Female Friendships: More Valuable Than Gold & Essential to Your Health

Isolation from others is detrimental human health–a fact proven in study after study. In one study, researchers found that individuals who had no friends increased their risk of death over a 6-month period. Another study showed those who had the most friends over a 9-year period cut their risk of death by more than 60%.

For women, the famed Nurses’ Health Study from Harvard Medical School found the more friends a woman had, the less likely she was to develop physical impairments as she aged, and the more likely she would lead a fuller life. In fact, the results were so significant, the researchers concluded that not having a close friend and confidante was as detrimental to your health as smoking or carrying extra weight. There’s more: when the researchers looked at how well the women functioned after the death of their spouse, they found that those women who had a close friend were more likely to survive the experience without any new physical impairment or permanent loss of vitality. Those without friends were not as fortunate.

A landmark UCLA study conducted in 2000, suggests friendships between women are special. They shape who we are and who we will become. Female friendships help calm us, fill in emotional gaps, and help reinforce our personal identities. The study indicated that women respond to stress with a rush of brain chemicals that cause them to make and maintain friendships with other women.

Until this study was published, it was generally believed that when humans experience stress, it triggers a hormonal cascade that revs the body into a “fight or flight” response-an ancient survival mechanism left over from when humans faced predators daily.

The UCLA study indicated that women in particular, have a wider behavioral repertoire than just “fight or flight” says Dr. Laura Cousin Klein, an Assistant Professor of Bio-behavioral Health at Penn State University and one of the study’s authors. When the hormone oxytocin is released as part women’s stress response, it buffers the “fight or flight” response and encourages her to tend children and gather with other women instead. When she actually engages in this tending/befriending, the study suggested that more oxytocin is released, which further counters stress and produces a calming effect. This calming response does not occur in men, says Dr. Klein, because testosterone-which men produce in high levels when they’re under stress-seems to reduce the effects of oxytocin. The female hormone estrogen; she adds, seems to enhance it.

It will take time for new studies to reveal all the ways that oxytocin encourages women to care for children and hang out with other women, but the “tend and befriend” notion developed by Dr. Klein may help partially explain why women consistently outlive men.

If friends counter the stress that seems to affect so much of our life, if they keep us healthy and even add years to our life, why is it so hard to find time to be with them? That’s a question troubles researcher Ruthellen Josselson, PhD, coauthor of “Best Friends: The Pleasures and Perils of Girls’ and Women’s Friendships” (Three Rivers Press, 1998). “Every time we get overly busy with work and family, the first thing we do is let go of friendships with other women,” says Dr. Josselson. “We push them right to the back burner. That’s really a mistake, because women are such a source of strength to each other.”

So, when hustle and bustle of everyday life causes you to say “I’ll catch up with her later” when a friend calls, you should reconsider. In the words of an old song, “Make new friends but keep the old; one is silver and the other’s gold.”

Mental Health Care Coverage in Minnesota – Supplementing Federal Healthcare Reform

In 2007, the governor of Minnesota proposed a mental health initiative and the legislature passed it. One of the more important components of the initiative was legislation amending Minnesota’s two programs for the uninsured – General Assistance Medical Care and Minnesota Care – to add to the comprehensive mental health and addictions benefit.

Who Is Covered?

General Assistance Medical Care covers those with income at or below 75% of the federal poverty level who meet one or more of additional criteria known as General Assistance Medical Care qualifiers. Qualifiers include waiting or appealing disability determination by Social Security Administration or state medical review team; or being in a homeless or live in shelter, hotel, or other place of public accommodation.

Minnesota Care covers children and pregnant women, parents, and caretakers up to 275% of the federal poverty level, except that parents and caretakers gross income cannot exceed $50,000. Single adults without children increased to 200% of federal poverty level by January 1, 2008 and will rise to 215% of federal poverty level by January 1, 2009.

What Services Are Covered?

For Minnesota Care, there are limits of $10,000 on inpatient care for any condition (physical, mental health, or addictions) for parents over 175% of federal poverty level and childless adults. For General Assistance Medical Care, inpatient benefits are fully covered. Both programs cover chemical dependency outpatient services. An intensive array of outpatient and residential mental health services are available.

What Is The Cost?

In Minnesota, the Medicaid Temporary Assistance for Needy Families population, General Assistance Medical Care and Minnesota Care are enrolled in comprehensive nonprofit health plans that are responsible to deliver and are at risk for the entire health benefit, including behavioral health. Adding mental health rehabilitative services (including adult rehabilitative mental health services individual and group rehabilitation services, assertive community treatment, intensive residential treatment and mobile and residential crisis services) to Minnesota Care was projected to cost $3.40 per person per month. For General Assistance Medical Care, which includes a homeless population, the cost was $7.01 per person per month. The additional targeted case management service was projected to cost $2.22 per person per month for Minnesota Care and $7.66 for General Assistance Medical Care.

The legislature appropriated a total of $1 million in additional state dollars in fiscal year 2008 and $ 3.5 million in fiscal year 2009 to add the adult rehabilitative services and case management in Minnesota Care. State funds previously targeted for case management were moved from the counties to the state in an amount of $4.4 million in fiscal year 2009.

What Led To Comprehensive Coverage?

The state collected data on the residents served by Minnesota Care, General Assistance Medical Care, and Medicaid managed care plans serving non-disabled populations, and discovered that an increasing number of individuals with serious mental illnesses were in these plans. Several insurance reforms – similar to those included in the national healthcare reform bill – modified the private market, including guaranteed issue in small and large group plans, broader rate bands, parity for mental health and chemical dependency services, medical loss ratios, high risk insurance pool, and others. A lawsuit by the attorney general called attention to health plan denials of payment for court-ordered treatment, for example for civil commitment or out of home placement for adolescents.

Health plans settled with an agreement that behavioral and mental health benefits would be covered by a health plan if the court based its decision on a diagnostic evaluation and plan of care developed by a qualified professional. In addition to the court-ordered services provision, the state contracts and capitation with prepaid health programs (Minnesota Care and General Assistance Medical Care) were amended to align risk and responsibility for services in institutions for mental illnesses, 180 days of nursing home or home health, and court-ordered treatment. There were also highly successful experiments reducing costs and improving outcomes for commercial and non-disabled Medicaid clients who were offered a more intensive community based mental health service that improved coordination with and linkages to behavioral healthcare, primary care, and other needed services.

These demonstrations produced a positive return on investment – $0.38/person/month – and gave the health plans tools to manage the increased risk that resulted from several insurance reforms, including parity, a statutory definition of medical necessity, and the court-ordered treatment provision.

The state supported comprehensive coverage because it sought to provide mental health and addiction services in Minnesota as part of mainstream healthcare. Minnesota’s mental health agency and other stakeholders desired to move mental illness from its historical treatment as a social disease requiring social services to an illness like any other. They wanted to foster earlier interventions and avoid shifting enrollees among different programs in order to access specific services. Operationalizing this change required rethinking medical necessity determinations, provider credentialing, contracting, procedure codes and other processes common to private insurance plans.

How Did It Get Through The Political Process?

Three factors significantly contributed to the political viability of a benefit expansion in the Minnesota Care and General Assistance Medical Care programs:

>> The governor of Minnesota and the administration provided strong leadership. The provisions to expand the mental health benefits in these plans were part of the governor’s mental health initiative, set forth in advance of the 2007 legislative session.

>> An extremely strong coalition of stakeholders formed a mental health action group. This group is co-chaired by a representative from the department of human services and included representation from the private insurance industry and organized and knowledgeable advocacy and provider communities.

>> There was strong support in the legislature for the expansion of benefits in Minnesota Care and General Assistance Medical Care, including from a member of the finance committee in the house, who has a son with schizophrenia. The creation of a mental health division in the health and human services policy committee also helped move the policy discussion forward.

Why Does This Approach to Healthcare Reform Work?

A recent survey of community behavioral health organizations found that on average, 42% of reimbursement for services came from private insurers. While this represents the average, the survey found that there was quite a range in reimbursement sources. For community behavioral health organizations that specialize in services such as Assertive Community Treatment or case management, Medicaid is the predominant reimbursement source, either through fee-for-service or managed care.

Reimbursement from private insurance and Medicaid managed care is uniformly better than Medicaid fee-for-service. In addition to higher rates, the private insurers and Medicaid managed care organizations have been willing to offer special contracts for packages of services for crisis care and hospital discharge plus aftercare.

Financing to Support Coordination of Behavioral Health and Primary Care Services

In October 2003, the Health Resources and Services Administration issued Program Information Notice (PIN) 2004-05 regarding Medicaid Reimbursement for Behavioral Health Services. The PIN requires Medicaid agencies to reimburse Federally Qualified Health Centers and Regional Health Centers for behavioral health services provided by a physician, physician assistant, nurse practitioner, clinical psychologist, or clinical social worker, whether or not those services are included in the state Medicaid plan. The PIN clarifies that “FQHC/RHC providers must be practicing within the scope of their practice under the state law.”

What might PIN 2004-05 mean for the Medicaid population? Categorically eligible Medicaid beneficiaries (e.g., TANF, aged/blind/disabled) may or may not be able to easily gain access to public mental health services, depending on definitions of target populations and medical necessity, which vary from state to state.

In states with public mental health systems that focus on populations with serious mental illness and serious emotional disturbance, PIN 2004-05 creates an opportunity for other Medicaid populations, with higher physical health and lower behavioral health risks, to obtain behavioral health services through a CHC. This is consistent with the HRSA initiative to reduce health disparities and create behavioral health capacity in CHCs. PIN 2004-05 helps to assure that safety net populations are served.

But what does PIN 2004-05 mean in terms of financing and the behavioral health services now provided to populations with serious mental illness? The answer varies from state to state because of differing Medicaid models. This variability requires every community partnership between a CHC and a CMHC to assess their specific financing and policy environment in order to identify a business model that will support integration activities. Such partnerships must develop policy direction that addresses the need for greater access to behavioral health services for the Medicaid population, without disadvantaging any populations now served by the public mental health system.

Learning from Pilot Sites:

“Depression in Primary Care: Linking Clinical and System Strategies” is a Robert Wood Johnson Foundation national program to increase the effectiveness of depression treatment in primary care settings. The program charged its eight demonstration sites with addressing financial and structural issues as well as implementing clinical models. A special issue of Administration and Policy in Mental Health and Mental Health Services Research contains a series of resulting papers, some of which speak directly to the financial and policy barriers in the system.

The pilots reveal the commitment of sites around the country that continue to patch together funding because they believe in the integration approach. For example, in Washington State there is a partnership between the CMHC and the Federally Qualified Health Center, where the CMHC’s clinicians in the FQHC sites are financed by an annual golf tournament – hardly a sustainable model. The IMPACT trials, Depression in Primary Care project, state Medicaid pilot sites, and an Aetna project all identify similar components for financing:

– Screening

– Care management

– Psychiatric consultation

These are close to the components identified in the report of the President’s New Freedom Commission on Mental Health, which emphasized that there must be a relationship between mental health and general health. However, these service components are currently missing from public and private sector billing codes and financing policy. The challenge – for federal, state and private payors – will be to align financial/policy incentives to support clinical integration, which research demonstrates is effective in achieving positive outcomes.

Barbara Mauer is a nationally known expert in behavioral health and primary care integration. She has more than 15 years of experience in this field and is a managing consultant for MCPP Healthcare Consulting in Seattle as well as a National Council senior consultant. She offers consulting services to public and private sector health and human service organizations on integration as well as strategic planning, quality improvement, and project management. Mauer has authored many papers and books on behavioral health and primary care integration.

References 1. Proser, M., Shin, P., Hawkins, D., “A Nation’s Health At Risk III: Growing Uninsured, Budget Cutbacks Challenge President’s Initiative to Put a Health Center in Every Poor County”, National Association of Community Health Centers, www.nachc.com/research/

Nine Recommendations to Increase Continuity of Mental Health Care For Schizophrenia Patients

Continuity of therapy is a vital component of quality care for people with serious mental illnesses and must be given more attention by consumers themselves, family members, advocates, providers, administrators, and researchers alike. At the moment, there is an important opportunity to develop a national consensus statement on the principles and practice standards that should form the basis of a continuum of therapy designed to provide realistic assurance that consumers can access vital medications when and where they are needed. Important strides have been made in identifying the specific factors which promote continuity of therapy – it is time to seize this important opportunity as yet another stepping stone to achieving the transformation of America’s mental health care system for the benefit of consumers and their families, our communities, and our Nation. A roundtable of mental health experts has developed a set of nine recommendations for enhancing continuity of medication therapy for persons with schizophrenia or serious mental illness, including schizophrenia. They are as follows:

Mental Healthcare Recommendation #1 –

Encourage collaborations between hospitals and community-based organizations. Use fiscal incentives to foster collaborations including the standardization of information and shared electronic health records.

Mental Healthcare Recommendation #2 –

Use a quality improvement approach to enhance continuity of therapy by benchmarking at the organizational level performance and outcomes standards regarding continuity of care.

Mental Healthcare Recommendation #3 –

Ensure all consumers have a level of care management for the transition from inpatient to community. Care management services should be reimbursable by all payers and the disincentives to providing it should be removed.

Mental Healthcare Recommendation #4 –

Hospitals and community providers should focus on the “Pull Model” of transition from inpatient to outpatient care. The Pull Model focuses on involving community-based providers in the transition planning process from the beginning. Provider organizations should focus on staff competency in engagement and strategies and motivational interviewing.

Mental Healthcare Recommendation #5 –

Accreditation standards should be aligned to address and improve continuity of therapy in treating serious mental illness. This may include developing standards to ensure evidence of an active process of care management and transition between levels of care, a quality review of the success of transition plans, and measuring engagement.

Mental Healthcare Recommendation #6 –

Consumers and their families should be educated about the benefits of maintaining their personal health care history. Ensuring that consumers have detailed information about their illnesses and treatment history will help ensure that providers have access to the information they need to provide appropriate care in a timely manner. The options here range from simple paper and pencil logs and medication histories to electronic records on memory sticks.

Mental Healthcare Recommendation #7 –

Consumer-driven recovery planning should include and the appropriate and necessary use of hospitalization. More thoughtful use of inpatient services could lead to a reduction in emergency room use and ultimately to a decrease in the number of hospitalizations.

Mental Healthcare Recommendation #8 –

Parties who collect data about mental health services and performance should share it with appropriate stakeholders in usable and timely ways. Many payers and public entities collect both population and individual specific information about mental health consumers and services. Population-based data should be shared with all stakeholders, including families and consumers to aid in enhancing the system of care.

Mental Healthcare Recommendation #9 –

There should be meaningful involvement of consumers and their advocates in all levels of system delivery and evaluation. Global involvement of consumers and their advocates in the care delivery process is essential. Examples include using peer specialists as part of a treatment team, active involvement in policy and planning, as well as involvement in developing and implementing performance measurement and evaluation.

Applying these Mental Healthcare Recommendations –

While we have learned that maintaining continuity of therapy has a positive impact on consumer outcomes, the barriers and other impediments to ensuring this continuum of care have been long entrenched in mental health and related care systems. An unacceptably high number of people with serious psychiatric issues – including schizophrenia, depression and bipolar disorder – are “falling between the cracks” in the transition between acute inpatient settings and the community causing harm and disruption in their own lives and those of their families and often bringing their recovery process to a halt.

A continuity of therapy initiative is likely to decrease inappropriate use of emergency room services by consumers with schizophrenia or other serious mental illnesses by assuring consistency in the disease management approach used by all community provider organizations. Both of these likely outcomes of continuity of therapy provide cost reductions for the hospital and cost offset for the investments in continuity of therapy initiative and related therapies.

In addition, the continuity of therapy initiative provides the community hospital with another very tangible benefit. The continuity of therapy initiative provides the relationships, process, and infrastructure for an overall discharge planning functionality for all consumers with mental illnesses. This discharge planning functionality is a new, and critical, element in modern behavioral health standards that began in 2007.

Family Behaviors That Grow Out of Developmental Trauma

Increasingly there are a number of families that are suffering intense multigenerational dysfunction that acts as a polluting agent that is interfering with the quality of life for all family members and significantly impairing or interrupting the normal psychological, emotional and social development of the children born into those families. This article is not a blame casting or finger pointing toward those families suffering with these well established patterns that generate pain and discontent in the lives of their members. This article is a simple examination of some of the common characteristics that emerge in these troubled families.

Many of the families that bring young children into clinical or therapeutic settings, particularly in the community behavioral health sector of mental health services, are in real emotional pain and desperate for relief and resolution. These families are frequently characterized by behaviors that show many of their collective family needs for stability, nurturance, empathy and mutual acceptance are not met in a predictable manner. This is true for the parents, and many times grandparents to the children; children to parents; and children to each other. Many of these families are well meaning, sincere people that are caught up in a pattern of poor quality attachments, emotionally explosive interactions, unpredictable reactive behaviors and some forms of physical or emotional abuse.

Many times these families come into contact with systems of care and correction such as (Child Protective Services, Schools, Juvenile probation) that tend to blame the parent for the family culture that they are actively following and treat them punitively without adequate respect, and while that is tempting to think in terms of blame, it doesn’t generally appear to be tremendously helpful to the blamed family. This is unfortunate, since that adds additional weight to an already struggling and impaired family system that can be emotionally unstable and unpredictable in the best of times. Many of these troubled families are already feeling overwhelmed and highly defended and self-protective because they lack emotional support and adequate healthy connections with others.

These families that are already in pain, frequently have low levels of trust for anyone, much less the systems that they are both trying to avoid and seeking help from. The father in one such family sat with a steady stream of tears marking his cheeks when he discussed how humiliated and manipulated he felt by the system that was supposed to be helping him, and as a result had developed an attitude of mild paranoia “I will never be treated fairly or with respect, I always get the short end of the stick, and it is usually got some nails in it… ” Feel untrusting doubtful of others motives is a common characteristic of highly disturbed families.

Sometimes when reading reports of child protective services, juvenile probation or other entities involved with these families in pain, there exists a repeated theme, Those in the system such as (Child Protective Services, Schools, Juvenile probation) tend to blame the parents, and sometime parents are accused of caring more for their own needs and wants than those of their children. This is a relatively predictable outcome of being raised in a highly disrupted family environment of chaos. Many of the parents are self-centered and very defensive, and when one wins a little of their trust, in many circumstances it becomes apparent that they have lacked adequate attention, affection, warmth, or companionship throughout their lives. The parents as well as their children are challenged to understand others, listening attentively, and/or finding effective and satisfying ways to interact with those around them.

Many of these families have competitive cycles where all the members compete for the title of being the defective one, the bad one, or the unwanted inferior one. Often the members of these families feel very much like they are unlovable. This painful emotional state may lead many of the family members endeavor to avoid or isolate themselves from those around them, as way to feel safe emotionally and reduce their disturbance of feelings. That to cope with the emotional pain they will in many circumstances remove themselves from situations that might provide support and encouragement instead frequently perceiving themselves as being different from other people, and not part of any group or community. This is characterized as frequent changes of relationships, residence and employment.

Families with the culture of dysfunction that is handed down from generation to generation are not evil people, but need increased support and the good will of others. They will not change quickly, but the first stage of that change is generally having a few trustworthy people provide acceptance and encouragement toward the growth of the individuals in the family. Harsh judgments from care and service workers, just reinforces the already painful, and misery causing emotional pain that has kept these families paralyzed from embracing real and effective changes and improvements.

Robert Rhoton PsyD Professor of Behavioral Science Ottawa University