By: Beth Anne Nichols, NH Mental Health Block Grant Plan Administrator
New Hampshire Department of Health and Human Services
In the rugged landscape that is New Hampshire’s mental health system, serious mental illness (SMI) is a powerful thing. On an individual level, an adult experiencing SMI becomes eligible for community-based psychiatric rehabilitation. Psychiatric rehabilitation consists of an array of services reimbursable by NH Medicaid alone. The privately insured may access these services via a sliding fee scale – if they are assessed and determined to be SMI.
The capstone of NH’s Community Mental Health provider programs is the case management and treatment for our SMI population.
If the ten Community Mental Health Centers (CMHC) are the spokes in the sturdy wheel of the SMI treatment services system, the hub of the wheel is the NH Department of Health and Human services (NH-DHHS).
The NH-DHHS has established the Adult Needs and Strengths Assessment (NH-ANSA) as the instrument that informs and directs the treatment, and records the treatment outcomes, of the thousands of SMI adults in the care of the CMHCs.
In the world of psychiatry, the classification of mental illnesses changes as the body of knowledge, experience, and science evolve. But the federal government’s – and the state of NH’s – definition of “Serious Mental Illness” has remained unchanged for decades. Labeling someone as “Seriously Mentally Ill” can create nearly as many social and vocational barriers as it does opportunities for psychiatric rehabilitation.
Into this world of mixed blessings comes the NH-ANSA. The original vision for the NH-ANSA was to serve as a standard for determining the presence of SMI, serving as the “ticket” to psych-rehab services like the valuable case management and “functional supports” provided in the community, at home, or in the workplace. Increasingly– as the treatment focus for a large portion of the SMI population under our care follows a progression of symptom management to functional improvements, especially employment stability– tracking impairment needs and improved functioning has assumed a high priority.
For NH community mental health programs, the ANSA, as a periodic measuring stick of symptom and functioning, has replaced a narrative annual assessment of functioning (though not without resistance!). Gradually, the CMHCs and growing numbers of their partners, are using the NH-ANSA to chart a path toward clear reporting of treatment and recovery trajectories. The NH-ANSA provides a sound objective basis for program screening based not only on diagnosis, but on levels of need and clusters of impairments that clearly inform treatment planning, and outcomes goals across the service system.
The NH ANSA to the Rescue
The federal definition of serious mental illness was created to assist in the determination of eligibility for Social Security disability benefits. Specifically, assessment of impairments interfering with the ability to maintain employment or other “major life activities” were a key component for Social Security disability determinations. New Hampshire embraced these criteria because of the strong link between Social Security and Medicaid.
Psychiatric diagnosis and symptoms form a slice of SMI criteria; the degree of “functional impairment” contributing to disability caused by mental illness is a much larger slice. The ANSA, with the elemental nature of its Life Functioning domain, provides an objective yardstick.
For those who are interested, NH’s SMI criteria are laid out in He-M 401 of our “Administrative Rules”. These criteria were the basis for the work of New Hampshire and Dr. John Lyons to crosswalk SMI requirements into the NH-ANSA.
Collaboration between an individual, their natural supports, and their treatment team to craft a treatment and recovery trajectory based on the ANSA removes the directive and top down nature of the narrative assessment previously employed by our providers.
Today the State of NH continues to collaborate with our providers and the Praed Foundation to polish the assessment instruments that can order the landscape of our mental health service system. The NH-ANSA, with its efficiency and objectivity, strengthens the foundations recovery for our SMI adults.
This reference to “the elemental nature” of ANSA items is well said. In contrast to other tools that try to reduce a lot of information into a small amount of items, TCOM tools have many, short and focused items. As such, you can use each of these little “elements” (i.e. items) to reflect vague regularly concepts such as “major life activities” or “functional impairments.” A list of ANSA items is a meaningful thing that can build into a concept that has regularly implications. A tool with less elemental items, though perhaps statistically valid, is not useful for actually accomplishing a regularly concept, since those concepts are not statistical — they are legal. Legal concepts are built off of real things that happen in the world — not statistical norms and their deviation. TCOM items bridge the gap between regulations and clinical life by being short and focused, and summing to math abstractly, but being built on real world “elements.”