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GrantWatch

GRANTWATCH: REPORT

Foundations’ Roles In Transforming The Mental Health Care System

Abstract

 
This paper highlights topics explored in a meeting of health grantmakers and mental health experts convened by America’s HealthTogether in February 2006. The meeting’s aim was to review the evidence on the burden of mental illness, explore the causes and consequences of a poorly functioning mental health care system, and stimulate discussion about philanthropy’s role in responding to a national call for transformation of that system. The meeting identified several priorities for foundation work. Examples of current work in these areas, from Grantmakers In Health’s Resource Center database, are presented.

Grantmakers can play an important role in system transformation. For more than a century, health philanthropy has helped develop mental health care as a field and build its knowledge base.³ Annual giving for mental health, however, has changed little in recent years and has declined as a proportion of total health giving.⁴ Advocating an increase in this funding and giving foundations a roadmap for engaging in mental health was the focus of a February 2006 meeting of grantmakers and mental health experts, which was hosted by America’s HealthTogether, an organization working to promote a broader recognition of mental health.⁵ Attendees discussed the burden of mental illness and the consequences of a poorly functioning mental health system and identified potential priorities for foundation work.

The Burden Of Mental Illness

Top The Burden Of Mental... The Foundation Response NOTES

 
The prevalence of mental illness and its societal toll make a compelling case for both raising public awareness and system change. Mental illness, more prevalent than cancer or diabetes, ranks first among illnesses causing disability in the United States.⁶ About one in four Americans annually experience mental health problems ranging in severity from temporary psychological distress to serious depression, schizophrenia, and bipolar disorder. Fewer than one-third of these people receive treatment.⁷ Racial and ethnic minorities are even less likely to obtain care; when they do, it is often of poorer quality.⁸

Mind-body connection. Co-occurring mental and physical illnesses are common. For example, about half of those in HIV/AIDS care have a comorbid mental disorder; and diabetics experience depression at two to three times the rate of nondiabetics.⁹ Mental health status can also affect recovery from physical illness. For example, a fifteen-year follow-up study of women treated for breast cancer found that the best single predictor of death or recurrence was each woman’s psychological response three months after surgery.¹⁰

Trauma. Large-scale public disasters, as well as threatening personal circumstances, can lead to trauma. Reactions to trauma range from mild and temporary to debilitating and enduring. Individuals, families, and entire communities may be negatively affected.

Barriers to care. Stigma keeps people from seeking care, but access is also impeded by inadequate insurance coverage, system fragmentation, and workforce problems. With the shift in treatment for mental illness from public institutions to community settings, health insurance has become the dominant form of financing. Even for those with health insurance, mental health benefits are often limited. Public policy, such as the federal Mental Health Parity Act, has narrowed but not closed this parity gap. Incentives in current financing and coverage for mental health services can also distort access to care and the services that patients receive. Fragmentation is a defining characteristic of mental health care. With little coordination and information sharing, health care providers, schools, social service programs, prisons, and government agencies make critical decisions about the services people receive.

An array of practitioners with little common training compromises the mental health workforce.¹¹ Many rural counties lack mental health professionals, and the rural workforce is ill equipped to treat patients from diverse cultural and linguistic backgrounds.¹² Physicians often find themselves on the front lines with inadequate mental health training.¹³

What is at stake? Effectively addressing the nation’s mental health needs is particularly challenging, because it requires collaboration both within and outside of the health sector. The stakes for not doing so, however, are high. Productivity losses due to mental illness surpass $60 billion annually.¹⁴ Mental illnesses are associated with lower IQ and poor school performance in children.¹⁵ Unaddressed exposure to childhood trauma can affect brain development and have lasting effects on overall health.¹⁶ Suicide may be the ultimate measure of system failure—it accounted for more than 30,000 deaths in 2001.¹⁷

The Foundation Response

Top The Burden Of Mental... The Foundation Response NOTES

 
Foundation giving for mental health was $20.4 million in 2004—approximately 6 percent of total health giving.¹⁸ From 2003 to 2004, funding for mental health dropped 11.2 percent. Foundations making grants included the few funders that focus solely on mental health and a broader number that also fund in other areas.

Even if they increase their giving for mental health, foundations alone cannot bring about system transformation. Their resources are modest compared with the billions of mental health dollars from public and private sources. Their contribution to system change comes from strategic use of their ability to convene; promote dialogue; add prestige to social causes; provide incentives for change; offer technical assistance; and fund in areas such as service model development, advocacy, public policy, and leadership development.

Meeting attendees identified four areas in which foundation investments would be particularly timely and fruitful in creating a better mental health system: addressing childhood trauma, promoting integration of mental health and primary care, improving access to mental health care, and supporting advocacy. Below, we present examples of foundation work, drawn primarily from Grantmakers In Health’s Resource Center database, to illustrate some approaches that funders have taken.

Addressing trauma in childhood. Grantmakers have supported programs that provide early identification of and services to children exposed to trauma. Victims of child abuse are among those at high risk for mental illness. The Health Foundation of Central Massachusetts, in Worcester, funded the Comprehensive Child Abuse Prevention and Protection Collaborative for preventing and treating child abuse in its service area. Aiming to close the gaps between medical, psychosocial, investigative, and legal services, the collaborative engages government agencies, local nonprofits, and area hospitals in coordinated efforts to design and implement child abuse prevention and advocacy programs.

A shortage of pediatric mental health care providers is a major access barrier. The Chicago-based Irving Harris Foundation’s Professional Development Training Network supports community-based training in pediatric mental health, emphasizing treatment of children exposed to trauma. These programs are meant to both prepare practitioners to treat childhood trauma and create a strong network of colleagues.

Promoting service integration. Advancing Colorado’s Mental Health Care is a joint project of the Caring for Colorado Foundation, Colorado Health Foundation, Colorado Trust, and Denver Foundation. The project began in 2005 after a 2003 study of Colorado’s mental health system revealed the need for integrated, community-based services.¹⁹ The project’s goal is to develop seamless, coordinated service delivery across agencies and to facilitate patient navigation. The grantees, a geographically diverse set of communities, are pursuing different approaches, including coordinating school health programs with community agencies; creating programs to prevent inappropriate incarceration of the mentally ill and provide links to services for those released from jail; and restructuring services for people with co-occurring mental illness and substance abuse disorders.

Another effort to promote integrated care is the John A. Hartford Foundation’s Project IMPACT: Improving Mood–Promoting Access to Collaborative Treatment for Late-Life Depression. Because depression is prevalent among the elderly and can greatly impair functioning and health, Hartford developed a model to treat it in the context of primary care. The project tested the effectiveness of a team approach to care in which each patient is assigned a primary care physician and a depression clinical specialist—nurse, social worker, or psychologist—who monitor progress and provide medication and therapy. This approach is now a nationally recommended model.

Improving access. Health funders have played an important role in expanding access to mental health services, particularly for marginalized and at-risk groups. The California Endowment’s (TCE’s) Special Opportunity in Mental Health Funding Initiative focuses on improving mental health for ethnic minorities, the linguistically and culturally isolated, and youth in the child welfare system. Through this initiative, TCE has worked extensively in underserved communities to address violence and improve mental health advocacy and cultural competence. For example, it funded Project ESSEA (Ethiopia, Somalia, Sudan, and Eritrea in Africa) to screen for mental illness and coordinate medical and other social services for African refugees and immigrants. Project leaders work with churches and mosques to address the stigma associated with mental illness and find opportunities for culturally competent care.

Foundations are pursuing programs to compensate for the lack of mental health professionals in rural areas. In the Pacific Northwest, the Northwest Health Foundation supported development of a curriculum for rural primary care providers so that they could learn to both detect mental illness and provide referrals to additional services. Also, the Missouri Foundation for Health has funded tele-medicine projects to help extend mental health services into rural areas.

Advocacy. The John D. and Catherine T. MacArthur Foundation has been a leader in mental health advocacy. For example, it supports the Judge David L. Bazelon Center for Mental Health Law, whose mission is to protect the rights of children and adults with mental disabilities. The center’s work focuses on policy analysis, coalition building, providing information to the public, and technical support for mental health advocates.

Saint Luke’s Foundation of Cleveland, Ohio, has funded the Mental Health Advocacy Coalition (MHAC) to increase awareness of mental health issues and advocate for policy change. MHAC commissioned a series of billboards conveying important mental health messages and has worked for policy change supporting parity in Ohio.

Raising public awareness is important for advocacy and informed policy making. The Hogg Foundation for Mental Health, in conjunction with the University of Texas at Austin’s School of Journalism, annually presents the James Stephen Hogg Award for Mental Health Reporting to showcase journalists’ powerful ability to increase awareness about mental health and mental illness.

AGAINST THE BACKDROP of growing evidence on the burden of mental illness and the need for change, this meeting aimed to spark new and renewed action by foundations. Work already under way suggests that philanthropy can help make system transformation a reality.

Editor's Notes

 
Lauren LeRoy (lleroy{at}gih.org) is president and chief executive officer of Grantmakers In Health (GIH), in Washington, D.C. Margaret Heldring is president of America’s HealthTogether, a policy group, also in Washington. Elise Desjardins is a program associate at GIH.

NOTES

Top The Burden Of Mental... The Foundation Response NOTES

 

1. Substance Abuse and Mental Health Services Administration, Transforming Mental Health Care in America—Federal Action Agenda: First Steps, July 2005, http://www.samhsa.gov/Federalactionagenda/NFC_TOC.aspx (accessed 14 April 2006).
2. Jimmy Carter, President’s Commission on Mental Health, Executive Order no. 11,973, Federal Register 42, no. 10677 (17 February 1977); and U.S. Department of Health and Human Services, Mental Health: A Report of the Surgeon General (Rockville, Md.: DHHS, 1999).
3. R.T. Brousseau, D. Langill, and C.M. Pechura, "Are Foundations Overlooking Mental Health?" Health Affairs 22, no. 5 (2003): 222–229.[Abstract/Free Full Text]
4. Foundation Center, Foundation Giving Trends (New York: Foundation Center, 2006).
5. The Richard and Rhoda Goldman Fund, California Endowment, and Robert Wood Johnson Foundation funded the meeting.
6. DHHS, Mental Health: A Report of the Surgeon General.
7. R.C. Kessler et al., "Prevalence, Severity, and Comorbidity of Twelve-Month DSM-IV Disorders in the National Comorbidity Survey Replication," Archives of General Psychiatry 62, no. 6 (2005): 617–627.[Abstract/Free Full Text]
8. DHHS, Mental Health: Culture, Race, and Ethnicity—A Supplement to Mental Health: A Report of the Surgeon General (Rockville, Md.: DHHS, 2001).
9. Institute of Medicine, Public Financing and Delivery of HIV/AIDS Care: Securing the Legacy of Ryan White (Washington: National Academies Press, 2005); and National Association of County and City Health Officials, "Supporting Collaboration between Mental Health and Public Health," May 2005, http://archive.naccho.org/documents/Issue_Brief.pdf (accessed 19 April 2006).
10. O. Ray, "How the Mind Hurts and Heals the Body," American Psychologist 59, no. 1 (2004): 29–40.[CrossRef][Medline]
11. IOM, Improving the Quality of Health Care for Mental and Substance-Use Conditions (Washington: National Academies Press, 2005).
12. Ibid.; and DHHS, Mental Health Providers in Rural and Isolated Areas (Rockville, Md.: DHHS, 1997).
13. IOM, Improving the Quality of Health Care.
14. President’s New Freedom Commission on Mental Health, Achieving the Promise: Transforming Mental Health Care in America (Rockville, Md.: New Freedom Commission, 2003).
15. IOM, Improving the Quality of Health Care.
16. Grantmakers In Health, In Harm’s Way: Aiding Children Exposed to Trauma (Washington: GIH, 2005).
17. Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, "Suicide: Fact Sheet," 30 March 2006, http://www.cdc.gov/ncipc/factsheets/suifacts.htm (accessed 19 April 2006).
18. Foundation Center, Foundation Giving Trends.
19. Triwest Group, The Status of Mental Health Care in Colorado (Denver: Mental Health Funders Collaborative, October 2003).

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