Abstract

In the city of New Orleans, a number of social, cultural, economic, and historical factors have affected the availability and accessibility of mental health services. To assist individuals suffering from mental illness in the city of New Orleans, various agencies, programs and databases have been implemented to promote easy access to the available mental health services. This study explores the ease of accessing available mental health services through telephone contact. The telephone was used as the main source of contact in this study to emulate the experience that a potential mental health client would undergo when trying to find treatment. National, state, and local mental health provider databases were used to compose a list of mental health agencies in the New Orleans area. One hundred and twenty-seven facilities were identified as mental health treatment agencies. Each agency was contacted by phone and requested to participate in the study by completing a 15-item questionnaire regarding the availability and accessibility of mental health services. Seventy-nine percent [n= 101] of the agencies contacted by phone did not answer or had an automated voicemail service. Descriptive information regarding the availability and accessibility of mental health services, types of services, and treatment populations are reported and discussed. This research addresses the disparities between the burden of mental disorders, resources and accessibility.

1. Predicament of Services: An Independent Survey of New Orleans Mental Healthcare System

Mental healthcare is fundamental in Louisiana and difficulty accessing it adversely affects the residents and society as a whole. Louisiana estimates approximately 4,659,978 residents; out of that number, 172,000 (or 5%) of adults 18 years of age and older suffer with Serious Mental Illness (SMI) ¹. Unfortunately, only 19,468 individuals were reportedly receiving services for serious mental illness (SMI) ¹. The state of Louisiana is ranked number 16 in the country for individuals age 18 and older with Serious Mental Illness (SMI) ². According to SAMHSA, only 38.2% of adults with mental illness in Louisiana receive any form of treatment from either the public or private sectors ¹. The remaining 61.8% receive no mental health treatment. According to Mental Health America (MHA) 2019 statistics, Louisiana ranks 41^st in access to mental health care ³. This ranking was determined by Louisiana’s access to mental health services that include: psychiatric hospitals, nonfederal general hospitals with a separate psychiatric inpatient unit, residential treatment centers for children with emotional disturbance, residential treatment centers for adults, freestanding outpatient facilities, and multi-setting (non-hospital based) MH (mental health) facilities. The city of New Orleans, Louisiana circumvents the plight of mental illness by providing a plethora of mental health services to its residents.

“In 2015, the total adult population in Orleans Parish was 360,524, and out of that group 19,468 individuals were receiving services for serious mental illness (SMI). Orleans Parish has a population of 46,762 children and youth between the ages of 9-17, and out of that group there are 3,273 children that receive services for serious emotional disturbances (SED) In 2015, New Orleans had a total population of 407,286; out of the population, 22,741 people were being treated for SED or SMI” ².

According to US Census data, New Orleans, LA has more mental health care service providers than the national average ratio of mental health service providers. The mental health provider ratio in New Orleans is 340:1; the national average is 500:1 ⁴. With a mental health provider ratio that excels beyond the national average, how does New Orleans attribute the number of SMI and SED residents that go without services? The purpose of this study is to examine the availability and accessibility of mental health services in New Orleans.

Mental health services in New Orleans, Louisiana has exhibited consistent proclivities throughout its history. In 1816, Charity Hospital became the first institution to provide inpatient services to the mentally ill ⁵. By 1847, Charity Hospital had concluded its services to the mentally ill due to deficiencies in quality care; but in 1852, the New Orleans Temporary Insane Asylum opened its doors ⁵. The New Orleans Temporary Insane Asylum provided services for thirty years; throughout its tenure, they changed their location multiple times. One of the locations was in a prison, but by December of 1856, the "insane department" was abolished and mentally ill inmates were directed to the state asylum ⁵. The New Orleans Temporary Insane Asylum foreshadows many of the issues that are prevalent in the city today. The city of New Orleans’ dilemma of quality of care and the substitution of mental health facilities for prisons are issues that are ongoing.

In 2005, Hurricane Katrina drastically changed the New Orleans mental healthcare system. Due to deinstitutionalization, New Orleans has lost several beds in psychiatric hospitals needed for mental health patients. An estimated 92 psychiatric beds were lost from the closure of Charity Hospital located in downtown New Orleans ⁶. This hospital accounted for over 80% of care costs before 2005, when Hurricane Katrina hit the Greater New Orleans area ⁷. The State of Louisiana Bureau of Health Services Financing originally reported, “In May 2007, the Louisiana Department of Health (LDH) was awarded a $100 million Primary Care Access Stabilization Grant (PCASG)” (as cited in LPHI, 2017, p. 8-9) ⁸. This grant was given to help provide more access to primary, mental health, and dental care services to all patients no matter their income.

Hurricane Katrina will always be remembered as one of the worst disasters in history. Evidence suggests that disasters can trigger different mental and physical health issues (e.g., trauma-related disorders, depression, anxiety, and substance abuse). In 2005, the Centers for Disease Control and Prevention (CDC) conducted a study of where 50 percent of returning New Orleans residents displayed signs of a need for mental health treatment ⁹. Similar research found that from 222 survivors surveyed, over half (52%) continued to experience poor mental and physical health 15 months after Katrina ¹⁰. According to the Substance Abuse Mental Health Services Administration (SAMSHA), “between 2005-2010, there were 93,000 residents (age 12 and over) of the New Orleans area and the surrounding cities of Metairie and Kenner that were classified as having a substance use disorder” ¹¹.

Based on a study conducted, it was found that those who suffer from both substance abuse and mental illness are 7.47 times as likely to be arrested and booked in comparison to those with substance abuse issues alone (5.32) as well those with serious mental health issues (1.84) ¹². In regards to mental health and substance abuse, the statistics indicate that when the two co-exist in a person, it is quite detrimental in terms of the probability that an individual will enter the criminal justice system. As a result of the correlation between mental illness and the criminal justice system, New Orleans created a Consent Decree with its police officers to minimize the use of force against those who suffer from mental health illness or are diagnosed with behavioral health issues. In order to do so the New Orleans Police Department (NOPD) initiated the Crisis Intervention Team (CIT). The CIT’s purpose is to evaluate situations and determine if there are any mental health issues that present themselves. CIT is the primary responder to mental health/ behavioral health issues. In an interview, an interviewee stated the CIT officers act as de facto case managers ⁶.

The National Alliance on Mental Illness indicated that individuals in a mental health crisis are more likely to have interactions with the police than get medical help. Over 2 million individuals suffering from a mental illnesses are arrested each year ¹³. Considering their now criminal history it is conceivably more difficult to get needed services because of a lack of funds, insurance, and overall accessibility.

According to the World Health Organization (WHO), availability is defined as the sufficient supply and appropriate stock of health workers, while accessibility is the equitable distribution of the health workers ¹⁴. According to the Office of Disease Prevention and Health Promotion, accessibility requires 3 distinct steps: (1) entry into the healthcare system (usually through insurance coverage; (2) location where needed health services are provided; and (3) rapport between providers and patients ¹⁵.

As indicated by the Office of Disease Prevention and Health Promotion, there is a direct association between insurance coverage and accessibility. According to Davis (2019), insurance coverage and access to care plays a major role in the treatment of mental health. One study found that individuals suffering from psychological distress experienced more difficulty accessing health care services than adults without such distress ^{16, 17}. Whether or not a patient has insurance or not, is just one issue. Other aspects to consider are the type of reimbursable services, such as the copayments, cost of medication and other costs for services.

The insurance companies that provide mental health services in the New Orleans area are: Atena, American Fidelity Assurance Company, Blue Cross Blue Shield of LA, CIGNA HealthCare, and Humana ¹⁸. TRICARE, Medicare, and Medicaid also provide mental health services to the New Orleans area. Insurances with low reimbursement rates lead to mental health care providers not accepting patients who have their health care plans. For example, in the 2000s, Medicare reimbursement rates for psychologists were on the decline, and a survey showed that 26% of psychologists had stopped accepting Medicare citing low reimbursement rates as the reason for their departure ¹⁹. Reimbursement rates for mental health services can range from $7. 83 to $504.62 depending on the type and duration of the service ^{1, 20, 21, 22}.

According to research, insurance issues are only one barrier; a bigger barrier is locating mental health providers who are available to meet the patient’s needs ²³. Williams, Gilroy, Chang and Seymour (2017) surmised in their study that depending on the insurance company and level of training, only 9.8% to 59% of providers could offer a new patient appointment with psychiatry appointments being particularly difficult to schedule. In their project, they used what is known as a “secret shopper” methodology. Three researchers made scripted telephone calls to all behavioral health providers within 20 miles of central Denver who were listed in the online insurance directories of Anthem BlueCross BlueShield, United Healthcare, and Cigna ²³. The researchers pretended to be patients with depression (mild to moderate). Insurance companies were contacted by researchers to make inquiries about scheduling a psychiatric appointment. The study concluded that up to 10 calls were necessary to obtain an appointment with a psychiatrist ²³. The methodology of this study provides clear evidence of availability and accessibility of mental health services therefore, the scripted telephone calls procedure is used as a data collection method in the New Orleans Mental Health Services Survey.

2. Method

This study presents findings from the New Orleans Mental Health Services Survey (NOMHSS) conducted from September 2019 through October 2019. The NOMHSS was used to collect information from agencies in the New Orleans area that provide mental health treatment services. This section describes the research procedure, material and analysis used in the study.

A database of mental health agencies was composed based on the following criteria: (1) agency licensed and accredited to provide mental health treatment (2) agency main location in one of the 17 Orleans Parish zip codes (3) agency provides mental health services to residents who live within the 17 Orleans Parish zip codes. National, state, and local mental health treatment provider databases were used to identify qualifying mental health agencies ^{20, 21, 22, 23, 28}. Agencies were classified by seven types of providers categories including: psychiatric hospital, inpatient psychiatric unit of a hospital, residential treatment center for children or adults, outpatient or day treatment mental health agencies, multi-setting mental health agencies (non-hospital residential plus outpatient or day treatment or partial hospitalization), and correctional facilities.

One hundred and twenty-seven facilities were identified as mental health treatment agencies. Each agencies’ main offices were contacted by phone and requested to participate in the study by completing a 15-item questionnaire regarding the availability and accessibility of mental health services. Data was recorded and analyzed. Descriptive statistics and research findings are reported in the results section in Table 1 – Table 6.

A 15-item questionnaire form, the New Orleans Mental Health Service Questionnaire Form (NOMHSS) (Table 7), was adapted from the Substance Abuse and Mental Health Services Administration, 2012 National Mental Health Services Survey (N-MHSS) ¹¹. The NOMHSS is designed to collect data on the services, characteristics, and accessibility of mental health treatment service agencies throughout the New Orleans area. Participates were allowed to select multiple items on the NOMHSS to provide detailed information regarding each agency. IBM Statistical Package for the Social Sciences (SPSS) was used for the statistical analysis of the collected data.

3. Results

Based on the research findings, there are over 127 mental health agencies available to provide services to individuals in the New Orleans area (Table 1). 79% of the agencies contacted by phone did not answer or had an automated voicemail service (Table 1). Roughly, 5% of the agencies contacted did not have a working phone number. Of the agencies that answered the phone, (15.6%) 80% of those agencies elected to participate in the study.

Of the 16 agencies that completed the survey, roughly 88% reported that consumers access their services through outside referrals, while 62.5% were from walk-in and court orders (Table 2). The majority of the agencies surveyed (81.3%) reported advertising their services through television, the internet, or other media formats (Table 2).

The mental health agencies surveyed in this study offer an array of services that include: intake services, diagnostic evaluation, referral services, mental health treatment services, substance abuse treatment services, outpatient mental health services, telemedicine therapy, and crisis intervention present in Table 3. Less than seven percent of the agencies surveyed indicated that they provide 24-hour hospital inpatient service (Table 3).

The majority of the agencies surveyed (68.7%) identified themselves as an outpatient, day treatment, or partial hospitalization mental health agency. Residential treatment center for adults (37.5%) and residential treatment center for children (31.3%) accounted for one-third of the agencies surveyed. 31% of the agencies that completed the survey identified themselves as a psychiatric hospital or other state government agency. State mental health agency (SMHA) and local, county, and parish government agencies accounted for 25%, while tribal government accounted for 13% of the agency classifications. 13% categorized themselves as a private for-profit organization, while 44% reported they are categorized as a private non-profit organization. 19% reported themselves as a separate inpatient psychiatric unit of a general hospital. Less than 7% (6.3%) identified their agencies as a multi-setting mental health agency or a jail, prison, or detention center. All but one agency (93.7%) reported being licensed as a mental health agency and having a National Provider Identifier (NPI) number (Table 4).

The agencies that agreed to complete the survey reported the following data regarding their treatment population. Children (aged 17 or younger) accounted for 44% of the treatment population, while 81% were young adults (18-25) or adults (26 or older). Mood and anxiety disorders were identified as the most prevalent disorder with 68%, while autism spectrum disorders, attention deficit, conduct disorders, schizophrenia and or other psychoses were 56% of the treatment population. Eating disorders (e.g., anorexia nervosa, bulimia) were identified as a large treatment group (62.5%) and other disorders not listed accounted for 56% of the population.

The majority of the agencies surveyed (50%) accepted cash or self-payment, while 63% accepted Medicaid and 38% accepted Medicare. Federal military insurance and private health insurance were accepted as a form of payment for 31% of the agencies. 31% of the agencies used a sliding fee scale and 38% offered treatment at no charge to clients who could not pay.

4. Conclusion

The research findings indicate that there are over 127 mental health agencies in the New Orleans area, which provide an assortment of outpatient, inpatient and residential mental health services. Of the sample selected, private non-profit organizations, outpatient, day treatment, and partial hospitalization mental health agencies were the larger groups. However, state-funded inpatient services represent a much smaller portion of the agencies sampled, which would suggest financial means play a part in the availability of certain mental health services. The data suggest that mental health services are widely available to individuals in the New Orleans area, but economic factors influence consumer options.

Regarding the accessibility of mental health services in New Orleans, research findings indicate that consumers may face obstacles communicating with service providers through the telephone. Barriers to access services can result in reducing the overall effectiveness of treatment and exacerbate consumers’ frustration and mental illness symptoms. Agencies that have no working telephone number or automated voicemail services may deter consumers from attempting to locate the help that they need.

The research method of investigation was designed to mimic a consumers attempt to access mental health services through internet searches, databases, and telephone contact. This design revealed limitations in a number of issues regarding the accessibility of mental health services, but it also restricted the sample size of the agencies surveyed. Future studies may find alternative data collection strategies (e.g., mailed surveys, staff interviews, or consumer interviews) more effective in attaining a larger sample size.

Acknowledgements

I would like to express my gratitude to all the Dillard University faculty and staff for their support in this endeavor. I would also like to thank Akia Armstrong, Kayla Hicks, Jayna Parker & Aaliyah Wood for their hard work and dedication to this research.

References