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City of Albuquerque/Bernalillo County System Gap Analysis

The State of New Mexico, with its abundant, natural beauty and rich, diverse multicultural heritage, has been at the forefront of innovation and implementation in providing behavioral health services in the public sector and has a very impressive foundation upon which to build.
The list is long:

  • Leading the country with the nation’s first state Behavioral Health Collaborative legislated in 2004 to address behavioral health challenges and quality of life across state agencies by coordinating services and braiding funding.
  • The development of inarguably one of the most utilized change focused evidence-based practices in the world, “Motivational Interviewing,” created here at the University of New Mexico by William Miller, PhD and Stephen Rollnick, PhD.
  • The creation of the evidence-based Community Reinforcement Approach and Community Reinforcement Approach Family Training used across the country to help individuals and families struggling with substance use disorder by Robert J. Meyers, William Miller, and Susanne Hiller-Sturmhofel et.al.
  • The University of New Mexico’s Project Echo, improving healthcare and providing expert technical assistance and education around the globe.
  • The early adoption of the certification and utilization of Peer Support Specialists and Family Peer Support Specialists across the state.
  • A leading-edge managed Medicaid Managed Care program for New Mexico, Centennial Care 2.0, that requires Managed Care Organizations (MCOs) to work systemically and attend not only to the physical and behavioral healthcare needs of our citizens, but also to the social determinants of health often driving chronic health conditions.
  • The Bernalillo County Behavioral Health Services Division expansion of the Comprehensive Assessment and Recovery through Excellence (CARE) Campus’ continuum of services for substance use and co-occurring disorders and the newly developed peer driven behavioral health Community Engagement Teams using outreach and in home services.
  • The visionary implementation and infusion of the principals of Trauma Informed Care and the Adverse Childhood Experiences Study well ahead of other jurisdictions across the country. These and other innovations led to the highly prestigious National Council 2020 Innovation at Work Award for the Bernalillo County Department of Behavioral Health Services, which launched 23 programs, invested $20 million into the behavioral health industry by partnering with service providers, committed more than $70 million to behavioral health projects and helped more than 50,000 people. These Bernalillo County innovative responses and interventions could not have occurred without the incredibly courageous, knowledgeable, and invested County Commission and leadership.
  • The City of Albuquerque, under the visionary yet practical leadership of Mayor Tim Keller, has taken a compassionate and action and results oriented approach to problems plaguing Albuquerque and other cities around the country – homelessness, violent crime, mental health and substance use problems, and inequities in cultural, racial, ethnic, sexual, and gender orientations – and moved toward the improvement of quality of life in Albuquerque making our City more attractive to economic development.
    • Projects implemented through the City’s Department of Family Community Services include funding to more than 100 programs across the City, especially focused on homelessness and related issues.
  • Mayor Tim Keller’s administration making the decision to create the Albuquerque Community Safety Department (ACS), a third branch of the City of Albuquerque’s first responder system: Police, Fire, and Community Safety, to utilize behavioral health experts and peers investing in community health and behavioral health responses, taking a public health and poverty informed approach to calls of distress, and allowing law enforcement resources to focus on violent and other crime.
  • The Bernalillo County Metropolitan Detention Center as one of the first in the nation to provide Medication Assisted Treatment to those suffering from Opioid Use Disorder during incarceration, soon to include Buprenorphine as well as Methadone.

To quote Dr. Vartan Gregorian about system change, he remarked that “In order to change a system you have to be either a loving critic or a critical lover.” With nearly 100 years’ experience between the three main writers of this analysis, most of those years in New Mexico, along with feedback from numerous focus groups and one-on-one conversations with local stakeholders, clients, family members, managed care leaders, City, state and County leaders and City, County, and state employees as this analysis was conducted, it is safe to say that New Mexico is filled with “critical lovers;” kind, enthusiastic, creative, engaged, and invested people. Some of these people and advocacy groups have worked for decades, at times with little or no reimbursement or recognition, to help create environments of healing and hope for the most vulnerable. New Mexico is blessed with diverse cultures where family and community is valued and prioritized—one of our richest resources!

This context of strength-based accomplishments and heart-felt compassion is important to understand as foundational when embarking to do the hard, clear-eyed work of identifying gaps in the system of care in Albuquerque and Bernalillo County and recommending changes. It is important to point out that this is an evaluation of the gaps in the behavioral health system of care, not the performance of Bernalillo County Behavioral Health Service Division or the City of Albuquerque’s Community and Family Services Department. Bernalillo County and the City of Albuquerque jointly commissioned this system of care gaps analysis, and this unifying action is to be strongly commended.

For the purpose of this gap analysis, the system of care refers to the complete network of indigenous and professional services and relationships that can support the long-term wellness of individuals and families and the creation of values and policies in the larger cultural and policy environment that are supportive of these processes. The system must include County and City governments and behavioral health services, physical health providers and hospital systems, insurers, homelessness and housing programs and shelters, law enforcement, jails and corrections, violence prevention and intervention programs, behavioral health and other social services providers such as DUI Councils, domestic violence programs, rape crisis centers, recreation programs, youth and family programs, the New Mexico Human Services Division, the New Mexico Behavioral Health Services Division (BHSD), the New Mexico Children, Youth and Families Department, the New Mexico Behavioral Health Collaborative, Native American pueblos, tribes, service providers, trade associations, business associations, faith-based providers, and ministerial alliances.

It is now a standard practice in behavioral health and systems change to base the work on trauma informed principles along with an understanding of the effects of Adverse Childhood Experiences. It is important to note that both evidence-based approaches have a foundational understanding that the primary human need as an infant, in the first 18 months of life, is for safe and secure attachment to loving care takers. Some might say that survival is more important than attachment, but what is known is that infants who do not attach to others physically will not survive. Insufficient attachment and subsequent Adverse Childhood Experiences, drive nearly all subsequent substance use disorders, especially opioid use disorder, and cause or exacerbate mental health challenges.

Adverse Childhood Experiences (ACEs) are nearly a universal experience of people who experience homelessness and incarceration and for about 60 percent of the rest of the population. These ACEs, to a greater or lesser degree, cause a fundamental disconnect from one’s body, emotions, intuition, connection to family, community, and sadly, to the natural world and a sense of joy, awe, and wonder. This creates a sense of being “other,” along with a hypersensitivity to judgment, punishment, and danger. This suppression also creates the feeling of anxiety and division within oneself, often leading to the acting out of emotions, instincts, and repressed pain. This causes myriad anguish, anxiety, depression, substance use, homelessness, domestic violence, crime, racism, and sexism and drives physical, chronic healthcare problems throughout the arc of a person’s life, with the monumental and tragic loss of human and fiscal capital. Some readers may be uncomfortable with this evidence and it is important to also note that personal responsibility, to the best of ones’ ability, is a hallmark of recovery and wellness. These maladies are being experienced in the United States (US) at higher levels and at younger ages. According to the National Council for Mental Wellbeing, prevalence of a mental health disorder stands at about 20 percent in the population of the US. However, 50 percent of those who develop a mental health or substance use disorder in their lifetimes show symptoms prior to the age of 21. Remarkably, 75 percent show symptomology prior the age of 24.

So, what actually helps individuals and families who may be challenged by homelessness, crime, substance use or mental health disorders begin to engage toward attachment? These issues are extraordinarily complex, but there is near universal agreement among researchers and clinicians on the foundational characteristics needed to help others, including the evidence-based practices developed in New Mexico mentioned earlier. These universal characteristics must be foundational throughout a system of care, including toward clients, families, providers, payers, and regulators. These foundational invitations to engagement and re-attachment are referred to as Trauma Informed Principles and include the skills needed to create environments for physical and psychological safety; trusting relationships; compassion toward self, colleagues and clients; genuine collaboration (including diversity, equity, and inclusion); genuine client choice; along with a sense of clarity and empowerment. People need allies, navigators, peers, clinicians, law enforcement, legislators, leaders, and friends and neighbors who exude, radiate, and live these principles. They become natural connectors, purveyors of hope, and help people feel connected and attached to, and a part of, the community.

These skills and attitudes can be planned, implemented, measured, monitored, and supported systemically, and they do not require a lot of new resources. However, they are the “clay” required to form a genuine living behavioral health system of care worthy of friends, families, community members, and those just passing through. Without them, too often, traumatized clients are treated in traumatized organizations, with often traumatized staff, and then returned to traumatized families and communities. To the extent the trauma informed principles are missing within a system, to that degree the system will be difficult to navigate, harsh, competitive, and wasteful. Difficult to navigate, harsh systems wear people out until they are arrested or need high-cost emergency room care. It has been shared that in a fragmented system that the process of getting help is more painful than living with the consequences of mental health or substance use disorders. This says something deeply profound about the need for changes.

In summary, it is the conclusion of our analysis that the largest gap, as will be described below, is also potentially the system’s greatest strength. The Albuquerque and Bernalillo County behavioral health system is flush with expertise, cultures, diversity, and individuals who exude compassion and trauma informed ways of being. The major gap is that, although we have services that have arisen in response and in reaction to crises that have increased over the years, we have yet to develop a single coordinated system of care in Albuquerque and Bernalillo County to connect, coordinate, nurture, manage, and make these resources readily known and available to customers. This is the next developmental step. The City and County have developed important, innovative social services in response to the crises of our times and of our community. The next developmental step is to plan, develop, implement, incentivize, measure, monitor and improve a single system of care as defined above.

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