Minnesota pioneers new mental-health treatment model, but it faces an uncertain future

A groundbreaking program that has improved the health of thousands of Minnesotans struggling with mental illnesses and addiction could soon be rolled out across the state, in what would be one of the broadest expansions of the state's community mental health system in decades.

The project flips the traditional health care delivery model on its head by bringing therapy directly to people in their homes and communities rather than forcing them to bounce between hospitals, medical clinics and psychiatrists. Minnesota is one of eight states selected by federal officials two years ago to develop the "one-stop shopping" model, using a statewide network of clinics to provide mental health therapy and addiction treatment.

Since then, nearly 20,000 Minnesotans have enrolled, with results showing early success at reducing rates of severe depression, costly hospitalizations and wait times for treatment.

Yet the new model faces an uncertain future. The federal funding that made it possible is set to run out by the end of June, which could trigger staff layoffs and reduced access to care. Gov. Tim Walz has proposed expanding the program's reach across Minnesota and making it a permanent part of the state's package of Medicaid benefits — a dramatic expansion of what has now been an experimental program. The proposed expansion would cost nearly $23 million through 2023, state officials estimate.

Republicans in the State Legislature are raising alarms over creating a new health entitlement at a time when the state is struggling to meet the care needs of a rapidly growing population of poor, elderly and frail people on Medical Assistance, the state's version of Medicaid. The program has not kept pace, for example, with the burgeoning demand for home care services and a severe shortage of care workers.

"This is not the time to be expanding the Medicaid system, not at all," said Sen. Jim Abeler, R-Anoka, chairman of the Human Services Reform Finance and Policy Committee, who is sponsoring legislation that would place limits on benefits. "We are on the verge of the collapse of our disability services because of workforce shortages ... and this would further destabilize the system."

Still, advocates argue that the state's mental health needs are great: More than 200,000 adults in Minnesota have a mental illness so serious that it impairs their daily ability to function. Deaths from suicide, opioids and alcohol have been rising in Minnesota since 2000 — with suicides and opioid deaths reaching record levels in 2017. If the "one-stop" program is expanded, advocates argue, it will save lives while reducing burdens on hospital emergency departments and county jails.

"We really have to do a better job meeting people where they are," said Human Services Commissioner Tony Lourey, who as a legislator sponsored a bill that led to the creation of the pilot program. "If we segregate all of these [services], we will most likely fail on every front."

Traditionally, patients suffering from mental health and substance use disorders have had to navigate a Byzantine system of primary care clinics, treatment plans and eligibility requirements in order to get help. In some parts of the state, wait times to see a psychiatrist can be up to three months. To complicate matters, people with both mental illness and substance addictions typically have to visit different clinics, with specialists who rarely talk to each other, advocates say.

As a result, many Minnesotans with mental illness seek care only when they experience a crisis, and end up in an ER or county jail, according to a 2016 report by a state task force on mental health.

Concerned that people were falling through the cracks, Minnesota in July 2017 began rolling out bundled health services through six community clinics, known as Certified Community Behavioral Health Clinics. Previously isolated services such as outpatient mental health therapy and primary care screenings were brought under the direction of coordinated care teams.

For the first time, patients could get multiple health needs met by a single provider. If they suffered from anxiety or were too ill or depressed to leave home, specialists would make house calls. People Incorporated, a St. Paul-based nonprofit and the largest of the clinics offering the new services, has sent outreach workers to meet clients in homeless shelters, detox centers, county jails and coffee shops.

"We have met with people anywhere and everywhere," said Jill Wiedemann-West, chief executive of People Incorporated.

The program also improved Medicaid funding for the participating clinics. The six clinics selected to offer the new bundled services have ramped up quickly to meet surging demand. During the first year of the pilot, they hired 167 new staff members, including psychiatrists, addiction specialists and peer counselors.

To date, the project has served about 17,000 children and adults in 18 counties, with early data suggesting that many may have gone without treatment for years.

"This is transformational," said Beth Krehbiel, chief executive of Zumbro Valley Health Center in Rochester, one of the nonprofit clinics providing the bundled services. "You can do what you absolutely need to do for the client, and tie everything together in one team and one plan."

Jackie Skjonsby of Coon Rapids credits the program with saving her life.

Last month, Skjonsby was on medical leave for a back injury when she learned that her position as a laboratory technician was being terminated. Skjonsby, who has a history of anxiety stemming from childhood trauma, said she suffered "a severe panic attack" as she sat amid a pile of unpaid bills in her kitchen. She began having suicidal thoughts, and told her son she was planning to throw herself on the railroad tracks behind her home.

"I felt like I was out in the middle of an ocean and no one would throw me a life preserver," she said.

That afternoon, Skjonsby called a crisis line and was told that a bed was available at a nearby residential center. Within 48 hours, a care coordinator from People Incorporated arrived and helped her sign up for state health insurance and Social Security benefits, and began scheduling therapy with a psychiatrist. Since she returned home, the care coordinator has stopped by three times to help with benefits paperwork.

"Sometimes, when the depression is severe, it's hard to even get out of bed," Skjonsby said. "To have someone come to your house and talk person to person is absolutely lifesaving." She added, "Medicine has not been run this way for a long time."

The project's early results have been promising: At four of the clinics, rates of severe depression have declined 28% among those enrolled. Hospitalizations have been reduced substantially across this patient population. Clinics have also cut average wait times for the patients' initial evaluation, from 20 days to 13, a change that can be lifesaving for people in mental health crises.

Even so, time may be running out for these new clinics and their patients. In addition to Walz's proposal to expand the program, the clinics need federal approval and matching federal money to continue operating after the pilot program ends June 30. Mental health advocates and a bipartisan group of lawmakers are pushing federal legislation that would extend the funding for another two years and expand the program to 11 other states.

If that fails, Krehbiel warned, "it would mean a return to piecemeal, fragmented care. And that has never been enough."

Chris Serres • 612-673-4308 Twitter: @chrisserres