Health Policy Solutions

By Moe Keller

The staff and board of directors of Mental Health America of Colorado (MHAC) send our most profound condolences to those who lost their loved ones in the tragic shooting in Newtown, Conn. No words can justly describe the loss they have suffered.

We can never know what was happening in the mind of the young man who committed the shooting in Newtown. What we can and must do is remember that our collective response to atrocities like these defines us.

At MHAC we believe the key to keeping our children—and all of us—safe from acts of mass killing involves a multipronged approach that includes prevention, access to services for the treatment of mental health conditions and substance abuse use disorders, and restricting access to guns and ammunition from individuals with the potential to commit violent acts.

Preventing gun violence means requiring a comprehensive and universal background check of both the buyer and seller in every single gun purchase in America. Preventing mass killings also means addressing the prevalence of semi-automatic assault weapons.

In Colorado it is easier to purchase an AR-15 assault rifle, the one used by the shooter in Newtown, than it is to access high-quality, affordable mental health and substance use disorder treatment in the community.

According a 2011 report by AdvancingColorado’s Mental Health Care, one in four Americans and 1.5 million Coloradans are in need of behavioral health care.

Categorizing such a large percentage of Americans and Coloradans as dangerous because they have a mental health diagnosis is inaccurate.

“The vast majority of people with psychiatric disorders do not commit violent acts,” said Dr. Richard Friedman, M.D., in an article in the New York Times.

Mental health treatment is essential to this sort of prevention effort. Because treatment works and can help prevent some people from doing harm, however, does not mean we can equate mental health conditions with violence.  The reality is that individuals diagnosed with mental health conditions are four times more likely to be victims of violence, according to the World Health Organization.

Further stigmatizing the idea of having a mental health diagnosis discourages people from honestly and openly discussing their mental health and seeking treatment when they need it.  We have to transform the way people think about mental health. We have to teach our kids that it is not only all right, but good and brave to talk about their feelings and their thoughts—no matter what they are—with people who want to help them.

It is important to speak using person first language and identify individuals with mental health challenges as people first instead a generic population defined by a health condition. Research demonstrates that two-thirds of individuals who are diagnosed with mental health conditions, including those with more serious conditions, recover. Unfortunately, the vast majority of media attention is focused on those that continue to be challenged by their mental health issues.  We have to appreciate and celebrate those who seek help and overcome their challenges.

It is essential that we have the resources to get individuals appropriate and affordable mental health care when and where they need it. Colorado ranks near the bottom on per capita mental health funding. Colorado’s largest provider of psychiatric inpatient services is its Department of Corrections; the next largest is the system of county jails. In order to have the resources we need to practice prevention and early intervention, we need to dramatically change the way we respond to individuals with mental health conditions.

MHAC is thrilled that the governor and the Division of Behavioral Health are making serious and smart investments in mental health.  Gov. Hickenlooper has proposed $18.5 million in new funding for mental health systems in Colorado in his 2013 budget. The budget request would expand the capacity of the state’s Division of Behavioral Health, establish a statewide crisis response hotline and crisis centers throughout the state, and expand the use of trauma-informed models of care in Colorado.  Our behavioral health system, as we can all see so clearly, should be front and center as we talk about how to create a stronger and safer Colorado, and let us not forget: a more just and equitable Colorado.

If we focus on prevention in the form of investments in mental health, we will see benefits everywhere from our budgets to our street corners. If we intervene early in the lives of our children and teach them to talk about their mental health and reduce the stigma associated with mental health conditions, we will have a healthier and more productive community.

MHAC’s challenge to the Colorado Legislature, to the U.S. Congress, to every elected official and policymaker in this country is to start taking measures today to ensure that the behavioral health needs of all are met and we are responsibly addressing issues that contribute to violence in our community.

Moe Keller is vice president of public policy and strategic initiatives for Mental Health America of Colorado.

By Katie Kerwin McCrimmon

Gov. John Hickenlooper is calling for an $18.5 million increase in state funding to strengthen mental health in Colorado with instant mental health updates available for gun background checks, a statewide 24-hour phone crisis hotline, walk-in mental health centers and a new streamlined commitment law to make Colorado communities safer.

Acknowledging that emotions are still raw over the mass killing Friday of 20 first-graders and six educators in Connecticut, Hickenlooper said the mental health overhaul — which will require legislative approval — has been in the works since two days after the Aurora theater shootings last July.

“The common element of so many of these mass homicides seems to be a level of mental illness” of the shooters, Hickenlooper said. “What happened in Newtown is beyond comprehension. After Aurora, I thought we’d never see something that would cause such deep despair.”

While there may be some disagreement about how gun control can help prevent mass killings, Hickenlooper said there’s clear agreement that better access to mental health will help keep patients, families and communities safer.

“Mental health seems like the one point that’s not controversial,” Hickenlooper said. “It connects to almost all of these terrible tragedies.”

Among the changes, the overhaul would:

• Create a new, more potent civil commitment law.
• Authorize Colorado’s courts to transfer mental health commitment records directly to the Colorado Bureau of Investigation in real-time so the information is available for firearm purchase background checks conducted through Colorado’s InstaCheck system. Currently the court system transfers data via CD just twice a year.
• Establish a new $10.3 million crisis response system including a statewide mental health crisis hotline and five new 24/7 walk-in crisis stabilization centers for urgent mental health care.
• Provide mental health care to jailed inmates in the Denver area through a 20-bed, $2 million center.
• Support people leaving mental health institutions through a $4.8 million program to establish better community care. (To view full details of all the proposed changes, click here.)

Flanking the governor as he made his announcement at the Capitol on Tuesday were mental health advocates and leaders from state agencies ranging from public health to corrections and human services.

They included former Colorado First Lady Jeannie Ritter, who has been fighting for better programs for the mentally ill for several years. While Hickenlooper’s overhaul only begins to restore dollars lost from mental health care during the recession, Ritter said the improvements offer a promising start.

“This is an issue whose time has come. It has percolated to the top,” Ritter said, noting that the horrors of both the Aurora and Newtown tragedies have focused unprecedented attention on mental health needs. “This is a start. People are sitting up and listening.”

Ritter said she’s pleased that Hickenlooper’s plan focuses on prevention.

“It’s readiness. It’s resources. We don’t want to continue on a path that’s totally crisis-driven.”

Ritter said insurance companies will need to do a much better job of reimbursing people for mental health care and hospitals will have to add back beds for mental health care even though those beds aren’t nearly as profitable as beds for cardiac care, for instance.

“I really believe this is the place to house these conversations and to get insurance companies to step up,” Ritter said. “Let’s help craft something. We know earlier interventions pay.”

Hickenlooper also said the pendulum may have swung too far after the movement in the 1970s and 1980s to deinstitutionalize hundreds of thousands of patients previously cared for in mental hospitals. The recent trend across the country to eliminate “psych” beds in hospitals is a problem, Hickenlooper said.

“Hospitals have shed entire wards. This is a trend we’ve seen all over the country and it’s been going on for decades,” Hickenlooper said.

While it’s less expensive and perhaps more humane to help many of the mentally ill in the community instead of in hospital wards, Hickenlooper said “it’s a legitimate question: Has the pendulum swung too far?”

While the governor acknowledged that we will never have a “failsafe system” for preventing mass killings, Colorado can do far better when it comes to mental health care.

“Whether or not you or someone in your family is in crisis…this plan is going to help deliver support services to people sooner and thereby be focused on prevention, reducing the probability of bad things happening to good people,” Hickenlooper said.

By Katie Kerwin McCrimmon

The woman is missing most of her teeth, but grins like a 6-year-old at a birthday party.

Unsteady on her feet, the 48-year-old homeless woman nonetheless proudly describes the meaning of the famous Emanuel Martinez mural outside Denver’s La Alma Recreation Center.

“The young Chicano man is the future. The Indian is our past,” says Gina Marie Crespin, who grew up in the Lincoln Park area and now spends her days in the neighborhood park.

“The eagle is power,” Crespin says, pointing to the center of the mural where the soaring bird’s wings spread to form two female figures and a brilliant blue butterfly springs from its chest. “That lady is the sun. The other is the moon.”

Crespin then points to the bottom of the mural and shivers.

“That skull, that’s death. It’s scary. The other side is a newborn baby.”

The dualities in the mural echo the opposing forces in this park, in this neighborhood and even in Crespin herself. On the one hand, she’s poetic. On the other, she is broken. On the one hand, poverty and crime have shattered this area. On the other, a $125 million redevelopment here aptly named Mariposa — butterfly in Spanish— is becoming a model for Colorado and the nation on how to build a new kind of community for the most vulnerable people where health is the cornerstone for all decisions and all new designs.

Asked about this effort, Crespin says she has one big health problem.

“I’m an alcoholic. I’m missing in action.”

Poverty, poor health grip neighborhood

Crespin is not alone in her struggles. By many measures, this neighborhood faces overwhelming challenges.

Poverty rates in the Mariposa area are nearly triple the average in Denver: nearly 40 percent compared to about 14 percent across the city.  More than half of children here are born to single, impoverished mothers. Graduation rates hover at just 12 percent and on standardized tests, the majority of students receive “unsatisfactory” scores. About 95 percent of students qualify for free and reduced-price lunches. Nearly half of residents are Latino, 41 percent are African immigrants or African-Americans, and almost all of the others are Anglo.

Residents exercise during health class at the new Mariposa public housing development in Denver.

Health problems are rampant. More than 55 percent of residents are overweight or obese. More than 38 percent report a health condition that prevents them from working, such as asthma, diabetes or heart problems. Three-quarters have high blood pressure. Few eat a healthy diet and only one-in-four residents exercise at least three times a week.

Lincoln Park itself, which should be the jewel of the neighborhood with its colorful playground and mural, its own recreation center and a large outdoor pool, has been a liability more than a health magnet for some. More than half of neighborhood residents report feeling afraid of violence in the area. They say the park is often filled with drug users and homeless people.

Still, Mariposa is tapping its rich history as a cradle for Latino power and Denver’s civil rights movement, its enviable location close to downtown, bike paths and light rail and is recasting itself as a “holistically sustainable, mixed-income, mixed-use transit-centered community.”

“La alma means soul,” said Denver Councilwoman Judy Montero, who represents this area and has fought hard to preserve its assets, like the recreation center, recently targeted for closure. “There’s a real sense of community here….During the civil rights movement, this was ground zero for a lot of activism, and because of that activism, the neighborhood continued to thrive.

“This is a national project that people are watching now,” Montero said.

When the redevelopment is completed by 2018, the new buildings here will have naturally-lit central staircases and giant bike storage closets inside the units to inspire people — 65 percent of whom don’t have cars — to continue walking, cycling or using public transportation. There is easy access to borrowed B-Cycle bikes and residents can get free passes for light rail.

Art and pocket parks aim to boost mental health and offer safe spaces for both children and adults to exercise outdoors. Community gardens will allow residents — many of whom are new immigrants from Africa —to grow their own produce.

Planners are trying to use trees, plants and traffic calming measures to make it easy and inviting to walk along a promenade from the light rail station at 10^th and Osage to the neighborhood’s art district on Santa Fe.  School officials are hoping to establish “walking school busses” to help adults and children get exercise and walk safely to school.

And, at the first completed building known as Tapiz at Mariposa, an ultra green 8-story public housing center with 100 units for elderly and disabled residents, people in the neighborhood gather regularly for classes on heart health and controlling diabetes.

Next door is the Osage Café, which is open to the public and boasts a state-of-the art kitchen and training academy for the Youth Culinary Academy. The center aims to train the next generation of chefs while teaching residents to cook healthier, less-expensive food from scratch. A collection of bright green Adirondack chairs have become a popular gathering spot next to the café. Their location is quite deliberate. Developers wanted to attract people to sit outside here both to create a gathering spot and so residents could become new “eyes on the street” directly across from the neighborhood park.

The ground floor of Tapiz also boasts a new community center with job training and health classes along with a permanent space for Arts Street, a nonprofit that serves young people in the area.

Residents stretch during a health class at the new Mariposa development.

Altogether, Mariposa will replace about 270 low-slung townhomes built in the 1950s with about 800 new housing units and 70,000 square feet of new commercial, retail and community spaces.

Housing Authority on cutting edge with Health Impact Assessment

In 2009, when developers from the Denver Housing Authority worked with neighborhood partners, residents and consultants to dream up a new master plan for the Lincoln Park/La Alma neighborhood, they became one of the first 20 or so entities in the U.S. to conduct what’s known as a Health Impact Assessment (HIA). Long popular in Europe but new to the U.S., HIAs aim to identify how a project or redevelopment will impact health.

Then in 2010, as reconstruction began, DHA developers ignited another health revolution. They decided to hold themselves accountable for improving health with every decision they made. They wanted to measure their success or failure and became on of the first in the country to use what’s called the Healthy Development Measurement Tool (HDMT). The tool measures health broadly from healthy housing and transportation to the economy, environmental stewardship and social cohesion — even how amenities affect people’s well-being

Erin Christensen, a consultant from Seattle for the sustainable design firm, Mithun, has worked on the redevelopment with Denver Housing Authority senior developer, Kimball Crangle. Christensen had heard about the concept of a health measurement tool and borrowed it from the San Francisco Department of Public Health, which had pioneered the idea. The Denver Housing Authority then became one of the first entities in the country to use the full-fledged health metric tool as the underpinning for an entire redevelopment project.

“It’s fairly unusual to use the tool in such a comprehensive way,” Christensen said.

Denise Payne and Katrina Aguirre teach a class together on heart health. Says Aguirre: “Just because we’re low-income doesn’t mean we can’t live healthy.”

Initially, developers used the HDMT to test various scenarios for how to rebuild the projects. They analyzed how competing designs would impact health and found, for instance, that many smaller green spaces would be healthier for residents than building one large open space. They also decided not to put exercise equipment in the new buildings, but rather to encourage people to support their existing community amenities and walk to the nearby recreation center.

“It’s such a part of our thinking,” said Crangle. “Every decision we make is filtered through a lens of health and the built environment: where we put spaces, who we partner with.”

Crangle has leveraged funding from multiple sources including $22 million from the U.S. Department of Housing and Urban Development, a $10 million stimulus grant, EPA awards and state and city funds. The Colorado Health Foundation also awarded the Mariposa project $757,000 to implement the healthy development tool and use design to improve health.

The area eventually will boast a greenhouse to provide a year-round gardening site, a walking path with art along the way and its own healthy living coordinator.

“A lot of times, health obstacles exist because people don’t know how to get involved. By having this liaison, you remove huge barriers and help people take charge of their health,” Crangle said.

Arts and culture support health

Both because of the area’s ties to the Chicano mural movement and to the Santa Fe Arts District, Crangle and Christensen learned during more than 100 meetings with residents and partners that art was central to health in this neighborhood.

Tonita Montoya, left, and Cheryl Jackson act out reactions to chest pain during a health class at Mariposa. Jackson, 53, had a real heart attack in August. “I was at home by myself. I live alone and don’t have a phone,” Jackson said. She felt terrible, but couldn’t get help until the next day. “I lay on the couch and prayed and cried. I had no way to call nobody.”

“Prior to this, I hadn’t thought about the connection of health to things like social cohesion, culture and art. Access to arts and culture promotes mental health. It’s fascinating to see that connection,” Christensen said.

Moving forward, the health tool will now guide a new effort called the Mariposa Healthy Living Initiative. It includes five campaigns: Get connected, healthy places, healthy eating, health care and wellness and lifelong learning.  The new initiative includes a report card of indicators to track progress along with tool kit so other communities can incorporate health into future redevelopment projects.

“Our goal is to create a user-friendly implementation tool and guide that can be used by developers, designers and community service providers to easily incorporate health,” Christensen said.

In years past, developers rarely considered how designs would impact health. As a result, the U.S. created sprawling suburban neighborhoods where driving has been a necessity and the obesity epidemic has exploded.

Improving health in public housing has become a hot topic in recent years, Christensen said. But, most efforts elsewhere in the country have narrowly focused on specific problems, such as better construction to prevent asthma or classes to improve heart health.

In Colorado, only six Health Impact Assessments have been done to date. For DHA to complete one of the first 15 or 20 in the country was notable. But, then to take the next step of implementing the health tool marked a second groundbreaking achievement, experts say.

“Their commitment to asking the hard questions and potentially making changes to their plans if they’re not seeing the metrics change, that’s what sets this apart from anything else I’ve seen in the state of Colorado,” said Jessica Osborne, one of two built environment coordinators for the Colorado Department of Public Health and Environment.

The scale of the Mariposa project makes it unique. And it targets people who need a health revolution the most.

“It’s serving a vulnerable population that has experienced a lot of disparities,” said Gretchen Armijo, the other built environment coordinator for the state health department, who also teaches classes at the University of Colorado Denver on HIAs.

She said the growing interest in health impacts is linked to the obesity epidemic.

“It has gotten our attention at a national level, at a state level, not just as a public health issue, but as an economic crisis. There seems to be an urgency to address this,” Armijo said.

This year, the first national conference on HIAs took place in Washington and just last week, Kaiser Permanente Colorado announced a $250,000 grant in concert with the Robert Wood Johnson Foundation and the Pew Charitable Trusts to support a new health impact project in Colorado.

‘Imperfect’ community health workers teach heart health

At Mariposa, health transformations are already under way.

Meet Tyechia “Denise” Payne.

A former resident of the Lincoln Park projects, the mother of four now lives in Park Hill, has taken up bike riding, lost 100 pounds since last fall and teaches a weekly health class at Tapiz at Mariposa.

“I was living in poverty. I didn’t have a lot. I decided I needed to do something with my life,” said Payne, 29.

Housing authority workers saw Payne’s potential and tapped her for training to become a community health worker. She and fellow resident, Katrina Aguirre, traveled to St. Louis to be trained in a HUD health program called With Every Heartbeat is Life.

The two now teach classes to Mariposa residents covering a range of topics from learning signs of a heart attack to cooking heart-healthy food on a budget.

The teachers are first to admit that they are not perfect. While both are eating much healthier meals, both still smoke. Aguirre has a thing for Pepsi. Payne loves McDonald’s. She just gave it up for good three weeks ago, but still craves her favorite menu items like the sausage biscuit.

Her humility makes her an engaging teacher for the students, one of whom noted in his food diary that he ate corn flakes with Pepsi for breakfast.

“They don’t have to listen to some doctor who’s perfect,” said Shaina Burkett, the housing authority worker who tapped Payne and Aguirre.

“I tell my students the real me so they’re not in it alone,” Payne said. “We encourage each other. It’s mind over matter. I’m here for a reason. Maybe I haven’t found that reason yet, but I need to be healthy enough to be here for that. I could be very important to someone I don’t know yet.”

Aguirre is living in the Lincoln townhomes that haven’t been torn down yet. Her youngest child is 8 and the older two are teenagers. Until the redevelopment, she said she was sometimes afraid to let her children walk a block and a half without her to their dad’s house.

“People would make trouble,” she said. The attitude among residents is changing.

“More people are not afraid. We want our neighborhood back. We can’t let our children see this (chaos) every day of their lives,” she said.

More of the current residents are willing to learn about being healthy.

“This class is bringing in a whole new light to people here. Just because we’re low-income doesn’t mean we can’t live healthy. I’m low-income. I have food stamps. I am still able to make healthy changes,” Aguirre said.

To entice the residents to take part in the class, DHA healthy living coordinator Elizabeth Rumbel brings healthy snacks and hands out donated prizes like King Soopers gift cards or tickets to museums at the end of each class. Residents who complete the full series of health classes receives a $150 payment.

“Incentives and free food work. Word of mouth works. Half of the people are in this class because a friend did it,” Rumbel said.

Having teachers like Aguirre and Payne also makes a big difference.

Elva Chavez has lived in the Lincoln Park neighborhood for 25 years. She raised grandchildren, one of whom survived a stabbing in the area. Chavez has fought diabetes by attending regular health classes. She has lost 75 pounds and now lives in a one-bedroom apartment in the Tapiz building. She calls it her “penthouse.”

“They have the biggest sense of compassion. In addition to their knowledge, they care about the people who come to class.”

In addition to sharing her food cravings, Payne is open about violence she has experienced. That gives her common ground with many of the residents.

“I experienced domestic violence,” she said. “That was horrible. I’m good now. Losing weight brought out a little more sunshine. I use that and try to give it to other people.”

‘In heaven in my penthouse’

Elva Chavez, 61, has lived in the Lincoln Park neighborhood for 25 years. She has raised several grandchildren, one of whom was stabbed during a street fight on July 4, 2003.

“He went out with a friend. I said, ‘Don’t go.’ It was a fight over a cigarette,” Chavez recalled.

Her grandson returned home pale and weak and slumped to her kitchen floor with a dagger still in his back.

“Since then, I’ve had diabetes,” she said, attributing her own health woes to the shock.

Her grandson recovered, and little by little, Chavez thinks the neighborhood is also beginning to heal.

Chavez has participated in many of the redevelopment meetings and was one of the first residents to live in the new Tapiz apartments. A survivor of child abuse and a recovering alcoholic who started drinking at age 8, she can’t believe her good fortune to live in such a beautiful, safe building. She calls her small one-bedroom unit her “penthouse.” The windows face west over the rail yards with a view of the mountains beyond. The walls are filled with photos of her grandchildren. On the stove, she is cooking chicken soup, full of vegetables. A new healthy diet and long walks have helped her lose more than 75 pounds since she was first diagnosed with diabetes.

Chavez takes advantage of weekly nutrition and diabetes classes that take place right in the lobby of her building and proudly has her diabetes under control.

A new 8-story mural at the Mariposa development shows both an African and a Latino woman.

On the outside of Chavez’ building, a giant new 5,000-square-foot tile mural fills an eight-story canvas. Titled “La Alma de la Mariposa” by Denver artist, Jeremy Ulibarri, the graffiti-inspired mural features a Latina woman and an African woman with a Somali head wrap.

Together, the women symbolize the butterfly taking flight here at Mariposa, a rebirth intricately tied to health.

“Our hope is that this will be a neighborhood where people live who want a healthier lifestyle in green buildings. They will not be auto-dependent. They will want rich amenities at their fingertips and will be active and engaged in community events,” said Crangle of DHA. “They will want to be in a neighborhood that is culturally grounded with a strong sense of heritage.”

By Katie Kerwin McCrimmon

“Frequent flyers” at hospital ERs sought emergency care at least four times a year and accounted for anywhere from 11 to 40 percent of total emergency room visits around the U.S., according to seven new studies unveiled this week at the annual meeting of the American College of Emergency Physicians in Denver.

In one of the studies, researchers in San Diego identified a group of “super users,” each of whom visited an ER 21 or more times in a single year. These patients bounced from hospital to hospital. While they represented just .2 percent of all patients, they accounted for 4.5 percent of all emergency department visits in the region.

The new studies found that frequent users typically have serious medical issues.

Many have mental health and substance abuse problems. Most are likely to have government health insurance through Medicare or Medicaid. It’s a misconception that most ER users are uninsured. And while some are addicted to pain medications, many have other health problems.

The studies — which sprang up separately and were not coordinated — defined frequent users differently, ranging from those who came to ERs at least four times a year to those who came seven times. The studies did not analyze the total costs that the patients incurred, but emergency physicians say the patients clearly need more, better-coordinated care, not less access to care.

Dr. Andy Sama, president of the American College of Emergency Physicians, left, and Dr. Robert E. O’Connor, an emergency physician at the University of Virginia, share findings from seven studies on ER “frequent flyers” during the annual meeting of emergency physicians in Denver.

“This is a finite number of people,” said Dr. Robert O’Connor, an emergency physician at the University of Virginia’s Medical Center in Charlottesville and author of one of the abstracts unveiled Tuesday. “In Wisconsin, the extreme high-end users (amounted) to 39 patients. You can come up with 39 individual treatment plans so patients receive the best care. It’s not as if we’re trying to bar these people from coming in to emergency departments. We’re trying to optimize their care.”

O’Connor attributed the burst of new research to digital health records that make it easier to track frequent users. Cost for care is also critical. As of Oct. 1, hospitals face penalties if patients are readmitted within 30 days of release. The fines do not apply to emergency departments if patients show up seeking care, but do not need to be admitted. Even so, health policy experts are keenly focused on learning about frequent users and reducing their visits and costs to health systems.

The trend has come to be known as “hotspotting” after Dr. Atul Gawande highlighted the work of pioneering New Jersey family doctor, Jeffrey Brenner, in the New Yorker in 2011. (Related: Hotspotting health revolution comes to Denver  and Saving the mentally ill, saving taxpayers. Throughout health care systems, researchers are now trying to use sophisticated data-mining to identify the most expensive patients and find better ways to care for them while cutting costs.

As more elements of the Affordable Care Act get implemented, emergency doctors expect use of ERs to increase since as many as 40 million previously uninsured people may flow into the system. In Massachusetts, after the state required all individuals to get health insurance, ER usage increased, O’Connor said.

In his own study in Virginia, O’Connor found frequent users who were admitted to the hospital were significantly more likely to be readmitted after 30 days. His study and the one from Wisconsin found, however, that patients who were frequent users did so for a relatively brief period — only a year or two. Results were mixed on whether repeat users were more or less likely to be admitted to the hospital from the ER.

O’Connor said ER doctors want to be able to work with health partners in the community who could reduce hospitalizations and help patients for less cost. But, when  patients show up in the ER late on a Friday night and the ER staff can’t coordinate with home health providers or ensure that patients will get the medication they need, doctors sometimes have little choice but to admit them.

O’Connor and Dr. Andy Sama, an emergency physician from New York and president of the American College of Emergency Physicians (ACEP), said frequent ER users are often demonized as abusers of the system when in fact they represent a small percentage of the total number of emergency patients and most seek care when they need it.

“Despite the widespread belief that these patients can be directed elsewhere, these patients for the most part need to be treated when they come in,” O’Connor said.

What’s more, the people showing up now in ERs may be the sickest of the sick since a raft of new urgent care centers may be attracting people with easily treatable respiratory infections or broken bones.

“If you have a sick population, it’s unfair to the patients and the hospital to penalize them for readmission rates, O’Connor said.

As policymakers struggle to cut costs in health care, ERs and hospitals receive the most blame for giving patients inefficient, high-cost care. But Sama said ER costs amount to just 2 percent of all health care costs in the U.S., according to an ACEP study.

“When you consider that we have 136 million contacts a year, only spending 2 percent is a pretty good return on investment,” Sama said. “These frequent users have complex medical problems, limited access to primary care, significant psychiatric complaints and are often dependent individuals with limited access to funds, poor living circumstances and difficulty in getting care.

“Our charge is to find better solutions for these patients. Our job is to solve their problems,” Sama said.

Potential solutions are springing up across the country. Among the most promising are home visits from nurses and health coaches who can help people with chronic problems stay healthy. New technology may also enable home health workers to transmit  patients’ vital signs directly to their doctors to better track them and avoid unnecessary hospital visits.

O’Connor said he and his colleagues need much better coordination with community programs and 24/7 access to digital health records. For instance, if a patient arrives at 3 a.m. and says a recent x-ray taken outside the hospital shows a problem, but O’Connor can’t access images, he has to order another x-ray in the hospital. That takes time and costs money. He also said it would be tremendously helpful to have instant access to a patient’s entire list of current and past medications along with notes from other providers.

ER doctors often have to start from scratch every time a patient comes in for care even if that patient is a “frequent flyer.”

O’Connor said the most promising improvements may come from viewing ERs as a hub and spoke model. The ER is the hub at the center of care, but spokes must reach out to various community partners who will help ensure that fewer people need full-fledged ER services.

“If we had better access to immediate resources, I think we could save the health system significant amounts of money,” O’Connor said.

Sama said much better mental health care systems would be a huge help to emergency physicians since so many patients come in with severe psychiatric problems.

Throughout the country, some new promising programs are coming through coordination with ambulance services.

In Colorado’s Eagle County, for instance, paramedics are not waiting for the sick to call them. They are working with doctors to arrange house calls to check up on patients and cut ER visits.

In Fort Worth, Texas, EMTs are identifying their frequent callers.

“A small percentage call 15 or 20 times a year. That becomes an issue for EDs (emergency departments) and ambulances, tying up services,” said Dr. David Ross, an emergency doctor at Penrose-St. Francis Health Systems in Colorado Springs who is also medical director for an ambulance company there.

Ross said in Fort Worth, paramedics found that people sometimes call for an ambulance when they’re depressed and don’t have an actual medical problem.

“Sometimes the (paramedics) will just go and visit them,” Ross said.

In Colorado Springs, paramedics are experimenting with a checklist that can reduce the number of alcohol abusers who end up in ERs. In the past, paramedics routinely took people who were drunk directly to the ER. They needed a medical checkup before they could be transported to a less-expensive detox center.

Starting in 2003, paramedics used a simple checklist to determine if patients really needed medical care or if they just needed to dry out. The two most important items on the checklist were whether a patient could walk and if the patient would consent to a physical exam. Paramedics found that they could safely bypass ERs for patients who could walk on their own and cooperated with care in the field.

In Colorado Springs, Ross said paramedics are now able to transport about 150 patients a month directly to detox rather than sending them all to ERs.

Ross said health experts in Colorado Springs are trying to develop similar systems for psychiatric patients. Colorado has a severe shortage of space in community programs for people with psychiatric problems, so many end up in ERs. If hospitals can work with outpatient clinics to create more space, they may be able to develop a checklist to evaluate psychiatric patients in the field and bypass ERs.

“Our model would maybe be to pair a paramedic with a psychiatric evaluator who would go to a scene and determine if a person could go straight to a behavioral health system,” said Ross. “There are solutions already in progress.”

By Katie Kerwin McCrimmon

Policy makers who want to simultaneously boost high school graduation rates and reverse health epidemics from diabetes to obesity should focus intently on helping the youngest children and their families, according to one of the nation’s leading experts on early child development.

Dr. Jack P. Shonkoff, director of Harvard University’s Center on the Developing Child met with Colorado policymakers on Thursday and spoke to children’s advocates at the annual luncheon for the Colorado Children’s Campaign.

His message was clear. Intervene early. Intervene now. And pool your resources.

“Early experiences shape the development of the brain and affect the development of other organ systems,” Shonkoff said.

The revolution in brain science has now proven that trauma suffered early in life — ranging from the stresses of poverty to abuse or a depressed parent — can cause brain connections to atrophy and change body systems that trigger much higher rates of illness later in life.

“We have known for a long time that people who experience significant adversity get sick more,” Shonkoff said.

At the same time, brain connections that begin to form in the first months of life are critical. Young children who are exposed to lots of loving chatter will experience an explosion of language skills as toddlers. Without early stimulation, the architecture of the young brain won’t develop in the same way and will provide a much poorer foundation for the future ability to learn.

“People who are worried about high school graduation rates should be worried about vocabulary at age 3,” Shonkoff said. “The size of your vocabulary by age 3 is a very big predictor of your reading abilities in third-grade and a big predictor of success in high school.”

Shonkoff said early experience is the “smoking gun” for both education success and long-term health.

Dr. Jack Shonkoff, director of Harvard University’s Center on the Developing Child, says the ‘nature vs. nurture’ debate is over. Genes matter and early childhood experiences, both good and bad, change children’s brains and their bodies.

“Things that happen early in life leave biological memories on your body. Bodies are physically marked,” he said.

Toxic stress derails healthy development, stunts brain growth and increases risks for an array of physical problems from poor cardiovascular health to drug and alcohol problems to depression.

“What’s new is this revolution in biology. It’s helping us understand how this happens.”

Shonkoff praised Colorado for its newly created Office of Early Childhood, which houses multiple government programs aimed at young children under one roof.

But that is not enough, Shonkoff said.

Colorado and other states should push further and blend all their efforts targeting young children and families. The same troubled families are intersecting with multiple government agencies ranging from welfare to housing and public health programs. Policymakers could save money by using identical interventions that will produce better results for children and families across the board.

“Science is offering to help us out,” Shonkoff said. “Don’t just focus on interagency agreements. The unified science of early childhood health and development could be the basis of everybody feeding off the same science.

“The beauty of this is that it’s the same science for education and health, for learning and mental health. It’s the science of how experience gets into your body, and how it affects your brain,” Shonkoff said.

The frontier in early childhood work, Shonkoff said, is to provide practical and targeted help for families. His center is working to connect scientists with policymakers on the ground so cutting-edge research can translate into immediate, fast-tracked policy changes.

For instance, if a mother is depressed, telling her to read to her child won’t work. She needs treatment for depression that will then enable her to provide greater stimulation to her child. Some parents and many low-paid day care workers, who themselves suffered a lack of stimulation in childhood, don’t know how to create an enriched environment for children. Shonkoff said it’s critical to strengthen parents and caregivers.

“This is not taking the place of families. This is not government raising families. We’re helping to strengthen families,” he said.

“This is a shift in the field. It’s just starting. It’s coming from this scientific understanding that excessive stress disrupts brain circuitry. How do we stop that?” Shonkoff said. “And while we’re working to eliminate poverty and violence, we could be building the capacity of adults to help buffer kids.”

Children can be resilient. Shonkoff said “decades and decades” of research have found that even in the worst environments — war zones or concentration camps for instance — some people can survive and thrive.

But one common factor is key, Shonkoff said.

“Any time you see resilient outcomes, there was at least on supportive relationship. Kids don’t become resilient alone.”

They need someone to teach them coping skills, a trusted ally who can give them a sense of safety, security and hope.

“Adults have this capacity. It’s coachable and teachable,” Shonkoff said. “In order to promote better outcomes for kids, we need to do more than give parents information….We have to build skills in parents and child care providers.”

Once upon a time, scientists spent countless hours tangling over whether genes or experience determined fate.

“ ‘Nature vs. nurture’ is a dead issue in science,” Shonkoff said. “We used to think everything was programmed in genes.”

But now that scientists have been able to map genomes and the field of epigenetics is growing, it’s clear that genes are working in different ways.

In other words, both nature and nurture have profound impacts on child development. And while scientists and policymakers can’t change the genetic cards children receive, they can try to prevent or counteract negative experiences.

The Affordable Care Act could help, Shonkoff said. While some states will choose to use prevention funding to help adults lose weight or quit smoking, Washington State, has decided instead to use prevention funding to bolster early education programs.

“If we’re really serious, we should go back to the beginning.”

By Katie Kerwin McCrimmon

COLORADO SPRINGS — The relationship is on the rocks.

Long divided into opposing cultures, doctors, who focus on the body, are trying to work side-by-side with behavioral health experts who try to heal patients’ minds. In a grand Colorado experiment called Advancing Care Together, 11 pilot sites are participating in a $4 million four-year experiment to bring these disparate worlds together.

And some are pining for a divorce.

Or at least they want a proper wedding that includes electronic medical records that actually talk to each other.

“If we want it, we’ve got a put a ring on it,” said Dr. James Meyer, with Miramont Family Medicine’s Parker office.  Meyer drew loud laughter from a room full of ACT participants who gathered recently in Colorado Springs.

Their struggles after a year in the trenches show just how complex real health reform will be.

Among the lessons learned so far:

• Physical space matters. A relatively small clinic in remote Cortez that was designed for integrated care is making the most progress. In fact, the Cortez Integrated Healthcare Clinic is now struggling with too many patients. Read more.
• At various sites, integration works better when behavioral and physical health experts trip over each other and are forced to share work areas. The behavioral health experts can “stalk docs” to make sure they are tapping their skills. And doctors, who are perpetually short of time, can give quick patient updates on the fly.  Patients benefit when they receive seamless care. Said Dr. C.J. Peek, an expert from the University of Minnesota Medical School: “You can’t put the therapist in a nice unused office with a couch and a fern. That person has to be in the traffic pattern, in the most cluttered place so you are tripping over each other. Out of sight. Out of mind.”
• The biggest health systems are struggling the most. In one that is supposed to be a national model for integration, it took a behavioral health expert two years to get an office at a medical clinic where she had been assigned. The rest of the time, she was supposed to float. With limited personnel and pressure for each provider to be more productive in less time, the counselor is supposed to spend just 20 minutes with each patient, a marked departure from the typical 50-minute or hour-long counseling session.
• Low-tech can work well. At Salud Family Health Centers, which has long had behavioral health experts in its clinics, counselors use white boards in common areas with doctors and simply mark a BH next to patients they want to see. They don’t wait for doctors to come get them since providers often miss signs of mental distress. Behavioral health experts see all new mothers and anyone who complains of pain, such as a headache or a stomachache that might be associated with a mental illness. Read more about integration at Salud. 
• Another innovator, Westminster Medical Clinic, has already gone through two therapists in a year and is hunting for a third. But even with unemployment high, it can’t find a qualified behavioral health expert who wants the part-time job. The first was great, but was hired away. The second only wanted to do limited work, never meshed with the rest of the staff and could make significantly more money doing crisis care at a hospital emergency room. Now Westminster has created a detailed contract it is calling a health compact that will govern how a future relationship will work. Central to its success will be housing the behavioral health expert in a room full of desks where the behavioral health experts will work “shoulder-to-shoulder” with the medical staff. Read more about Westminster’s initial efforts. 
• None of the sites can figure out how to pay for integrated care over the long term. For now, some ACT innovators feel they must “be creative” with health insurance billing codes in order to make ends meet. Others fear they will be dependent on grants forever. A separate experiment that will soon begin in Grand Junction aims to determine if a nonprofit health insurance company, Rocky Mountain Health Plans, which is not an ACT participant, can cover behavioral health in primary care settings through monthly “per member” fees instead of typical fee-for-service models. Read more: Insurance company bets on benefits of integration.
• Distrust between behavioral health experts and doctors is rampant. Some counselors think doctors simply prescribe unproven medications, then send patients packing without considering the potential value of therapy. Meanwhile some medical experts think behavioral health experts are slow, unresponsive and never keep them posted about patient progress. What’s more, some doctors hate the way mentally ill patients who should be seen through Colorado’s network of mental health facilities “get fired” if they fail to show up for appointments and ricochet right back to overwhelmed doctors.
• Electronic health records for medical and behavioral health care don’t interface even when that care is located in the same clinic.
• Some providers said they have “change fatigue.” They’re exhausted from the perpetual reforms in medicine.
• A solo medical practitioner in Basalt in the Roaring Fork River Valley near Aspen, Dr. Glenn Kotz, is making great progress at integrating by creating partnerships with nonprofits in the area. But because he’s so busy seeing patients each day and financial pressures are paramount in private practice, Kotz pours his energy into creating partnerships and innovating his practice from 4 to 6 a.m., then sees patients as fast as he can the rest of the day.

At the conference that brought representatives from the 11 sites together with a high-powered advisory board full of national experts on integration, there were moments when it felt like a fistfight might break out. But, these are health experts with advanced degrees. They duked it out through impeccably-cited dueling PowerPoint presentations instead.

Sounds chaotic. Right?

Yes, and that’s just what the unflappable leader of ACT, Dr. Larry Green, was hoping would happen at this stage of the game.

“It’s going better than I expected,” said Green, with the imperturbable air of an elementary school principal serene amid a group of naughty knee-high charges.  “It’s important to recall what our aim is. Our aim is to change practice. It’s hard.”

Even if opposing experts sometimes wanted to smack each other at their annual gathering on the flanks of Pikes Peak, at least they were in the same room, sharing results from real-life on-the-ground experiments. At each of their sites, they were testing unique methods that Green and others hope will someday amount to the “secret formulas” providing a playbook for integration around the country.

“Our name says we’re advancing care together, not apart. The institutional impediments to taking proper care of people are now out in plain sight. Pretty much anything is now discussable,” said Green.

Dr. Mary Jane England, chair of the ACT steering committee, a professor at the Boston University School of Public Health and one of the top mental health experts in the country, was downright rosy in her assessment of how the Colorado pilots are doing.

“You are leading the nation. We in Massachusetts have now covered 98 percent of people. We have a cap on expenditures and bundled payments … But you’re doing the really important work out here.

“You really are grass roots. This isn’t easy. This is change. It’s very exciting. You are now very much in the national forefront,” said England who chaired a watershed 2005 report for the National Academies’ Institute of Medicine on improving care for people with mental health and substance abuse problems.

Forefront, shmorefront. On the ground, reform is exhausting as are challenges that cut right to the core of patients’ lives.

Dr. Kotz, the solo doctor at MidValley Family Practice in Basalt, says the mental health system in his area that is supposed to help his neediest patients isn’t working. He is dealing with one family that has experienced severe trauma, abuse and domestic violence. He believes that both the mother and children should be getting care from the mental health facility. But, Kotz said his patients are not getting adequate care, so they keep coming back to him.

“I don’t want to paint this just as a negative picture. I think they try to do their best, but they are overwhelmed,” Kotz said.

To provide behavioral health to his patients, Kotz has partnered with the Aspen Hope Center, which is funded by the Aspen Valley Medical Center.  He now has a therapist employed by the Hope Center who works in his office part ime. Together they see the patients who have the toughest behavioral health challenges.

“They are high-need both from the medical and mental health standpoint,” Kotz said.

Some are bipolar or suicidal. One patient has been hospitalized 15 times.  Another is just 21, suffers from schizophrenia and has been hospitalized for the third time in three months.

Kotz said some mental health providers have expectations that patients can’t achieve.

“If you don’t show up, you’re fired.”

Then they wind up back at his practice.

To fill the gap, Amy Gensch, the Hope Center therapist in Kotz’ office, has simply taken on the family that suffered trauma and abuse so they won’t fall through the cracks.

“It’s the worst trauma I’ve ever seen,” Gensch said. “They had two therapists within two months. It didn’t work for them.”

Gensch and Kotz work together seamlessly, flagging each other down casually when they need to consult.

“It works really well,” said Gensch.

Their primary desire would be to expand their capacity.

“The statistics showing the number of mental health patients that come to primary care seeking help proves to me that it’s an absolute need to have primary care and behavioral health integrated,” said Kotz.

So, the goal is worthy. The path to get there remains difficult to find.

“Nobody has this figured out yet,” said Green, director of ACT. “We are comfortable enough to show all the warts now. We’ve got miles to go before we sleep.”

By Katie Kerwin McCrimmon

The biggest obstacle to blending physical and mental health care is money.

Doctors can’t bill insurance companies for treating their patients’ mental health woes and psychologists can’t treat physical ailments. So the two health specialties remain separate, while confused patients get splintered care and often get sicker.

Most experts acknowledge that the system is ridiculous, but feel shackled to insurance company billing codes.

Enter an insurance company that wants to prove once and for all that integrated physical and behavioral health care is both better for patients and less expensive in the long run.

In a new experiment set to start next spring in western Colorado, the nonprofit health insurance company, Rocky Mountain Health Plans, will give hefty “umbrella payments” to three primary care practices that are already working to integrate behavioral health. Also known as “global payments,” the funding will replace traditional “fee-for-service” payments that reimburse doctors for each visit with a patient or each test they order. The insurance company will then encourage the health providers to give patients excellent integrated care. That will vary from site to site and will depend on patients’ needs. Care could include a traditional office visit with a doctor or a health coach, email exchanges, telephone counseling or a typical counseling session. Patients will get all the care in the familiar setting of their primary care office.

At the same time, Rocky Mountain will give the control groups — three other primary care practices that are also trying to integrate behavioral health  — reimbursements under the traditional “fee for service” model, where providers bill for appointments and procedures.

Actuaries and data experts will then compare costs and patient outcomes. (Click here to read more about the experiment.)

The aim is to prove quickly that patients do better when doctors are paid to keep patients well rather than worrying about seeing as many patients as fast as possible to keep the cash flowing. Rocky Mountain ultimately wants to change the way it pays providers throughout Colorado and spur change around the country.

“This is not an academic exercise,” said Patrick Gordon, director of government programs for Rocky Mountain and executive director the Colorado Beacon Consortium, a coalition of nonprofit health groups that is seeking to boost the quality and efficiency of health care in western Colorado. “This will be a transformative pilot that is being built with the goal of replicating success across the country.”

Throughout Colorado, Rocky Mountain insures about 220,000 people. Altogether the primary care practices that participate in the pilot will serve 30,000 to 50,000 patients including the full spectrum of privately and publicly-insured patients. The organizers have not yet picked the practices that will participate.

Rocky Mountain is fronting the cash for the reimbursements. A group called the Collaborative Family Healthcare Association will coordinate the project while the Colorado Health Foundation is paying for an evaluation to see how well the three-year program works.

Clinical psychologist Benjamin Miller  will evaluate the effort. He is director of the Office of Integrated Healthcare Research and Policy in the family medicine department at the University of Colorado Denver.

“This is a total game changer in every facet,” said Miller. “It’s disruptive innovation. We’re telling the system, ‘We’re not going to play by the old rules anymore. We’re going to play with new rules and we want you to operate as a team.’”

Miller said the experiment “takes off the handcuffs of payment reform” and should produce some useful results.

“Everyone wants to know the answer to sustainability,” he said.

Currently, doctors are stuck trying to string together grants, fudge billing codes or give free office space to counselors in hopes that they’ll provide help to patients while creating their own streams of revenue.

Under the new concept, worries about finances will be gone.

“We’re going to take that off the table. Here is the financial support to make this sustainable,” Gordon said.

Rocky Mountain is pumping millions into covering up-front costs for various efforts to strengthen primary care practices and thereby reduce much more costly health expenditures such as surgeries, ER visits and lengthy hospital stays. The effort to integrate behavioral and physical health is part of the larger vision to bolster primary care.

Gordon could not say exactly how much the integration experiment would cost. But, in the long run, he and others are confident that giving patients much better primary care will help achieve the elusive holy grail of health reform: “bending the cost curve,” or slashing the increasing costs of health care in the U.S.

“We know that behavioral health integration is absolutely essential,” Gordon said. “The cost and structure of the payment model will probably vary from site to site. This project will give us much deeper insights into what those factors are.”

Gordon said initial estimates show that if primary care practices give high quality integrated behavioral and physical health care to all patients in western Colorado who earn at or below 250 percent of the poverty level — or about $56,000 a year for a family of four — health providers could cut the rate of growth in health expenditures by 4 to 5 percent over three years.

“Even relatively modest impacts on (growth) trends can produce more than enough to pay for all of these interventions,” Gordon said. “It also puts us in a position to share gains with government payers and employers.”

The ultimate goal is to make behavioral health sustainable in primary care. That means giving people help with a much wider array of issues beyond traditional mental health concerns such as depression or schizophrenia.

For instance, Gordon cites the potential benefits of a technique called motivational interviewing in which health providers spend time asking patients how they want to change their lives. The technique can help change unhealthy behaviors such as smoking, poor diet or a sedentary lifestyle, all of which lead to poor health outcomes.

“When you engage a patient in what they want for themselves…they are much more likely to …change elements of their own behavior,” Gordon said. “This is very much in contrast with the traditional didactic approach of most conversations between physicians and patients.”

One of the most promising methods for inducing behavior change is to start group visits for people with diabetes, for pregnant moms or for obese people.

“They have proven to be very powerful,” Gordon said. “You get a peer dynamic. And it’s the group that drives the discussion more than an authoritarian physician.”

By Diane Carman

Hunter Doherty “Patch” Adams is a physician who has “never made a penny from medicine.” He treats patients with laughter and loving, and he rebels openly against the “tyranny of market capitalism.”

He said he is “ashamed” of the U.S. health care system. “It’s not about health. It’s not about care. And it’s not a system, it’s a business.”

Adams spoke at the Tivoli Student Union on the Auraria campus Wednesday, challenging his audience to join his revolution of joy for the sake of their own well-being and that of the planet.

“You can decide to never have another bad day,” said the mustachioed doctor wearing bright patterned clown clothes and a dangly earring.

In the volumes of medical journals and peer-reviewed studies, Adams said, “there’s no evidence that it’s good for you to be serious. There’s no value to apathy, indifference, meanness, unkindness. Selfishness is never good for you.”

In contrast, the literature is full of evidence of the health benefits of “joy, love, humor … thoughtfulness,” he said.

A self-described provocateur, Adams rejects traditional medicine’s view of mental illness.

“To me, depression is never an illness, ever,” he said. “It’s a pharmaceutical company diagnosis.”

Depression, he insists, “is a symptom of loneliness. All you have to do to get rid of depression is have an active friend dancing in your head.

“I’ve never disliked a patient enough to give them a psychiatric diagnosis or medicine.”

Instead, he said, he held one patient for 12 hours to calm him and treat him with compassion instead of drugs.

Adams, who was hospitalized in his late teens when he was suicidal, said it wasn’t until the third hospitalization that “lightning struck” and he realized, “Don’t kill yourself, dummy, make revolution.”

He completed medical school at the Medical College of Virginia in 1971 and founded the Gesundheit! Institute, which provides medical care for free. He most famously was the subject of the 1998 feature film, “Patch Adams.”

Adams challenges his audience to embrace happiness.

“For the last 5,000 years, we’ve celebrated pain and suffering. History is about wars and winners and how bad the winners treated the losers,” he said. “There’s no party chapter.”

In religious training “we’re taught there’s salvation in suffering. … We love pain and suffering.”

He considers it profoundly unhealthy.

Being happy “is not an ethical or a moral thing,” he said. “It’s a damned old choice. And it’s clearly really good for you to be happy.”

Adams advocates communal living to increase friendship and human interaction, and to reduce costs and the impact of 7 billion people on the environment. “The smartest thing I did was to start a commune in 1971,” he said. “It made all this possible.”

Despite his active decision to be happy, Adams said he experiences the full range of emotions, including sadness and anger.

“When I hold a child who is dying of starvation and has no muscle mass … is just a sack of bones and doesn’t have the energy to speak … it’s hell.

“I want to tax the rich 95 percent,” he said. “Maybe it’s more important to love everybody than to have a thing.”

To get stuck in the “pain paradigm of sad, sad, sad and angry, angry, angry is like masturbation,” he said. Emotions should provoke action. His activism is focused on market capitalism.

“If we don’t stop market capitalism, we will be extinct in this century,” he said to applause.

At 67, he said he’s in “the ice cream phase of life,” so preventing the destruction of the planet must fall to the young. But at this point in life, he’s not about to start withholding his opinions.

“Emotions are there to guide people. I trust them. When I hear someone heaping a pile of b—s—, I speak up.”

In response to a question from a medical student seeking advice on how to pursue a path of treating the poor outside of the for-profit health care system, Adams offered an audacious suggestion.

“If you owe $200,000 when you graduate, don’t pay it. Work in Africa. There’s no such thing as debtor’ prison.”

It’s what he did, he said. When he finished medical school, he wasn’t making any money, so he didn’t pay off his student loans. “Later, when I started making money from other things, I paid it all back.”

Joy, he said, “is a platform on which you launch your life.

“I dove into the ocean of gratitude and never found the shore.”

By Katie Kerwin McCrimmon

Six students in crisis flooded the counseling center on the first day of school this fall at the University of Colorado Colorado Springs.

Last year, the number of UCCS students who needed emergency or crisis counseling tripled over the year before. And the director of the campus counseling center says the number of students seeking care has been steadily rising along with the student population in recent years.

In Boulder at CU, the number of students seeking counseling has been steadily climbing for eight years and last year the school’s psychological and counseling services center treated or reached out to more than 15,000 students and faculty.  The upward trend is the same at Colorado State University in Fort Collins. In the fiscal year that started in the summer of 2009, CSU counselors served about 8 percent of the student body. That jumped the next two years to about 13 percent. And this year from July 1 through the first week of school, the counseling center served 740 students or 18.6 percent more students than during the same period last year.

“They’re bursting at the seams already,” said Janelle Patrias, coordinator for mental health initiatives for the CSU Health Network, where student fees of about $39 per semester cover the first five individual counseling sessions, behavioral health workshops and some drug and alcohol prevention programs. Fees have inched up to keep pace with demand.

Since prevention is critical, CSU  has launched a program this fall to have counselors work directly with students recently released from psychiatric hospitals. It is believed to be the first such program in the nation.

Aurora theater shooting suspect James Holmes started accumulating weapons as he was flailing in an elite neuroscience graduate program at the University of Colorado Denver. His apparent mental health struggles have highlighted concerns about students under stress, although most suffer with mild depression or anxiety, and never become violent.

A nationwide trend

Nonetheless, at other Colorado campuses and universities across the country, deans, researchers and behavioral health experts have been seeing spikes in recent years in visits to counselors and mental health facilities. Incoming students are arriving in poor emotional health aggravated by academic and financial pressures. 

Scholars Arthur Levine and Diane R. Dean tapped scores of interviews and surveyed more than 5,000 students at 270 colleges and universities for their new book, “Generation on a Tightrope, A Portrait of Today’s College Student.”  They found that students are stressed about school, worried about future job prospects, abusing alcohol more than ever and have been coddled so much by their parents that many may not be equipped to handle adult pressures.

“There are more stressors in students’ lives,” said Dean, associate professor of higher education administration and policy at Illinois State University. “What’s compounding it at the same time is that they’ve been raised in such a way that they’re less prepared than ever to deal with it.”

She and Levine spend an entire chapter documenting parents who range from helicopters (who hover), stealth protectors (who swoop in) and lawnmowers (who mow down anyone in their student’s way). Some parents communicate from afar with their young adult children multiple times a day and intervene on everything from academics to disciplinary hearings. Some have even pestered university officials to wake their students up for class.

“The message to students from their parents is, ‘You’re not capable. I will do it for you.’ They’re not developing appropriate social skills or coping mechanisms. This is the generation that was never allowed to skin their knees. Everybody gets a trophy and nobody ever fails,” Dean said.

“They’re used to being over-rewarded and applauded for what prior generations would have seen as average.”

Dean’s research and surveys from the American College Health Association have found that 75 percent of students reported experiencing stress; nearly half said they were dealing with anxiety; and 25 percent said they had been depressed in the last year.

The causes for the angst vary. The sour economy has added pressure to students who are taking on more debt and working more hours to pay for their degrees. No longer is college merely a time to ponder the meaning of life, take basket-weaving and excel in the art of partying. Facing a bleak post-college job outlook and the prospect of boomeranging back to their parents’ basements after college, students feel pressure to earn degrees that will bring high-paying jobs.

Stigma easing

In the past, stigma about mental health ailments may have prevented some students from seeking psychological counseling. Experts see it as a sign of maturity that many students now are asking for help.

“We see it as a positive that young people are being identified earlier and are receiving more adequate treatment for any mental health disorder,” said Patrias, CSU’s mental health coordinator. “They are able to come to school whereas in years past, with the onset of disease, many weren’t able to manage their disease and go to school.”

The Americans with Disabilities Act requires schools to accommodate students with both physical and mental ailments.

Patrias says parents are more connected to their students than ever before, but she doesn’t see it as a negative. She believes it’s helpful to have them keeping tabs on their students’ mental health.

She is not certain why CSU’s rates of students seeking counseling are so much higher than those of comparable universities . National surveys from the Association for University and College Counseling Center Directors have found that similar-sized four-year universities would typically see about 5 percent of students seeking their services whereas CSU’s mental health system is serving about 13 percent of its students.

Colorado has disproportionately high suicide and depression rates, a challenge that faces behavioral health experts working with people of all ages.

University counselors at various Colorado universities think rates of usage may be on the rise partly because they are getting better at reaching out to students who may need help. At CSU, counselors make presentations for all students at summer orientation and let them know how to find help. They will see students the same day they walk in for care.

At CU in Boulder, Karen Raforth, director of counseling and psychological services, has gotten creative with her outreach efforts, conducting stress workshops, holding office hours in strategic buildings far from the counseling center to reduce stigma, hiring therapists who speak nine languages and reaching out to one of the toughest groups to penetrate, international students.

Photo by Glenn J. Asakawa.

International students ‘don’t get stressed’

Raforth recently attended a reception for international students. She introduced herself and was careful not to use words like “depression” or “mental health.”

“I run the counseling center. You might run into me,” she said to one student, introducing herself.

“We don’t get stressed,” the student informed her.

Raforth said that’s a typical reaction. So, she talks instead about cultural issues and urges the students to seek her out if they’re having challenges adjusting to life in the U.S.

CU also offers programs tailored specifically to veterans, students of color and students who are gay, lesbian, bisexual and transgender (GLBT).

While Boulder seems like a tolerant place, Raforth says surveys show African American and GLBT students are among those who report being least satisfied on campus.

“It only takes one person to ruin your day,” she said.

The chief complaints among all students relate to depression, academic pressures, relationship problems and fear of disappointing parents.

“We hear ‘I flunked my exam. My girlfriend threw me out. My parents are getting a divorce. I got my first ‘F,’” Raforth says.

When the economy started tanking in 2008 and 2009, Raforth said she heard more students voice fears about money.

“It was abrupt for many folks. Economic stress can take a toll on the entire family. It closes down your options,” she said.

Some students never wanted to be at a particular campus in the first place and came only because they had no other option.

Substance abuse a problem

These days, it’s more common to hear about students who are having difficulty taking care of themselves. Few get enough sleep, eat a healthy diet and get enough exercise. Substance abuse is rampant and aggravates mental health woes.

Counselors see demands for their help ebb and flow throughout the academic year. The beginning of the year can either be a honeymoon or a time for homesickness. Demand rises again during midterms, eases around the holidays when the students head home and peaks again during spring midterms.

Photo by Casey A. Cass.

Exam times at the end of each semester bring in severely depressed students.

“It’s make or break time. A lot of the students who come in then are in serious trouble. They’re at the end of their rope. It’s knotted and their hanging on. The ones we see then probably should have been in here by midterms. They’re a mess, fewer in number but more worrisome cases,” Raforth said.

What’s clear is that students have excellent access to same-day, low-cost care. In Boulder, there is no charge to see a mental health counselor. The visits are covered through student fees. At CSU, students can get care at either the medical clinic or the counseling center. Behavioral health experts staff both location and all students seeking medical care are also screened for mental health concerns.

In Colorado Springs, students pay for care on a sliding scale. Student fees at the fast-growing university don’t cover mental health visits.

Dr. Benek Altayli, the director of UCCS’s counseling center, said she’s never turned anyone away, but studies show students are more invested in their care if they’re responsible for a co-pay. Sometimes she has charged as little as 25 cents per session.

Her center cares for students based on the urgency of their issue. They provide psychotherapy to individuals and groups for traditional relationship issues, depression and anxiety.

“If someone says, ‘My world is falling apart. I can’t take it anymore. I’m thinking about hurting myself. I’m going to drop out of school today,’ then there’s a crisis going on and they can’t wait,” Altayli said.

If students are at risk for harming themselves or others, counselors will see them immediately. If they’re in no imminent danger, but facing a crisis, therapists will see the student within 48 hours. Both the emergency and crisis calls are the ones that rose at such a fast clip last year and could rise again judging by demand as school began in late August.

The complaints at the beginning of the year indicated utter disarray: “I’m not ready to be here. I don’t have money to buy books. My living arrangements are not what I want. My parents are not being supportive.”

Sometimes the particular concern a student voices may not be the most crucial part of their visit. Rather, she said it’s fundamental that a student who feels out of control steps up and asks someone for help.

“The data shows that students are more stressed out. Period,” Altayli said.

Students ill-prepared for independence

She agrees with Diane Dean, co-author of “Generation on a Tightrope,” that coddling parents have not prepared their young people for independence.

“Students don’t just wake up one day and now they’re adults. It’s important throughout high school to pay attention to training the child to become independent, to teach them how to balance a checkbook and show them that using a credit card does not mean you have unlimited resources,” she said.

She has parents who call her and say they think their student needs to be seen at the counseling center. Or parents will want to know how counseling is going and therapists must explain that by law they cannot confirm that a student is a client.

“Taking over their lives is not healthy and helpful,” she said. “We have some parents who want to take over everything. They call administration, records, the dean of students or if they’re sick, the health center. They want to do everything for their child.”

But, it’s vital for young people to learn to advocate for themselves and to ask for help if they need it, Altayli said.

Dean said it’s clear that universities are going to need to continue strengthening their programs for students in crisis.

“These instances of mental health issues are not going to diminish. We’re anticipating more students coming with more complex problems,” she said. “It’s an important issue for public health and safety.”

By Diane Carman

Long before five people were killed at the University of Iowa in 1991, signs of trouble were apparent to those around the former graduate student who opened fire on his colleagues. Similarly, the shooter in the Virginia Tech massacre in 2007 had a long history of psychological struggles, and people around him said he had been acting strangely in the days and weeks before he killed 32 people and wounded 17.

The refrain on both campuses was the same: If only people had known what to do or who to call for help.

These incidents were key factors in the development of threat assessment teams at Iowa State University and Virginia Tech, which were among the first institutions to create the programs designed to identify and treat persons who may be a threat to themselves or others.

Threat assessment teams have vaulted into the news following the Aurora movie theater killings last month. Accused shooter James Holmes, who had been a neuroscience graduate student at the University of Colorado Denver, was receiving care from a psychiatrist, according to court documents. Police are now probing whether his psychiatrist or other university officials reported concerns about Holmes’ behavior to the school’s threat assessment team in the weeks prior to the shooting that left 12 dead and 58 injured.

The work of threat assessment and behavioral intervention teams is little known or understood, but the FBI and other law enforcement organizations consider these teams to be crucial for reducing violent behavior on campuses, in workplaces and in other public settings.

Proving that they prevent violence is not so easy, however. “This begs the question,” says the FBI on its website. “How can a negative be proven?”

For those working with threat assessment teams, however, the benefits are obvious.

“There’s a statistic out there that if we catch somebody early in the process of a psychotic break, there’s a 90 to 95 percent chance things won’t spiral down,” said W. Scott Lewis, a partner with the National Center for Higher Education Risk Management  and president-elect of the National Behavioral Intervention Team Association.

Lewis said that “virtually every” higher education institution has created some kind of formal or informal threat

W. Scott Lewis

assessment team in the last decade, though the concept of monitoring students and providing advice and support has been around for centuries. “It goes back to the old European models with the seminaries where monks and priests lived there and kept an eye on the students.”

The more formal team approach spread across the country in response to deadly incidents. The National Behavioral Intervention Team Association estimates it has 700 to 800 active members.

A 2008 report  on threat assessment teams calls the Virginia Tech shooting “the ‘9/11’ of higher education.” Since that day, “campus administrators and others across the country have increasingly focused on safety issues generally and, more specifically, on the management of disruptive students who may also have serious mental health issues.”

So now, instead of a meeting in the dean’s office with a couple of faculty members trying to figure out what to do, more often cases involving troubled students or staff members will be referred to a professionals who are assembled in teams that specialize in evaluating threat risks and developing treatment or other intervention programs.

Lewis, who is a fan of the proactive approach taken by behavioral intervention teams, said that some university threat assessment teams still are ad hoc organizations that meet only when a threat is identified, while behavioral intervention teams generally are full-time programs that are designed to address problems in very early stages — long before a threat might be perceived.

How teams work

Threat assessment and behavior intervention teams usually include counselors, mental health professionals, campus police officers, disability specialists and legal advisers.

They run outreach programs to teach students, faculty members, residence hall advisers and university staff members from administrators to custodians how the teams work and what kind of behaviors are considered red flags. The teams rely on the full cooperation of university community, so they work hard to teach their colleagues what to look for and how to report information.

“We’ve looked at a number of incidents over the last many years, and it’s very rare for an escalation to significant volatile behavior without exhibiting concerning behaviors before that,” said Gene Deisinger, deputy chief of police and director of threat management services at Virginia Tech. Deisinger also was involved in the creation of one of the first threat assessment teams when he was at Iowa State University in 1993.

The key to an effective threat assessment team is to identify the “concerning behaviors” early, neutralize the threat and design a response that addresses the individual’s specific needs.

Red flags might include missing class, significant weight loss, signs of cutting, strange postings on Facebook, troubling statements in term papers or class journals, covert or veiled threats either online or in person, bizarre behavior in discussion groups, treatment for alcohol or drug abuse, disassociating in class or any number of other behaviors.

Lewis said many programs use a rubric to plot the information and determine how serious the situation might be. If a person is found to be in a crisis, universities can mandate mental health treatment.

“The process is designed to provide a fair, objective and reasonable assessment and response to identified concerns,” said Deisinger.

It’s not about what teams can make people do, he said. “Our approach is to emphasize a caring, consultative approach.”

To a great extent, that is the result of some not-so-successful experience with other models.

In the aftermath of the Virginia Tech shootings, several universities emphasized that troubling behavior be reported without thinking about what the appropriate response to that information should be.

“Many tried a zero-tolerance approach,” which generally was perceived as punitive and resulted in low levels of reporting, Deisinger said.

As the programs evolved, however, emphasis on communication, counseling and solving problems increased and made the teams more effective.

Gene Deisinger

Sometimes, the incidents that are reported as potential threats are found to be simple misunderstandings. The behavior or conversations were taken out of context and are “much less ominous than initially perceived,” Deisinger said.

Other times, the problems are serious and possibly life-threatening.

Deisinger told of an international student who was exhibiting bizarre, disruptive behavior and began showing a fascination with weapons. He was having trouble with a faculty member who “didn’t have the most agreeable manner of problem-solving.”

The student was brought to the attention of the threat assessment team, which helped him get treatment for his developing mental health crisis. It also worked with the faculty member to help him develop better skills for working with students and others.

Ultimately, Deisinger said, the student returned to his home country where he received psychiatric treatment and continued his studies via distance learning programs.

Deisinger has maintained contact with the student’s family. “His health has markedly improved,” he said. He has a job and “feels grateful for the assistance he received.”

At the same time, the other students at the university were able to concentrate on their studies again without being distracted by fears for their own safety.

Not every intervention is that successful, however.

Lewis recalled two incidents in which he was involved where students with serious mental health problems came into behavior intervention programs and, despite months of counseling, treatment and intensive support, took their own lives.

Need is great

Most university programs receive hundreds of referrals a year once the threat assessment teams are well established, which usually takes two or three years. The teams follow up on information that is provided and develop intervention plans, but they also engage members of the faculty and staff to continue to monitor cases and provide support.

“My goal is to develop a consultative relationship with people who have concerns about the safety and well-being of the community,” Deisinger said. “We want people to be active agents.”

Often people will come to the threat assessment team saying, “It may be nothing, but…”

Deisinger encourages them. “When in doubt, consult,” he said. If behaviors seem outside the norm, the team can determine if they pose a threat.

What he won’t abide is what he calls “the plop effect.”

“That’s when people plop the problem on my desk and think they’re absolved of it.”

Universities are big places, Deisinger said. “We can’t afford to have you plop and run.”

Deisinger and Lewis said it’s difficult to demonstrate that the teams have prevented violent incidents, but seldom does the bizarre, threatening behavior continue or escalate once the team is involved.

“We should strive for the goal of eliminating violence on campus, but it’s an unrealistic goal in its absolute,” said Deisinger. “We can’t absolve the world of all risks. What we can do is reasonable mitigation of the risks we can influence. It’s very important for us not to over-promise and under-perform.”

Cost varies

The threat assessment and behavior intervention teams can be costly, depending on the number of cases that occur on each campus, whether the teams are full-time operations, and the size and level of staff support involved.

“It depends on who’s on the team,” Deisinger said.

But the alternative may not be cheaper.

We know that addressing the threats and concerns that arise can be expensive, he said. We also know from hard experience that “failing to do so can be very, very costly.”