Will Humble Behavioral Health, Wills Blog

Helping Loved Ones Get the Care they Need – Secure Residential Treatment: A Crucial (and Scarce) Resource for Supporting Mental Health Treatment (Part III of III)

One of the biggest barriers to providing effective treatment for persons with a serious mental illness who need court ordered treatment in Arizona is the lack of secure residential facilities that can provide secure court-ordered care.

These specialized facilities are key for ensuring people with an SMI get the care they need in a safe, structured environment. Secure facilities provide a controlled atmosphere where patients can receive individualized therapy, medication management, and life skills training, which are critical components for recovery.

Research suggests secure residential facilities are highly effective at stabilizing individuals with an SMI, reducing the likelihood of relapse, and preventing unnecessary hospitalizations, underscoring that treatment in secure environments can be a game-changer for people who require intensive care but aren’t suited for traditional outpatient or voluntary inpatient settings.

AHCCCS plays a key role in ensuring access to these essential services. For AHCCCS to fulfill its mission of supporting individuals with SMI, there needs to be an adequate supply of more secure treatment facilities.

Sadly, Arizona is falling short in that regard… even before the closure of St. Luke’s Hospital.

St. Luke’s lays off employees after license suspension
Arizona suspends operations at a St. Luke’s psychiatric hospital
St. Luke’s psych hospital may re-open under new operator

In Arizona, the shortage of secure residential treatment capacity is particularly dire. 

In 2022 we were finally able to get badly needed funding ($25M) to construct 5 Secure Behavioral Health Residential Facilities (SBHRFs) with 15 beds each.

Unfortunately, that funding was swept in the 2023 state budget at the behest of the ACLU, leaving a critical gap in care that continues to affect Arizona’s most vulnerable.

Without secure residential facilities, some persons may end up cycling in and out of emergency rooms, hospitals, or even jails—none of which provide the sustained treatment needed to manage their mental health effectively.

When states lack enough secure residential treatment options (like Arizona) patients are left without access to the proper level of care, increasing the burden on emergency services and acute psychiatric hospitals.

For Medicaid programs to be successful in treating individuals with a SMI, they must have the infrastructure to support all levels of care, including secure residential treatment.

The absence of SBHRFs in Arizona is a huge gap in the care continuum and is compromising the health and safety of individuals and communities.

Arizona has an opportunity to correct this gap and reverse the tragic decision to nix funding for SBHRFs, but it will require state policymakers to prioritize the funding necessary to create these facilities.

Hopefully the next legislature and the governor will listen more to mental health professionals and families and less to the ACLU – and get these badly needed facilities up and running.

Without more secure treatment facilities Arizona will continue to fail to meet the needs of its SMI population, leading to poorer outcomes for patients and increased costs across the healthcare system.

The time to act is now—before more lives are lost or further destabilized by inadequate care options.

Call to Action: The Arizona Legislature must make secure residential treatment facilities a funding priority in the 2025 state budget. Providing comprehensive care for individuals with serious mental illness is not only a matter of public health but also a moral imperative.

Read the 3-Part Series
Helping Loved Ones Get the Care They Need: Navigating Arizona’s Court-Ordered Treatment Process for Persons with Mental Illness (Part I of III)
Helping Loved Ones Get the Care they Need: Secure Environments Can Enhance Care for People with Serious Mental Illness (Part II of III)
Helping Loved Ones Get the Care they Need – Secure Residential Treatment: A Crucial (and Scarce) Resource for Supporting Mental Health Treatment (Part III of III)
Will Humble Behavioral Health, Wills Blog

Helping Loved Ones Get the Care they Need: Secure Environments Can Enhance Care for People with Serious Mental Illness (Part II of III)

Recent literature supports the effectiveness of treating some people with serious mental illness in secure environments, particularly when they need intensive care.

Secure environments like psychiatric inpatient units or secure behavioral health residential settings provide a controlled and therapeutic space that can help stabilize patients while minimizing risks.

Inpatient Psychiatric Units and secure residential facilities provide a combination of safety and structured care that is crucial for folks with a SMI who may be at risk of self-harm or violence.

Research shows that when properly designed, secure environments help reduce adverse events, support mental health recovery, and create therapeutic relationships between patients and staff, while avoiding unnecessary coercion.

A 2022 meta-analysis on inpatient suicides emphasizes that secure, therapeutic environments with proper safety measures can significantly reduce risks in psychiatric patients. This highlights the critical role of secure settings in stabilizing patients during acute crises.

How Inpatient Psychiatric Units Can Be Both Safe and Therapeutic | Journal of Ethics

Mental Health America highlights that involuntary treatment (including inpatient commitment) is essential for patients who require structure to engage in treatment that they would otherwise avoid​: Involuntary Mental Health Treatment | Mental Health America

These findings underscore the importance of secure psychiatric environments for individuals with an SMI, especially those needing intensive, non-voluntary care. These settings not only provide safety but also enhance therapeutic engagement, facilitating long-term recovery.

In our next post we’ll discuss how Arizona’s shortage of secure treatment facilities is undermining care for persons who need a more secure setting for their court ordered treatment.

Read the 3-Part Series
Helping Loved Ones Get the Care They Need: Navigating Arizona’s Court-Ordered Treatment Process for Persons with Mental Illness (Part I of III)
Helping Loved Ones Get the Care they Need: Secure Environments Can Enhance Care for People with Serious Mental Illness (Part II of III)
Helping Loved Ones Get the Care they Need – Secure Residential Treatment: A Crucial (and Scarce) Resource for Supporting Mental Health Treatment (Part III of III)
Will Humble Behavioral Health, Public Health, Wills Blog

Helping Loved Ones Get the Care They Need: Navigating Arizona’s Court-Ordered Treatment Process for Persons with Mental Illness (Part I of III)

Dealing with a loved one’s serious mental illness (SMI) can be overwhelming, especially when they don’t recognize that they need help. This lack of awareness, known as anosognosia, can prevent people with SMI from accepting treatment.

In these situations family members in Arizona can turn to the legal process of court-ordered evaluation and treatment to ensure their loved one receives the care they need. Sometimes families need to seek a civil commitment to ensure treatment.

Civil commitment is a legal process to get treatment for persons who are a danger to themselves or others (or gravely disabled due to a mental illness) but who are unwilling to voluntarily seek treatment (see ARS 36-501).

How Court Ordered Treatment Works

Arizona law outlines a process to help families get their loved ones evaluated and treated through a court order. The process begins with a court-ordered evaluation.

First, a family member (or any responsible person over 18) files an application at a hospital (known as a screening agency). Screening agencies can help the family fill out the form, which goes to a doctor to review for approval.

A judge ends up getting the information from the screening agency and is the person who ultimately decides whether the person should be involuntarily hospitalized or get outpatient treatment in the community.

When a judge does decide the person needs treatment they’re often ordered to get a combination of inpatient and outpatient care for 365 days (most of those days being in an outpatient setting).

Orders in Maricopa County include the following:

  • See your prescriber once a month (for the next 365 days);
  • See your case manager once a month in the home; and/or
  • Take your medication as prescribed for the next year.
Where Does Treatment Happen?

In some cases outpatient treatment is sufficient, but people who are a flight risk or resistant to treatment sometimes need a secure residential or clinical setting, especially at first.

For people at risk of elopement, a secure facility offers an environment where treatment can be delivered consistently and safely. These settings (inpatient or secure residential) provide both clinical care and the security needed to prevent patients from leaving before their treatment is complete.

Navigating Arizona’s court-ordered treatment process can be complex, but it’s often a critical step in ensuring that individuals with serious mental illness receive the care they need.

By advocating for the right treatment environment—especially when security is a concern—families can help their loved ones stay on track with their recovery. More about that in the next post. 

Read the 3-Part Series
Helping Loved Ones Get the Care They Need: Navigating Arizona’s Court-Ordered Treatment Process for Persons with Mental Illness (Part I of III)
Helping Loved Ones Get the Care they Need: Secure Environments Can Enhance Care for People with Serious Mental Illness (Part II of III)
Helping Loved Ones Get the Care they Need – Secure Residential Treatment: A Crucial (and Scarce) Resource for Supporting Mental Health Treatment (Part III of III)
Will Humble Social Determinants, Wills Blog

KFF Releases Election Fact Sheets About the Health Care Landscape in Every State

A new KFF tool generates data-driven fact sheets that lay out the health care landscape in every state against the backdrop of the 2024 election.

These state “snapshots” provide information on a variety of health care topics that may be the focus of campaign and policy debates. Topics include health costs; medical debt; women’s health policy, including state abortion, contraception and maternity laws and policies; health coverage, including the Affordable Care Act, Medicare and prescription drug coverage, Medicaid, and employer-sponsored insurance; gender affirming care; and basic information on health status, population and income. 

The new tool is part of KFF’s broader collection of Election 2024-related resources, including our side-by-side comparison of the candidates’ positions and records on health policy issues.

Will Humble Public Health, Wills Blog

Public Health Journalism this Week

Props 315 and 135 take the legislative role too far (Rob Robb substack)

Proposition 135: Should you vote yes or no on the measure? (ktar.com)

Prop 315 supporters argue it will save money; opponents say it will cost lives (azcapitoltimes.com)

Former state employee faces charges in Arizona Medicaid fraud case (azcentral.com)

St. Luke’s lays off employees after license suspension | 12news.com

Phoenix workers at St. Luke’s behavioral health facilities face layoff (azcentral.com)

Arizona Horizon | Telehealth in Medicare PBS

Arizona opinion: Energy incentives empower our rural clinics (tucson.com)

OPINION: Sunshine to Savings: How solar energy became accessible for Arizona families (coppercourier.com)

Will Humble Injury Prevention, Prevention, Public Health, Wills Blog

Phoenix to Redeploy Some Red Light Cameras. What’s the Public Health Evidence?

Red light cameras save lives. Photo speed cameras probably don’t.

From 2001 to 2019 the City of Phoenix set up a handful of red-light cameras at strategic intersections with frequent violent crashes. The city council discontinued use of red-light cameras in ’19 because of concerns about “privacy, effectiveness and discrimination”.

Last year Phoenix Police asked the Council to reinstate them. The Council did so this week, approving the installation of 10 red light cameras across strategic Phoenix intersections. The Council was receptive to adding more red-light cameras in the future depending on the results.

Red-light cameras are coming back to Phoenix

In addition to the ten cameras, the Council approved deploying 6 speed cameras (they say to be moved throughout the city every four to six weeks at intersections with a high number of speed-related crashes and school zones).

What’s the Public Health Evidence?
  • Red-light running cameras (evidence-based)
  • Speed cameras at green lights (NOT evidence-based)
  • Fixed midblock speed cameras posted on long stretches of road (NOT evidence-based)
  • Portable speed towers (NOT evidence-based except around schools)
  • Mobile speed vehicles (NOT evidence-based except around schools)

Public health literature suggests well-placed red-light cameras save lives and reduce severe injuries. Photo speed cameras probably don’t.

Data collected by Phoenix PD suggests that the 12 cameras that had been used prior to 2019 resulted in a 31% drop in red light running crashes at the cross-streets they were used and a 57% drop in red light running crashes in the directions the cameras were facing.

A landmark study for photo enforcement was done by Retting et.al. and published in the American Journal of Public Health examining the impact that photo enforcement had in Oxnard CA after they implemented their photo enforcement program.

Intersections that had red light cameras installed had a 29% reduction in injury crashes. T-bone crashes from red light running were reduced 32% and violent T-bones causing injuries were reduced 68%. Overall accidents at the intersections were reduced by 7%.

There’s less clear evidence that speed cameras are effective public health interventions. There’s almost nothing in the literature that I could find one way or the other for speed cameras.

However, a few years ago a research team that included Dr. Chengcheng Hu, director of biostatistics for the Phoenix campus of the UA Mel and Enid Zuckerman College of Public Health, Dr. Steven Vanhoy, a recent graduate of the UA College of Medicine – Phoenix, and several colleagues from Banner – University Medical Center Phoenix, offers some insight.

The researchers examined crash data along a 26-mile segment of Interstate-10 in Phoenix where speed cameras had been placed every 2 miles as well as a 14-mile control segment where no cameras had been deployed.

They compared crash data from Jan. 1 to Dec. 31, 2009 (when cameras were in place) to data from Jan. 1 to Dec. 31, 2011 (after the cameras had been removed).  They found that the removal of the photo radar cameras was associated with a two-fold increase in admissions to Level 1 Trauma Centers from car crashes in the areas where the cameras were removed.

Editorial Note: Nobody likes getting a traffic ticket, but photo red light enforcement can significantly reduce severe injuries if placed in the right intersections. There’s less evidence that photo speed enforcement works.

When photo speed cameras are used as a revenue generating tool (as it is in Paradise Valley – which places speed cameras practically every 500 meters throughout the town especially on roads with artificially low speed limits) it undermines public support for photo enforcement as a public health intervention.

Unless jurisdictions like Paradise Valley (who use photo enforcement as a revenue tool as opposed to a public safety tool) cool their jets, we risk an eventual statewide preemption of all photo enforcement, to the detriment of public health.

Will Humble Opioids, Wills Blog

Opioid Overdose Deaths Decline: A Turning Point Fueled by Harm Reduction & Settlements?

Over the past year, the U.S. has seen a significant decrease in opioid overdose deaths, including those involving fentanyl. After years of rising fatalities, this decline is promising and suggests that several key strategies are working together to reverse the trend.

Interestingly, there hasn’t been an across-the-board reduction in opioid deaths. Some states have done quite well in the last couple of years. For example, Nebraska has reduced opioid deaths by a remarkable 36%. Other states have seen big increases like Alaska with a 54% increase.

As you take a look at the charts above (courtesy AZPHA member and epidemiologist Allan Williams, PhD) you’ll see that Eastern and Midwestern states have been doing better than the western states. Arizona remained about the same – with a 1% increase in opioid deaths over the last couple of years.

One major factor for improvements in some states has been the wider distribution of naloxone (Narcan), the overdose-reversing drug. Communities across the country have increased access to naloxone by making it available without a prescription and training the public in its use.

This life-saving medication, when administered promptly, can reverse an opioid overdose, preventing deaths​ – but only if it’s in the right place at the right time – with first responders and bystanders.

KFF Health News

​Another factor contributing to the decline is the expansion of harm reduction programs. These include needle exchange programs, safe consumption sites, and medication-assisted treatment using drugs like buprenorphine and methadone. States that have adopted these measures have seen significant reductions in opioid-related fatalities. By focusing on keeping individuals safe and engaged with recovery services, these programs are proving effective at curbing overdose deaths.​

A new influx of opioid settlement dollars could be playing a key role in the reduction. In recent years, pharmaceutical companies involved in the opioid crisis have had to pay billions in settlements to states and local governments. These funds are being used to improve addiction treatment programs, enhance public health interventions, and expand harm reduction efforts. In many communities, this funding has led to better prevention, treatment, and recovery support​.

What’s Up with All that Opioid Settlement Money & How Come There’s No State Plan for It Yet?
More Opioid Settlement Money on the Way

Finally, state-level interventions and improved fentanyl monitoring have helped reduce fatalities in regions hardest hit by the opioid crisis. States like Vermont and North Carolina have seen overdose deaths decline by as much as 30%, thanks to coordinated efforts that combine law enforcement, public health, and community engagement​.

Opioid crisis: Fall in US overdose deaths leaves experts scrambling for an explanation | BMJ

It would be fascinating to do a crosswalk between the results among the states in terms of opioid death rates and the way their states and communities have been using their opioid settlement dollars. After all – a key tenant of public health practice is to make sure you measure and publish the results of your interventions so you can both measure your own performance and help others learn from you too.

Sadly, I couldn’t find a journal article that dives into the detail of how states are using their money and the trends that they’re seeing in the field. Sounds like a good practical project for an enterprising graduate student or professor of public health!

Overdose Deaths Are Finally Starting to Decline. Here’s Why. | Scientific American
Will Humble Disease Control, Vaccination, Wills Blog

Pertussis Surge in 2024: Why Arizona is at Greater Risk

Whooping cough, or pertussis, is making a big comeback in 2024. The CDC reports that pertussis cases this year have greatly increased – nearly five times higher than during the same period in 2023.

Whooping Cough Is on the Rise, Returning to Pre-Pandemic Trends | NCIRD | CDC

CDC says the increase is partly due to the lifting of COVID-19 precautions, like mask-wearing and social distancing, which had kept respiratory infections lower than they otherwise would have been. Unfortunately, even people who were vaccinated are at risk because protection from the vaccine fades over time​ (pertussis is a bacterial disease rather than viral which is partly why vaccine induced immunity fades over time).

Pertussis can infect people of all ages, but infants under one year are the most vulnerable to severe complications, including hospitalization. Most infants contract the illness from close family members, especially older siblings or caregivers who may not even realize they are sick.

That’s why it’s critical for children to follow the recommended vaccination schedule. The CDC recommends that children receive five doses of the DTaP vaccine to protect against pertussis. These doses are given at 2, 4, and 6 months, with booster shots at 15-18 months and again between 4-6 years old. Adolescents should then receive a Tdap booster at 11-12 years old to keep protection.​

While this surge is affecting the whole country, Arizona is particularly at risk for larger outbreaks. Vaccination rates among Arizona’s children are way too low. In fact, recent data show that herd immunity against measles, another vaccine-preventable disease, has dropped by half in Arizona kindergartens, signaling broader issues with vaccine coverage.

Herd immunity in AZ kindergartens drops by half

The Vaccines for Children program, which provides free vaccines for uninsured and low-income families, has been hampered by regulatory hurdles, making it harder for providers to participate and get vaccines to the kids who need them most.

Years of Full Court Press Childhood Vaccination Advocacy Pays Off: ADHS Finally Overhauls their Vaccines for Children Policies – AZ Public Health Association

Increasing vaccine hesitancy, paired with these bureaucratic barriers, means more children are vulnerable to diseases like pertussis. Without improving access to vaccines and addressing vaccine hesitancy, Arizona could face even more serious outbreaks in the future.

While AZPHA is encouraged that the Arizona Department of Health Services has revised their policy documents to make their implementation of the Vaccines for Children program less punitive, we remain vigilant to ensure that the critical cultural change at the Agency is underway to actually implement the new policies in good faith.

Time will tell.

Will Humble Health Insurance, Public Health, Wills Blog

Harris Pitches Idea to Have Medicare to Cover In-Home Care: The Proposal

Vice President Kamala Harris recently proposed an expansion of Medicare to cover in-home care services for seniors. The plan aims to help families care for aging relatives at home, reducing the reliance on nursing facilities, which are often far more expensive.

If passed as discussed by the VP this week, Medicare would cover services like home health aides, aiding with daily living activities such as bathing, dressing, and managing medications.

This proposal is targeted at middle-income families who don’t qualify for Medicaid in their state but still often struggle to afford long-term care (e.g. Assisted Living).

Kamala Harris to propose new Medicare home care benefit for seniors

Currently, Medicare only covers in-home care under limited circumstances like short-term skilled nursing after a hospital stay, or part-time help with physical therapy and medical management.

The new proposal would expand eligibility to cover more routine, non-medical care, which is currently either out-of-pocket or falls under Medicaid for low-income individuals.

Note: Medicaid is the biggest payer for long-term care insurance in the country, with nearly 50% of long-term care paid through Medicaid (AHCCCS in our state). But, in order to qualify for long term care under Medicaid people generally have to spend most of their money first.

I couldn’t find a Congressional Budget Office analysis of the costs and offsets for the plan, but the campaign website said they believe the “change would be funded through savings generated by Medicare’s ability to negotiate lower drug prices.”

That’s pretty much all the details I could find for the proposal – but thought y’all might be interested.

Will Humble Medicaid, Public Health, Wills Blog

Telehealth in Arizona Medicaid: How AHCCCS Is Expanding Access to Care

Unlike Medicare, which is a federal program that’s managed ‘top-down, Medicaid (which provides healthcare to low-income persons and others with disabilities etc.) is a shared federal and state responsibility and provides more flexibility. As such – state Medicaid programs aren’t dependent on Congress for allowing for telehealth services.

Telehealth has been revolutionizing healthcare access for millions of people, and AHCCCS has been at the forefront of this transformation in the last couple of years… finally embracing telehealth services especially in areas like behavioral health.

AHCCCS Telehealth Services: What’s Covered?

AHCCCS’ Telehealth Policy Manual allows members to receive medically necessary services remotely using electronic communication tools like video conferencing, phone calls, or secure messaging for certain services like:

  • Behavioral Health Services: Counseling, psychiatric evaluations, and medication management are all available via telehealth. This is particularly important for those in rural or underserved areas who may struggle to access in-person behavioral health support.
  • Chronic Disease Management: Members can manage chronic conditions, like diabetes or hypertension via regular telehealth check-ins with their healthcare providers. This helps avoid unnecessary hospital visits and improves disease management.
  • Primary Care Visits: Routine checkups, some follow-up appointments, and preventive care can now be done remotely, providing members with greater flexibility.
  • Therapy and Rehabilitation: Physical therapy, occupational therapy, and speech therapy services are also available via telehealth, making these services more accessible to members who may have transportation or mobility challenges.

The Role of the Arizona Telehealth Advisory Committee

Arizona law requires that AHCCCS listen to their Telehealth Advisory Committee as they make decisions about what kinds of telehealth services to authorize and encourage.

The committee evaluates the effectiveness of telehealth services, helps set standards for delivery, and advises on any changes necessary to improve patient outcomes. This collaboration ensures that AHCCCS continues to expand and improve telehealth offerings in ways that are both effective and cost-efficient.

AZPHA commends AHCCCS for its recent commitment to embracing telehealth as a vital part of the healthcare in Arizona. 

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