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Innovations in Care
Profiles of Leading Funders
The Meadows Foundation
At the end of a quiet Dallas street lined with nineteenth-century homes sporting turrets and grand porches sits the stately Victorian headquarters of the Meadows Foundation. Since its creation in 1948 by oil tycoon Algur Meadows and his wife Virginia, the Meadows Foundation has distributed more than $1.2 billion to 3,500 Texas institutions. All of the homes lining this quiet street are owned by the foundation and used to provide free office space to 39 local charities, freeing the nonprofits to spend their resources on programs rather than rent. The Meadows Conference Center also offers meeting and collaboration space free of charge.
After conferring with experts and practitioners, the foundation made mental health one of its areas of focus and approved their first mental-health strategy in 2001. Over the next 10 years, Meadows wrote many checks to support nonprofits working on the subject. But hard data and results were few and far between.
In 2011, when the foundation developed its second ten-year plan, it engaged psychologist Andy Keller to find ways of defining success. He brought in data from around the country, and leaders from across the state to make sense of it. The analysis showed that their region faced serious mental-health problems, and that Meadows was not having the impact envisioned. The foundation realized it needed to change its playbook.
It was at this same time that more than two dozen children and staff were killed at Sandy Hook Elementary by a mentally ill individual. The Texas Legislature went looking for opportunities to improve identification and treatment of disturbed persons. The Meadows planning team realized that better data could help state decisionmakers be more successful.
An institute is born
After consulting across the state, the foundation created an independent, philanthropically-driven institute for improving mental-health policy in Texas. Other funders in the state, including Lyda Hill, the Houston Endowment, and the Hackett family signed on as supporters. The Meadows Mental Health Policy Institute (MMHPI) was formally announced in April 2014 as a multisite, statewide organization with analysts and projects in Austin, Dallas-Fort Worth, San Antonio, Houston, Amarillo, the Rio Grande Valley, and other locales.
To lead the initiative, Meadows Foundation president Linda Perryman Evans brought in people skilled at connecting ideas and policymakers and building coalitions. Tom Luce was a well-known education reformer and political networker. Phil Ritter had relationships throughout Texas in the business, government, and philanthropic communities. Keller worked side-by-side with them for two years and became CEO of the institute in 2015. MMHPI quickly became a valuable resource for legislators, judges, and other state officials.
Keller believes that care for mental health can be improved if it is treated more like other diseases. For instance, clinicians now regularly screen for diabetes in medical settings, and insurers have recognized that diabetes management provides a strong return on investment. Expert medical panels have advised that screening for depression can likewise have a “moderate to substantial net benefit.” Yet many physicians don’t raise depression as a patient health issue without prompting. Thus, one of MMHPI’s early initiatives is promoting universal screening for depression across Texas.
Luce became involved in a plan to consolidate five state health- and human-service agencies into one. He helped fold into this effort more attention to behavioral health. With MMHPI’s counsel, various pots of mental-health and substance-abuse funding, totaling $7 billion, were aligned with a new strategic plan that integrated enhanced tracking and accountability. Included in that sum was more than $3 billion in federal Medicaid dollars.
One result was improvement of intensive, community-based care. MMHPI is now working with the state legislature and regulators to expand intensive, community-based service capacity, particularly for children in the foster-care and juvenile-justice systems, and to better leverage existing Medicaid authorities to promote evidence-based care.
Another result of the new emphasis on behavioral health is a $15.5 million redesign of the Austin State Hospital. The state and UT-Austin Dell Medical School aim to transform this deteriorating mental-health center into a leader in brain health and community-based care. MMHPI is contributing to the project and plans to share its improvements with other inpatient facilities across the state.
Treating mental wellness as part of everyday health
MMHPI sees better integration of mental-health care into the wider medical system as a cornerstone of improvement. It supports an approach called integrated (mental and physical) health, which makes the primary-care doctor the “quarterback” who calls on counselors and psychiatrists as needed. The counselor ideally sees the patient the same day that a mental-health problem is detected, via a “warm handoff” from the primary-care doctor. MMHPI is urging medical schools to train students in this method.
One of the institute’s goals is 100 percent detection, treatment, and remission of depression. They estimate that 85 percent to 90 percent of depression can be addressed at the primary-care level, while only 10 to 15 percent will require specialty care. And unlike care in rehab centers, a great deal of depression treatment at the primary-care level is paid for by employers.
MMHPI is building on several decades of work by other philanthropists. Led by the John A. Hartford Foundation, donors supported one of the largest ever randomized clinical trials for depression back in the late 1990s. The philanthropy-supported Project IMPACT demonstrated the effectiveness and cost efficiency of the type of care sketched above. Foundations like Hartford, Robert Wood Johnson, California Health Care, Hogg, and others convened experts to spell out the clinical details of this approach. The National Council for Behavioral Health then advocated for a reimbursement code from the Center for Medicare and Medicaid Services (CMS), giving clinicians a means of billing for their time. When CMS approves a reimbursement code, commercial insurers are also more likely to adopt it.
Relatively few private insurers reimburse for behavioral-health treatment. The insurance industry largely carves out behavioral health into special Employee Assistance Programs. Compared to the broader medical industry, mental health tends to have a separate insurance system, and many cash-only providers. So MMHPI is showing employers how much productivity is lost to untreated mental conditions and urging them to fold mental-health treatment into their wider medical services. The Texas Business Group on Health, a purchasing coalition of human-resource executives at large companies, is an ally in this.
The institute is betting that when employers start demanding mental-health care, insurers will expand reimbursements for integrated care. More family doctors will then open their practices to counselors. And patients will experience the trickle-down effect in easier access to help.
“We have to treat mental illness the same way we have approached other physical illnesses,” urges Dr. David Lakey, former commissioner of the Texas public-health system and MMHPI’s partner in developing a coalition of department of psychiatry heads across all the medical schools in Texas. “This is just another physical illness.”
One barrier, Lakey and MMHPI agree, is limited interest among primary-care doctors in adding more mental-health treatment. Their solution is to train more family physicians and convince them to add drug and psychological counselors into their practices.
Fixing small blockages and inefficiencies in the system is often more effective than pursuing grand-scale policy efforts, according to Luce. The Meadows vision is to keep chipping away at these small obstacles until there are none left.
One Mind has been a philanthropic leader in funding brain research and reframing serious mental illness as a brain disease. A public charity that has raised $380 million over the past two decades, the organization is a leading funder of basic and applied science on mental illnesses like schizophrenia and bipolar disorder.
The organization’s Rising Star award program, launched in 2005, distributes $250,000 grants to promising brain-science researchers. Several Rising Star winners have gone on to make significant contributions to the field. Joshua Gordon, a 2010 awardee, is currently the director of the National Institute of Mental Health.
Traditionally, mental illnesses have been grouped by symptoms, by thoughts and behaviors. One Mind takes a different approach. The organization identifies the basic biological mechanisms at work in conditions like schizophrenia and traumatic brain injury.
This approach recognizes that while the behavior of a person with bipolar disorder may at times be similar to someone with depression, the origin of the first disease has more in common with autism or dementia. The foundation’s bet is that illuminating the physiological processes of brain diseases will help researchers develop cures. Insights developed at the molecular, neurocircuit, or biological level for one brain disease may be translatable to others.
One Mind also recognizes that life events and other environmental stressors can have physiological effects on the brain. The group recently launched an initiative to identify biomarkers in the brain that are associated with trauma or serious stress. If those are found, linkages between experiences and brain changes could be traced out and acted upon.
While the foundation’s focus has been science and research, it also participates in public advocacy. It is funding a PBS series by Ken Burns to raise awareness about brain disease. It campaigns for “open science,” the widespread sharing of findings in basic research to accelerate new treatments and techniques. It created a group, the Kennedy Forum, that brings together leading experts on mental illness, substance abuse, and intellectual disabilities for discussions about brain health. The forum has since spun off as a separate nonprofit.
One Mind sees itself as a “venture philanthropist.” Much of this derives from the entrepreneurial background of its early backers. As a young man, president Brandon Staglin landed in a hospital with a diagnosis of schizophrenia. He and his parents eventually tracked down a skilled psychiatrist. Through trial and error they found a helpful medication. Computer-based cognitive exercises that were precursors to current apps like Brain HQ and Lumosity were therapeutic. Social engagement, including ongoing support from his family, auditing classes at UC Berkeley, and volunteering at a marine mammal center was also foundational to his recovery. These experiences cemented for Brandon and his family the importance of early intervention, active experimentation, and a holistic approach to beat mental illness.
Brandon’s father Garen Staglin built and sold Safelite AutoGlass, then took another company public a decade later. Using his business skills, he started raising funds for One Mind in 1995. He pushed the foundation to pursue research funding for experimental concepts.Fixing small blockages and inefficiencies in the system is often more effective than pursuing grand-scale policy efforts.
One Mind’s current bet is on aggressive early intervention immediately after a young person experiences a first psychotic break. Its leaders believe the disease course, and life course, can be altered by a form of team care called Coordinated Specialty Care, which combines medication, psychotherapy, family-based therapy, and supported education and employment. This approach was tested in the multisite clinical RAISE trial funded by the National Institute of Mental Health. Individuals who get this treatment within 18 months of showing symptoms improve one and a half times faster than persons getting standard care for schizophrenia. Individuals who access this type of care are more likely to stay on their parent’s employment-sponsored plans and find work of their own, reversing what is often instead a downward spiral to disability.
The Substance Abuse and Mental Health Services Administration currently earmarks $50 million for this kind of care, which along with state and local funds plus Medicaid payments enables treatment of almost 8,000 people. One Mind estimates that another $1 billion would be needed to treat the 75,000 patients who could benefit from this approach. Staglin believes this could save the U.S. much larger sums in the long run, by reducing later costs for emergency-room treatment, hospitalization, or accommodation in lockups and homeless shelters. One Mind has convinced California legislators to expand funding for this approach and hopes to spread the effort nationally.
Cohen Veterans Network
With a $275 million gift in 2015, Connecticut financier Steven Cohen launched the Cohen Veterans Network with a philanthropic charge to improve mental-health outcomes for post-9/11 veterans and military families. The organization has a particular emphasis on post-traumatic stress, depression, and pressures experienced in transition from active duty to civilian life. The group has established clinics in 11 cities, with 25 planned by 2020, treating thousands of individuals. These clinics provide high-quality, low- or no-cost mental-health care in community settings that are convenient for vets and active military, with innovative approaches and privacy protections unavailable to persons who use V.A. or Defense medical facilities.
To run his new creation, Cohen recruited Anthony Hassan. Starting as a radio operator with field artillery soldiers, Hassan had a 25-year Army and then Air Force career. He deployed to Iraq in 2004 as a military social worker on the first-ever Air Force team created to prevent and control combat stress. He also ran the largest military substance-abuse and family-advocacy programs in the Pacific, and earned his doctorate in social work while an officer in the Air Force.Cohen clinics feel like friendly mom-and-pop establishments...but on the back end they are as sophisticated as any elite medical institution.
Hassan counts his overseas military time among his most rewarding work. “People in deployed locations are more willing to ask for help, so helping people there is very gratifying,” he says. After leaving the service he became a director of social work at the University of Southern California.
Culturally competent, family friendly
At one of the clinics Hassan established for Cohen, in Silver Spring, Maryland, a visitor is met by a smiling receptionist and children playing in the waiting room. Clinic director Tracy Neal-Walden wore the Air Force uniform and earned a doctorate in clinical psychology. When asked if veterans’ families exhibit more signs of trauma, she registers veiled surprise at the question. “Veterans and their families, if anything, show more resilience,” she says, “They are trained to make sacrifices.”
Employees of the Cohen clinics are culturally competent and evince pride in military culture. Across the network, nearly 50 percent of all workers are either veterans, military family members, or former DoD or V.A. employees.
The treatment rooms of the clinic are painted in calm blues and filled with green plants and natural light. The soothing atmosphere matches the clinic’s philosophy. CVN coaches its clients in healthy thinking, coping strategies, and various behavioral therapies. Between 20 and 30 percent of clients have a diagnosis of post-traumatic stress disorder—which Hassan notes is highly treatable. The clinics also treat depression, anxiety, and substance abuse.
The system Hassan has put in place starts with the idea that individuals cannot be understood in isolation and are best treated as part of their family unit. CVN has found that military veterans often come for help at the urging of a spouse or other loved one. Clinics often encourage whole households to be seen together.
The clinics are designed to remove barriers to treatment and care. They open after typical business hours. They are free or low cost. They provide child care. Staff can order clients an Uber if they do not have access to transportation. If they prefer, patients can be treated from home via video conferencing.
CVN clinics build important partnerships with long-standing community nonprofits that offer parallel services. For instance, the Silver Spring clinic enjoys a warm relationship with the regional Easter Seals chapter, which provides employment, respite, and child-development services. Recognizing that there are many physical, social, and economic factors that go into health, the Cohen network works with universities, community-health organizations, and veterans’ centers. Hassan is currently talking with doctors and clinics about the possibility of more closely folding behavioral-health interventions into primary health care.
On the front end, the Cohen clinics feel like friendly mom-and-pop establishments. They intentionally share office space with local community nonprofits in many cases. But on the back end they are as sophisticated as any elite medical institution, with electronic health records, and dashboards tracking utilization, outreach, and appointments. Such tools allow the clinic directors to meet goals like screening clients the same day they call and seeing them within seven days. CVN allocates substantial funding to financial modeling, utilization review, and follow-up outreach. The clinic directors and CVN leadership confer regularly. All the clinics adhere to a guidebook that spells out daily practices in detail.
Research and data
The CVN clinics have also developed a research and training pipeline that attracts interns from schools of social work like the University of Pennsylvania, Columbia University, and the University of Southern California. Three of the CVN clinics are co-housed at universities, allowing a close relationship with academic researchers and access to the Institutional Review Boards that must approve any medical research today. (Difficulty navigating IRB bureaucracies is often a significant obstacle to independent science investigators.)
All of this is important because Cohen has plans to use high-quality research to advance the entire field of military mental health. Hassan recently hired Rajeev Ramchand, a research expert on military families with experience at RAND and Johns Hopkins, to make intensive use of CVN’s voluminous clinic data to predict high-risk patients, make the system smarter over time at diagnosis and treatment, and develop better leadership.
CVN is considering expanding its reach through some form of virtual community designed for veterans and military family members. It is also expanding its telehealth capacities to care for clients in their homes. This will allow CVN to reach more veterans in rural or remote areas, cities without clinics, and neighborhoods where traffic is an obstacle to clinic visits.
The charity has a sister organization known as Cohen Veterans Bioscience. Led by physician-scientist Magali Haas, CVB is a research arm incubating diagnostics and treatments for brain injury and traumatic stress. It is hoped that the close relationship between the two organizations will reduce time lags between discovery and changed practice, an issue across much of medicine. The effort is still in its early stages—finding researchers, sharing data, and seeking better biomarkers of mental illness. One early product will be a packet of data indicators that can be used to identify and manage high-risk clients.
Launching and operating a Cohen clinic is a complex effort. To get the most bang from Cohen’s gift, there are efforts to find partners for each new clinic who can contribute or help raise 50 percent of the operating costs by year six.
Because of its emphasis on quality and personalism, low patient costs, open access, and high-quality research, the clinics are not cheap. The clinics accept TRICARE insurance for military families, and Humana and HealthNet private insurance. The network also participates in the V.A. Choice program.
These insurance reimbursements, though, cover just a third of the cost of care. Reimbursement rates are simply too low. “We argue that mental-health reimbursement should cover the true cost and value of care, not some antiquated fee-for-service reimbursement rate,” states Hassan. But until that changes, national and local philanthropy are central to sustaining these clinics.
Hassan is unapologetic about CVN’s costs. “Providing accessible quality care is expensive,” he says. But “to cut corners on mental health care is disastrous. It is a small price to pay to prevent a suicide or to heal a family.”