic plan and timeline for meeting priority needs. The Committee’s top priority recommendations, which operate interdependently as a five-part package, include 1) universal screening; 2) expanded diagnostic clinics; 3) enhanced resources, referral and training; 4) workforce development capacity building; and 5) time-limited intensive early intervention.

Recent Accomplishments

  • As a result of the Council’s advocacy, the State Board of Education and Early Development added advanced nurse practitioners to the list of medical personnel that can make an autism diagnosis for special education purposes (adopted 6/12/09).
  • The DHSS Division of Public Health received a federal grant which focuses on increasing access to screening and diagnosis for children residing in rural and remote areas of the state. Children in these areas are typically diagnosed with autism one to three years later than children who reside in urban communities.
  • The Center for Human Development at the University of Alaska Anchorage has developed a system to assist and train advanced graduate professionals to secure national credentials as Board Certified Applied Behavioral Analysts (BCBA); board certification requirements include completion of five graduate-level courses, 1,500 hours of field experience and passing the national examination. Based on current population size, Alaska has need for at least 30 BCBA specialists. A program is also being developed to train undergraduate and paraprofessional direct service personnel. The first annual week-long Summer Institute for professionals and paraprofessional was held in the summer of 2009. In addition the Office of Children Services through its Early Intervention/Infant Learning Program will be offering training on evidence-based strategies to promote social and communication skill acquisition by very young children, starting in summer 2010.

Recent Challenges

  • Studies have shown that some children with autism who receive intensive, autism-specific intervention services (at least 25 hours per week) for three or more years, need significantly fewer, or even no supports as they progress through school and into adulthood. Currently, there are four ways families typically receive services: 1) through the Infant Learning Program up to age three; 2) through the school district from ages 3-21; 3) through the Division of Senior & Disabilities Services (home and community-based Medicaid waivers or grant-funded services; and 4) through private therapists and/or paraprofessionals. Recommended time-limited, intensive early interventions as described above are generally not available in Alaska. The Department is currently exploring a variety of options for providing time-limited intensive early intervention services (i.e., new waiver, modification of current waivers, provisions of the Deficit Reduction Act).
  • Some individuals with autism will require long-term supports available through a waiver. These services include but are not limited to social skills training, facilitated communications, positive behavioral support and intensive therapy services (e.g., speech/language therapy). These services could potentially be added to current waivers or some might be able to be included under existing services such as intensive active treatment.
  • Although more and more states are passing bills mandating private insurance coverage for autism, currently insurance plans in Alaska do not include coverage for autism. HB 187 and SB 250, if passed, will require private insurance coverage of autism services, including Applied Behavior Analysis, up to $36,000 per year through age 21.

Outcome Data

  • Recent autism diagnostic clinic data shows a 44% increase in children served over the 2007 baseline, which suggests that adding services and a provider were effective expansion tactics.
  • The Alaska Autism Resource Center provided general training to 1,750 individuals and provided information and referral services to approximately 3,000 individuals at 30 community health fairs.
  • A total of 15 individuals are being supported to secure their national credentialing as Board Certified Applied Behavior Analysts. It is anticipated that a new cohort of at least six individuals will begin their two-year studies in fall 2010.

Early Childhood Mental Health Cross-Systems (ECCS) Workgroup

The early years represent a period of tremendous opportunity and risk for children.  Although all periods of development are important, brain growth and development are most profound during the first few years of a child’s life. The foundation for intellectual, emotional and moral development established during these early years becomes the basis for future growth and learning.  Children who do not receive the care and nurturing required for optimum development early on may have difficulty making up for the lost opportunities later.

The more risk factors young children experience, the more likely they are to experience adverse mental health outcomes as children and to be negatively impacted as adults.  Neuroscience calls special attention to the potential risks to healthy social and emotional development for young children facing toxic levels of stress that accompany such things as abuse and neglect, traumatic events, and poor parenting.  According to the Office of Children’s Services, approximately 65% of the children in out-of-home placements in Alaska are children from birth through eight years of age.  In the 2004 Alaska Market Rate survey of child care programs, 38 percent of programs reported asking families to withdraw a child under the age of 6 with social/emotional problems. In FY 08, almost 18% of children enrolled in the Infant Learning Program had social/ emotional delays of 50% or more.  Alaska Medicaid data shows that in FY 07, 2621 young children below the age of 8 years had Medicaid mental health billings claims.

We know that we can intervene successfully to improve outcomes for children. Research and science have dramatically increased our understanding about the types of supports and programs that are helpful to young children and their families. There is no longer any question about the long term impact of early experiences on young children. The relationships young children have, the environments they live in, and the circumstances surrounding their families all influence the long term outcomes for children. 

Recent Accomplishments

  • The Early Childhood Mental Health Institute was held in May 2009 to improve the skills of mental health practitioners already working in the early childhood field. Training was provided on  “Responding to Infant and Early Childhood Mental Health Needs Within the Context of Relationships”, “Helping Young Children and Families Impacted by Trauma: A Components-Based Intervention Approach”, “Identification of Sensory Processing Difficulties and Intervention with Young Children and their Families”, and “Infant Mental Health and DIR Approach (Developmental,  Individual-Difference, Relationship-Based)”
  • The ECCS (Early Childhood Comprehensive Systems) Early Childhood Mental Health Cross-Systems Workgroup obtained approval for mental health providers to use the DC: 0-3R (Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood) to diagnosis children birth through five.  A cross walk from the DC: 0-3R to the ICD9 billing codes was created for Medicaid billing.
  • Many parents are working outside the home, and children are spending more and more time in out-of-home care.  Too often children with behavioral or social emotional concerns move from program to program because early childhood staff members are not trained to deal with their difficult behaviors and work with their families.  To address these concerns, an early childhood mental health consultation grant was awarded to Anchorage Community Mental Health Services.  ACMHS is working in partnership with thread (formerly Child Care Connection) to respond to requests from early childhood programs and parents in the Anchorage area with concerns about individual children. The intended outcomes for this project are to help to stabilize a child’s placement, increase the quality of care and link families to needed services. 

Recent Challenges

  • There continues to be a lack of understanding about the importance of addressing childhood mental health concerns as early as possible and about the long term impact when problems go undetected or unsupported.  When problems are not addressed, they grow in magnitude and severity, taking their toll on families and creating the need for more costly interventions later on.
  • There is a lack of funding directed toward this population.  Funding strategies need to be developed and utilized that include pooling or reallocating existing resources, integrating services into to programs that families typically use, bringing children and families into the service system early, and decreasing the need for more intensive services at a later date.

HIV/STD Program

Prevention and intervention activities undertaken by the HIV/STD Program for sexually transmitted diseases (STD) include surveillance of reportable conditions (chlamydia, gonorrhea, syphilis); support of screening and testing programs; ensuring treatment of all individuals diagnosed with a reportable condition; and partner services for STD. Additionally, the Program provides STD medical and epidemiological consultation, technical assistance, capacity-building services, and clinical and partner service training for health care providers in Alaska.

The HIV/STD Program funds partner services for newly reported HIV/AIDS clients and funds the targeted HIV prevention activities through grants to various agencies statewide. These efforts target those at highest risk to acquire HIV, programs in 2010 include: (1) targeting young and Alaska Native men who have sex with men (MSM) ; (2) targeted outreach to homeless and runaway youth, injection drug users, and heterosexual adults at increased risk; (3) HIV counseling and testing in community release centers and correctional facilities, and to social networks targeting highest risk individuals; (5) educational, support, and social groups for HIV-positive persons; (6) individual HIV prevention counseling for HIV-positive persons in medical care; and (7) social marketing campaign for rural Alaska on HIV prevention. HIV Care services are directed to individuals who are in need of medical care through state HIV care grants to community-based organizations for individualized case management; client advocacy; access to HIV-related medications; and payment for outpatient medical, dental, mental health, and other supportive services for individuals and families affected by HIV.

Recent Accomplishments

  • HIV/STD Program staff have established and enhanced HIV Care services through collaborative partnerships with public and private medical services providers across the state. Included are the Alaska Native Tribal Health Consortium Early Intervention Services for HIV Care, Anchorage Neighborhood Health Center, Interior Community Health Center (Fairbanks), Department of Corrections, and private medical providers. Coordination and collaboration across agencies helps individuals with HIV to receive comprehensive individualized medical services.
  • STD Program staff have built and maintained collaborative working relationships with numerous public, private, and non-profit agencies (Municipality of Anchorage Reproductive Health Center, Department of Corrections, Department of Education and Early Development, Alaska Native Regional Health Centers, Alaska Native Tribal Health Consortium, Planned Parenthood, Section of Nursing, Division of Juvenile Justice, etc.) to further our shared goal of reducing the burden of sexually transmitted diseases in Alaska.

  • The internet has successfully provided outreach, counseling, and referral to hard to reach MSM and high risk youth in Alaska.

Recent Challenges

  • Statewide delivery of STD services with an inadequate public health infrastructure continues to present a significant challenge for STD prevention activities.

  • Alaska may not be able to meet the demand of providing medication to all eligible individuals in the near future. There continues to be a growing population of individuals with HIV infection due to a longer life span for infected individuals and a steady rate of new infections each year. Newly approved antivirals are more expensive. The new treatment guidelines recommend starting individuals on antiretrovirals earlier in their infection; therefore more individuals are in need of increasingly costly medications.

Office of Minority Health Planning Project

The Office of Minority Health Planning Project is an initiative to increase the overall awareness of health disparities of racial and ethnic minorities in Alaska and assess the feasibility of establishing an Office of Minority Health within the Alaska Department of Health and Social Services.

In 2008 an Alaska site visit from the US DHHS Secretary and multiple conversations at local and regional levels resulted in resources for a feasibility study about developing an Office of Minority Health. In January 2009, the US DHHS Office of Minority Health awarded the Alaska Department of Health and Social Services a $50,000 one–year planning grant.  

The funds received from the United States Department of Health and Social Services (USDHHS) Office of Minority Health provide a framework for action to improve the health and well-being of racial, ethnic, and other disadvantaged populations in Alaska by: (1) increasing knowledge and understanding of health conditions and risk factors; (2) developing strategies in partnership with other entities to improve health promotion, disease prevention and access to quality health care; (3) assessing the need for and viability of an Alaska Office of Minority Health; and (4) improving partnerships for reducing health disparities. 

The Alaska HSS is making progress in identifying how it currently addresses minority health and how an “office” (or other entity) will enhance existing efforts.  The next phase of the planning project will provide clarity in how to define “minority” health and provide tangible and measurable goals and outcomes for a potential office.

Recent Accomplishments

  • State leaders have established a project working group with a varied representation across all minority health sectors throughout the State. 
  • Held and summarized key informant interviews conducted to 1) examine strengths and challenges in establishing an Office of Minority Health in Alaska, and 2) offer recommendations for next steps and further considerations. 
  • Compiled and documented current efforts, resources, and data

Recent Challenges

  • Concerns by key informants about (1) specifically designating an office to address racial and ethnic minority health, especially when DHSS has a variety of initiatives already designed to address these areas; and (2) the definition of a “minority” group needs clarification as persistent health disparities exist among the rural versus urban Alaska population.  Alaska is a diverse state with many unique challenges and it will be important to consider how to define and address minority health.
  •  Given the small state population and smaller racial and ethnic minority population, it is difficult to measure health indicators specific to race and ethnicity and assess the needs of other populations by geographic area (e.g. rural, urban communities), and special populations and disparities (e.g. seasonal workers, young children, elderly, gay, lesbian, bisexual, transgender, etc.) 

Senior Behavioral Health

Senior services providers report a growing number of clients experiencing serious behavioral health needs. Aggressive behavior and substance abuse are becoming more common and more problematic in settings such as senior centers and independent-living senior housing. Pioneer Homes and assisted living facilities are seeing more seriously mentally ill (though often previously diagnosed) individuals, and report that they are not prepared to serve these clients in a general population setting. When behavioral health issues overlap with ADRD, treatment is particularly difficult to locate.

Isolation, depression, and grief issues are also common among older Alaskans. Seniors often refuse to seek help from sources such as a community mental health center or a local Alcoholics Anonymous meeting because of perceived stigma. Special approaches are necessary to identify, make contact with, assess, and provide behavioral health services to seniors. In many communities, no programs are in place to meet these unique needs.

Recent Accomplishments

  • Funding was received beginning in FY 2009 for the SOAR (Senior Outreach, Assessment, and Referral) Project, an effort based in the Division of Behavioral Health (DBH) to use special approaches to target seniors in need of behavioral health assistance. The first SOAR grants to local agencies are being distributed in FY 2010.
  • The Trust has worked with Chugachmiut and SEARHC to implement IMPACT (Improving Mood, Promoting Access to Collaborative Treatment for Late Life Depression) and SBIRT (Screening, Brief Intervention, Referral to Treatment) programs, with pilot programs in Kake, Seward, Port Graham, and Anchorage Neighborhood Health Center (ANHC). (.  IMPACT and SBIRT are programs for depression and substance abuse, respectively, which combine the involvement of primary care physicians with behavioral health approaches. This model has been shown to be especially effective with seniors, who are less likely to seek help directly from more conventional sources. Between June 1 and July 31, 2009, ANHC screened approximately 225 patients for depression. 

Recent Challenges

  • Pioneer Homes are facing increasing pressure to find solutions in caring for residents with extreme behavioral health problems. They are not licensed to care for them, nor is API an option for long-term residential care.
  • A 2007 survey of assisted living homes indicated that administrators and staff are in need of training to help them cope with aggressive behaviors by clients experiencing ADRD or other behavioral health conditions.

Outcome data

SOAR, IMPACT and SBIRT service data will be available as projects come online.

Senior Fall Prevention

The Alaska Senior Fall Prevention Coalition, including the Alaska Commission on Aging (ACOA), began a senior fall prevention campaign in September, 2009. All Alaska senior centers received a fall prevention tool kit from the Coalition, including a poster, slideshow, checklists, and more. A new set of materials will be sent out regularly by the Coalition. The tool kit is also available on the ACOA’s website.

Accidental, and usually preventable, falls are the number one cause of injury to Alaskans age 65 and older, often causing serious injury such as brain trauma or hip fracture. Approximately one-third of older Alaskans will fall each year, and an average of 579 seniors will be hospitalized as a result. Even minor fractures increase a senior’s risk of dying within the next five to ten years, according to recent research. Falling and the fear of falling can lead to depression, loss of mobility, and reduced independence in seniors.

The Senior Fall Prevention Coalition encourages Alaskan communities to commit to reducing risks for seniors and people with disabilities by keeping sidewalks and parking lots free of snow, ice, gravel, and uneven pavement, and by offering education, home modification programs, and exercise classes to improve seniors’ strength and balance.

Traumatic Brain Injury Project

Every day someone is involved in a car crash, a fall, a sports injury or other incident that results in a traumatic brain injury (TBI) that alters the way he or she may live over a lifetime.  Alaska has one of the highest TBI rates in the nation. Of recent concern is a significant, but as of yet unknown, number of Alaskan service members returning with diagnosed and undiagnosed brain injury. With appropriate and available care, rehabilitation, community and family supports, even the individual who is most severely injured can live at home, return to school or work, or engage in meaningful and productive life activities.

Recent Accomplishments

  • The Alaska Brain Injury Network (ABIN) and its partners have begun an update to the 10 year state plan for TBI in Alaska.  The 10-year plan outlines strategies for reducing the incidence of brain injury and minimizing the disabling condition through the expansion of services and supports for TBI survivors and their families.
  • DHSS Senior and Disabilities Services and ABIN collaborated in the development of a state TBI Case Management Program, the first direct service program for TBI survivors administered by the Department of Health and Social Services.  Funded with MHTAAR, the program will serve adults with TBI who might benefit from case management services including service linkages and monitoring, problem-solving and compensatory strategies.
  • The Alaska Mental Health Trust Authority continues to grant funds to support the development of a comprehensive system of care for Alaskans with brain injury.  Grants currently support the Alaska Brain Injury Network to serve as the State TBI Advisory Board as well as provide information and referral to over 500 Alaskans.  Funds have also supported workforce development activities including the development of the distance-delivered “Introduction to Brain Injury” 3-credit academic course, which has been offered to 40 professionals, paraprofessionals, and consumers across the state.  Upcoming courses include a specialty workshop for vocational counselors and an advanced brain functions/case studies 8-week course for rural providers.
  • ABIN received federal funding to support the hiring of a TBI Program Coordinator, workforce trainings, and a TBI study focusing on regional data for Alaska Natives and non-Natives.

Other Examples of Current Initiatives, Projects, and Activities That Fill Service Gaps

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