Duggin said that not all community health centres receive funding for (crisis diversion services), partly due to inequities in funding provided by their counties. More than half of the families in his seven-county region’s Community Mental Health Center in northeast Mississippi – and one-third in Noxubee – are living in poverty. The responsibility for providing community-based mental healthcare services was delegated by the Mississippi Legislature to 14 regional Community Mental Health Centers. Region 5, the 15th center, was closed due to financial difficulties. According to Phaedre Cole of the Mississippi Association of Community Mental Health Centers, the centers provided uncompensated indigent service for more than $33 million last year. Officials from several community centers stated that revenue shortfalls, disparity in government funding, and a fragmented state mental health system are making it difficult for some centers remain viable and to provide vital mental health services. This has had devastating consequences. Many Mississippians suffering from mental illness are being forced to spend time in jails, emergency rooms, and psychiatric hospital because they lack the support and treatment they need at the local level. The government is losing more money due to a lack of community-based services. The most costly ways to address mental health issues are inpatient hospitalization, emergency departments and the criminal justice system. This includes using the police as first responders. Debbie Plotnick is Mental Health America’s vice-president for mental health advocacy and system advocacy. Plotnick stated that it can take between eight and ten years for someone who has suffered from a mental illness since childhood to receive a diagnosis. Their condition can worsen, making it difficult for them to complete school or keep their jobs. By the time they turn 18, they are not only disabled but also poor and eligible for Medicaid. Dr. Marshall Belaga, Jackson psychiatrist, said that mental illness doesn’t just affect the person with it. It also “destroys families.” Plotnick stated that mental illness can lead to more divorces and abuse and that children are less likely be able to learn well if they live in an unstable environment. She said that this requires a community infrastructure to offer support and treatment before individuals reach Stage 4 which can lead to homelessness, imprisonment, and hospitalization. Advocates for disabled people say that Region 8 Mental Health Services community centre, which is located in the metropolitan area, provides such an environment. It is an example of what can be achieved with sufficient funding, resources, and intervention services. Emile Craig, Region 8’s director, stated that a Crisis Intervention and Diversion Program was implemented in partnership with local law enforcement agencies, courts and jails. This program ensures that no person in the region is kept in jail because they have a mental illness. He stated that Region 8 also trains community partners and law enforcement officers on how to deal with people with mental illnesses. Craig stated that since 1998, no one in five of the five counties has been placed in jail for having a mental illness. He said that the Region 8’s success in providing care in a relaxed environment is not limited to the crisis services. The other component is the coordination of all its inpatient or outpatient services with Region 8. Region 8 is home to 18,000 residents and includes Madison and Rankin, two of the most wealthy and fastest-growing counties within the state. According to Dave Van, the executive director of Region 8, Region 8 has the advantage of having a Crisis Stabilization unit, which is a short-term inpatient acute care facility that stabilizes people who are in crisis. “We also have local contracts to private acute care facilities for individuals who are determined to have mental illness if our Crisis Stabilization Unit fills up.” Van said that some counties do not have any private facilities that offer acute psychiatric treatment. Craig stated that one of the reasons people are in a mental crisis is because they don’t follow their medication instructions or they are underinsured or uninsured and can’t afford their medication. “Region8 works with local pharmacies and pharmaceutical companies to ensure that every individual we serve can obtain the necessary medications, regardless of their financial resources and access to adequate insurance coverage.” Angela Ladner from the Mississippi Psychiatric Association stated, “Region8 is offering more than the core services required, and I think they’re doing a good job presently. It’s what all mental health centers should do. However, providers at other community centres are equally dedicated but will not be able provide the same quality of services as Region 8. Problem is inconsistency in care Mississippi’s Department of Mental Health grants community centers state and federal funding, but they have to apply. They also receive funding from their local counties. Cole stated that some centers might have other sources of revenue, such as private grants or donations. Cole stated that he believes each community center does a good job providing services. Cole stated that each of us faces unique challenges and benefits. This is in addition to the difficulties inherent in a rural state like Mississippi. He also serves as the executive director for Life Help in Region 6. The region includes 12 counties located primarily in the Delta. It is one of the most rural and poorest parts of Mississippi. Micah Dutro is the legal director at Disability Rights Mississippi. He said that he believes the centers provide excellent care. It is the inconsistent care that is the problem. This issue was the basis of a September 4 ruling by U.S. District Judge Carlton Reeves against the state. Reeves found that Mississippi had been unnecessarily incarcerating thousands of people in mental hospitals. However, the state’s community-based programs are insufficient. Reeves directed state officials to collaborate with a special master, a court-appointed person to ensure that judicial orders are complied with. This is to prioritize community-based care and speed up the process. Officials from several community centers in rural and economically poor areas of the state say that they do their best with what resources they have. Duggin, whose Region 7 consists mainly of rural areas, stated that funding is essential to provide additional services. Client care is affected by a new level of complexity. In 2011, Mississippi’s Division of Medicaid created a managed care program that gave several private insurers the ability to handle reimbursement claims. According to Duggin, and other providers, the managed care program sometimes refuses payment for certain services. Sandy Rogers, executive director of Communicare in region 2, said that Mississippi’s Day Treatment Service is not an inpatient program like it is in other states. However, Medicaid and managed care companies are often reluctant to pay for this service because they believe people don’t need such high-quality inpatient care. Matt Westerfield is the director of communications for the Mississippi Division of Medicaid. He stated that Medicaid won’t pay for Day Treatment if it is given on the same day or with another service that Medicaid considers redundant. Duggin stated that the mental health system was already complex enough before the managed-care program was implemented. The managed-care program created a new level of complexity for client care. According to the 2018 Economic Impact Statement of the centers, over 110,000 Mississippians were served by the community centers last year. Dutro stated that most of those served by community centers are low-income or poor and have either Medicaid insurance or are not eligible for Medicaid. Dutro suggested that the state could solve the problem by expanding Medicaid to make it easier to get insurance. He also said that “Medicaid makes up 72.6 percent” of their revenue. He also stated that $3.1 million was spent in 2018 on indigent services for children, youth, and families that could not afford mental health services. The Warren Yazoo Behavioral Health Center in Region 15, which is located in west central Mississippi absorbs the costs of those without insurance. Bobby Barton is the executive director of Region 15. The region served 3,600 people last year and provided uncompensated indigent service to over $980,000. Bobby Barton, executive director of Region 15, said that the region provided services to all regardless of their ability to pay. The region served 3,600 people in 2018. Rogers stated that the other challenges facing Region 2 are its geographical location and getting clients to appointments, as many people lack transportation, and a shortage of psychiatrists. Rogers stated that Medicaid does not provide non-emergency transportation. However, Rogers said it is not reliable and not “readily available” in all regions. She also said that Region 2 has difficulties getting clients to appointments because many people lack transportation. This service can be a strain on the operation as they are often short of staff and takes a lot in terms of manpower hours. Rogers stated that Medicaid could reimburse mileage to help offset the cost. Rogers stated that they employ psychiatric nurse practitioner to fill the gap left by a lack of psychiatrists in the area. According to the American Medical Association Master File/MMS, Mississippi had 4.86 psychiatrists per 100,000 residents in 2017, compared with the 9.35 national average. According to Dr. John Mitchell of the Office of Mississippi Physician Workforce the majority of Mississippi’s psychiatrists are located in the region 8 metro area. To increase the number Mississippi’s psychiatrists, the Physician Workforce and the DMH are working together to create a psychiatry residency at Mississippi State Hospital. Statistics have shown that most people live within 50-100 miles of the place where they completed their residency. Mitchell stated that if you train more you can retain more. Bad rap or a well-intentioned system “gone awry”? The federal government pressured the state to increase its community-based services. Judge Reeves stated that Mississippi still “operates an unlawfully discriminatory system against persons with serious mental illnesses.” DMH increased the number of its mobile service teams, known as PACT, from two in 2014, to 10 in 2018. Because of the limited resources available, these teams provide ongoing support services for people with serious mental illness. However, they cannot be sustained in rural areas. Officials from DMH stated that in fiscal 2020, which began July 1, DMH will provide funding for the same type of mobile service in Regions 1, 2, 7, 11, and 14. This is through a program called ICORT (Intensive Community Outreach Recovery Teams). These teams work 24 hours a day and reach clients directly, unlike PACT. However, they do not require as many staff. In October 2018, the DMH piloted Region 2’s ICORT program. Joy Hogge is the executive director of Families as Allies, a Mississippi disability advocacy group. She says that parity in the state’s mental healthcare system can only be achieved if there is a better infrastructure. This will allow community centers to have access to electronic health records, track services, and share information. Jackson psychiatrist Belaga, who retired from St. Dominic Hospital in Jackson after 10 years of service and has joined Hinds Behavioral Health Services Region 9. He also believes that a statewide electronic health record system is essential to ensure patients are kept informed and not lost. Belaga explained that when someone is in a mental crisis, they can’t check to see if they have been treated at a Community Mental Health Center. Because medical records are not shared between the hospitals and centers, it is impossible for the doctor to verify that the person was there. According to Belaga, doctors at the hospital can’t develop “a coherent treatment plan.” Belaga stated that he has seen 18 people come to the emergency department with the same psychiatric problem. He suggested that the DMH could create a statewide electronic health records system. This would allow emergency rooms to view patients’ medical histories, check their medications, and connect them with the local community centers to provide the support they need to stay stable and prevent future crises. Van, a Region 8 veteran in mental health, stated that while the state’s out-patient mental health system may seem fragmented, he believes it is able to provide the necessary support services to help patients stay stable and avoid hospitalization. Van also said that legislators created the system in the mid-1970s with the intention of giving local officials and residents the ability to decide the best way to meet the needs of their communities. Ladner stated that the system’s design was well thought out, but has been criticized. Ladner stated, “I would compare the current mental healthcare system to charting an itinerary to a destination. But not giving everyone a map of how to get there. But we still expect you will get there. But not everybody will.” Shirley L. Smith, Report for America Corps member, is an investigative reporter for Mississippi Center for Investigative Reporting. This non-profit news organization seeks to hold government officials accountable and empower citizens in their local communities._x000D