single men and women. and we do that year round, we are most known for that service. in terms of the soar project, we are targeting folks who are in our shelter and who are living outside, unfortunately, living outside but are engaged with our outreach and engagement team. soar stands for ssi, ssdi, outreach, access, and recovery. it's a project that started in 2005 when the federal government was holding policy academies to address homelessness across the country. and almost, probably at least half of the states that participated in those policy academies said that one of their goals was to try and increase access to ssi or ssdi, but no one knew how to do it. when people are living outside or in the shelter, one of the key things that they need are an income in order to be able to find their own home and live in their own home. and a lot of folks that we serve don't come in with an income, but have a significant disability that would make them eligible for social security.

for the clients that i work with, because of the mental health or substance abuse issues that they have, it's difficult for them to access the benefits and sometimes they don't even know that they are eligible for benefits. so making them aware of that is a key point sometimes. social security is set up that the people who want these benefits or who are going to apply for them are supposed to be able to walk in on their own or sit down at a computer on their own and do the application. this doesn't work really well for people who may have a brain disorder, who have trouble thinking or organizing their thoughts or if they have been homeless for a long period of time. they haven't had continuity of care, so they may have been seen in an emergency room in one community and in another emergency room someplace else and in a detox in a third place. and it's all jumbled up, they don't remember where they were, they don't remember what they were treated for. they certainly don't remember the names of the doctors and so forth. so it becomes very difficult for them to actually fill out this application and do it on their own. in the last year, we've had many of our case managers

trained in the soar approach and since that training, it's led to wonderful results and people who are getting benefits for the first time. once i was diagnosed with my disease, cirrhosis, and the doctor, the first thing he said, you can't work anymore, which i was working up until that point. so that is when i was really desperately homeless. the first time that bill and i sat down together to fill out his application, he was denied and after that i did the soar training. so i had all this knowledge and i knew what social security was looking for. they are looking for his ability to function. so we were just trying to prove that his disability limited his function which, in turn, limits his ability to work. and with that knowledge, we were able to get him his benefits. initially the doctor told me that i needed to be on a strict diet. so being able to have access to money to go to the grocery store, i can buy fresh vegetables, fruit, things like that, which is very good for me.

when i can make my own meals now, it helps immensely. i applied for ssi initially because i just came out of the hospital due to two amputations due to diabetes. well, let's just say it will give me a complete and total sense of independence again. when people receive an income, they are able to move out of the shelter or out of a car and into their own home. before soar, people who were doing these applications were getting approved at about 10 to 15 percent and after soar, nationally, we are achieving a 73 percent approval rate within 93 days. it's really fundamentally changed the way that people approach these benefits. john, i want to go back to our previous panel dialogue on the difficulty to reach people. what are some positive best practices that we can implement? i know, richard, you mentioned some, but let's start with john. well, there's a few states and richard mentioned

new york and maybe richard has a little bit more details on that, but there's also rhode island, who actually is thinking about using its soar program, s-o-a-r program as a way to be able to think about enrolling individuals. the soar program was very helpful in terms of getting people who qualified for medicaid but weren't enrolled in medicaid to actually enroll in medicaid. and it's a definitive program where people can call and get assistance and people will talk them through the system? yes. and actually even work with them face to face, work with them to walk through the applications, meet them even in the places where they have to complete the applications. very good. any other best practices, richard? well, i think the philosophy is trying to meet people where they are. the idea is to recognize that people who are in that under 133 percent of the poverty line who are currently uninsured tend to be single, childless adults.

they tend to be very poor. half of those people are under 50 percent of the poverty line, so they are extremely poor, very often homeless or have unstable housing, therefore, hard to kind of track down to one place and disproportionately, don't necessarily speak english as their first language. so i think what has developed is some strategies to trying to kind of touch these people where you are likely to find them. so you go to shelters, you go to latino community organizations and you don't just focus on the health and the behavioral health sectors, that you reach out more broadly to the larger social service sector. john, you mentioned using soar in rhode island. i mean, it's been a successful program i would think there would be a really wider conversation about using it nationwide because it's- that is one of the things that we are looking at.

in addition, not only just those individuals that are below 133 percent of the federal poverty level, but for those individuals between 133 and 400, you have got a lot of youth in there that are not insured. and for the most part, the way that youth communicate these days is through pdas and other devices. so again, thinking about strategies by which, for those youth that have pdas that might have a mental health or substance use condition, to try to reach out to them around the importance of insurance. because i can certainly remember when i was 21 or 22 and somebody wanted to take money out of my paycheck for insurance, i thought twice about it. but the fact remains is that i think we're going to have to do a little bit of a business case for those individuals. and as richard said, meet them where they are at, which is generally on their pda. well, if i may take it a step further. in our state, we are in the process of going through comprehensive training. the front door, again, is often the outpatient and residential treatment programs.

the treatment programs don't understand the relationship between the state law, the parity act, and the affordable healthcare act. so that is what we are doing is we're going door to door and providing comprehensive training. and i think all states need to do that. there's an awful lot of misinformation out there. even the insurers themselves are confused and may misrepresent inadvertently what the benefit is. i can't tell you how important this is. it is actually somewhat simpler that one might imagine. people do show up in time of crisis in all of these places. and if our front doors are not thoroughly trained in the inter-relationship between all of those laws, it's not going to work. we've got to do this. and it is particularly important for the providers to take that role. john, i want to come back because we mentioned during break the whole intersect between the publicly funded programs, the privately funded behavioral health programs and how those will interact with the mainframe healthcare system.

how is that going to happen, are they going to survive that transition, how is that going to work? well, i think that the integration of primary care and behavioral health is critical. we know that there are a significant number of individuals in our healthcare system that have a mental health or substance abuse disorder. and, as deb said, in some cases it is 25 percent, one out of four. a lot of people that have a mental health and substance abuse condition have another condition, another health condition or a chronic health condition that they need, not only just primary care, but also specialty health care. over the last several years, samhsa has embarked on a primary care behavioral health integration project prior to the affordable care act being in place. if you look at a number of provisions in the affordable care act, there is a variety of strategies, including incentives for states, as well as providers,

to begin to really be serious about good strategies that will be successful in the integration. and similarly, there's a whole notion that we started to talk about which is the electronic health records. richard, i want you to address that. is that primarily being done not only because of the technology is there, but do we stand to save a substantial amount if people begin to allow their records to be exchanged? well, there are a couple of motivations for doing that. first of all, coordinating care, preventing bad medication interactions, preventing errors have been very tightly linked to the ability to sort of organize information and communicate it quickly. so really that is i think the jumping off point for the electronic medical record. the fact that it might also save money by avoiding

duplication, etc., is i think also hoped for and there is sort of some suggestions that that might occur. but even if it didn't save money, it's an important thing to do based on quality, on preventing mortality, preventing morbidity, so i think it is important for that reason. the federal government started off by focusing really on doctors and acute care hospitals. there is a report to congress due very soon that will assess what needs to be done to bring long-term care providers, home health agencies, behavioral health providers into that type of program. and so really it's been done in multiple waves, just out of the size of the problem. and so there's a report that is coming out pretty soon from the office of the secretary of hhs setting out the steps that

you would need to take to continue to expand the electronic medical record. and patrick and deb, for the consumer, this is going to be mean what? well, we're worried in the drug and alcohol side and grateful for the efforts going on between samhsa legal action center. we've got a patient population that doesn't want somebody to know they are using an illicit drug. we are kind of grateful that this is moving slowly with careful consideration of each wave. our folks sometimes don't come to help because they are afraid somebody will find out they have a problem, so this has to be handled with extraordinary sensitivity. it's the same thing with the mental health consumer community. there's actually a large division because some people really do see the benefit of having a single healthcare record that contains all the needed information. but there's also a lot of history behind the mental health consumer movement that has left a lot of people very bitter and not trusting of the system.

so we actually, we have many different names that we call ourselves as people who receive mental health services. some of us choose to call ourselves consumers of mental health services, some call themselves survivors. and generally when they use the word survivor, they don't mean surviving their mental illness, they mean surviving the mental health system. so when you have that kind of division, it definitely sets up a problem for getting buy-in to the idea that there is going to be this central record. the other area where it really is going to have a big effect is among returning vets and national guard and reserve and on duty military people because they are so concerned, particularly the people who are still on duty, that if they go someplace for assistance, there is going to be this record there that is going to ruin their career. and so the anonymity part of it is extremely important to them.

so we have to look for safeguards and we also have to look for a lot of public education of the potential patients as they are going into the system and we will be talking a little bit about that when we come back. [music] there are 43 states that have an insurance law and there is a need for someone in each state to provide training on the state law, how it relates to the parity act, and then how it relates to all of the phases and phasing in of the affordable and accountable care act. the good news is drug and alcohol is included in the affordable healthcare act and the parity. one of the things that we are still struggling with, though, is how to access the benefit and we've really got to

work out a pathway for families. it is just imperative that this be dealt with in an urgent fashion or the outcomes are death, people end up in jail, and emergency room admissions go way up. it is imperative that the new healthcare reform act have a pathway that is workable for this particular illness. what is the cost of drug and alcohol addiction? i lost my job. i lost my home. i lost my health. i lost my self-respect. i lost my freedom. if you have a drug or alcohol problem, remember, treatment is effective and recovery is possible. for information on drug and alcohol treatment referral for you or someone you know, call 1-800-662-help and see what you could save. i got my life back. i had no idea it was going to be so hard. i didn't know what to expect.

you hear the stories, but i never took any of it seriously until i found myself here and then i realized i was going to have to work hard for my recovery. if you or someone you know has a drug or alcohol problem, you are not alone. call 1-800-662-help. recovery was the hardest job i ever had and the most important. brought to you by the u.s. department of health and human services. [music] the mission of the national council for community behavioral healthcare is to, through our membership, to reach out to individuals who may not have access to behavioral health services or may not know that those services are available to them. and mental health first aid is a way that we can teach the generaral public about menl illness and how they can help. well, what's the difference between say, just nervousness or normal anxiety and something that

might rise to the level of disorder? mental health first aid is a program for the general public, for people who maybe don't know, could know nothing about mental illness. we have signs everywhere about how to recognize if someone is having a stroke. any questions about nonsuicidal self-injury, this behavior, before we move on to talk about anxiety disorders? but i have never heard anyone come out and say these are things to recognize that someone in your family might be mentally ill and, even further, what to do about it. much like regular first aid, it teaches people to recognize signs and symptoms, de-escalate crisis and, if appropriate, provide referral to services. many groups could benefit from mental health first aid training. what does anxiety look and feel like? we learned four or five different questions to ask people to determine if they were suicidal or not. and then we role played and gave some examples of good things to say and bad things to say.

like in cpr you have abc, airway, breathing, circulation. in mental health first aid you have algee- assess for risk of suicide or harm, listen nonjudgmentally, give reassurance and information, encourage appropriate professional help, and encourage self-help and other support strategies. our focus on ways to stop the distress, not the behavior. you can understand it in layman's terms. the general public can understand it. we teach that mental illness is just like physical illness, it's just like diabetes, it's just like heart disease in that it's disabling, it's real, but it's also treatable. the more people who know where referral sources are, the more that they will refer. and quite often people hesitate because they don't know what to do even if they identify a problem. when i heard that there was a concrete way that i could learn how to react, that was very appealing to me. let the person know that you're available to talk when they are ready. mental health first aid does not teach people how to

diagnose mental illness, it does not teach people how to treat mental illness. it's a first aid course. remember we talked about substance use disorders co-occurring with other mental, forms of mental illness. someone may self-medicate if they are depressed or self-medicate if they are anxious. substance use disorders are, in fact, disorders. they aren't just bad behavior or weak will. it is a mental health issue, so no matter what the drug of choice is, it is still a problem and we have to get people to recognize that it's still a mental health problem that can be addressed and can be treated. here's the statement-self harm is a failed suicide attempt. you see lots of fiction, lots of fiction, why is that? why do you think that is the case, nicole? if we can get on that front edge, i believe that we can reduce the total cost in health care. john, has, does aca shift this focus into prevention and wellness and what is that going to mean?

the prevention and wellness is prominently highlighted throughout the affordable care act. i think the secretary talks about shifting it, shifting the conversation around sicker people to healthier people. there are a number of provisions that i think are worth talking about. obviously the establishment of the national prevention council, which was established, i believe, at the beginning of this year, has a number of people on it that are actually knowledgeable about substance abuse and mental health. there is the prevention and public health trust fund, which was started in 2010 at $500 million dollars last year that grows over the next couple of years to, i believe, $2 billion dollars. then most recently the center for disease control has just released their community transformation grants

that have a fairly significant focus, obviously on prevention, but also prevention of substance use, alcohol use, and tobacco use. very good. and patrick, what does that mean for the behavioral health care? how do we do prevention in the context of public health within the behavioral healthcare system? when we talk about prevention and behavioral health, it is almost like we are talking about a different thing to a large degree because we are certainly not talking about preventing people from having an illness. what we are talking about is preventing people going into crisis, generally, and into a deeper end of services. so it's really, really critical that we put a lot of emphasis on prevention and recovery, resiliency based programs in mental health because the difference in cost and services between somebody coming into a system and receiving the aid they need at the beginning that will help

keep them out of the hospitals and the crisis units can be as high as 10 to 1. i mean, in some states, the cost of keeping a person in a state psychiatric hospital for a year is $120,000 dollars. whereas the cost for keeping somebody in the next highest level of service, which is generally considered to be our sort of community treatment teams, act teams, is about $12,000 dollars. so it's 10 to 1. and we have seen the exact opposite happening with all the cuts going on the state levels because they are cutting the front end first. it is easier to cut these recovery-based programs because they know they need to keep those hospital beds. the problem is that every time they do that, they need to keep more hospital beds. can i jump in here? sure, i was just going to go to tell us because part of the act talks about no-cost sharing and i am hearing all of these ka-ching, ka-ching, ka-chings up here. let me just say a couple of points that builds on patrick's point.

i think the science, we are a point right now where the science has taken a major leap. and so recently the institute of medicine has come out with several reports on preventing behavioral health problems in children and adults. the scientists at the nimh and niaaa all have early intervention studies going on that are extraordinarily promising. and i think that actually the science should make us a little bit more optimistic about our ability to actually prevent disorders. so, for example, the affordable care act has a nurse-home visitation program as part of it. and that has been studied for 30 years. the first randomized trial was 33 years ago and it showed that you could actually prevent lots of bad things from happening to children as they grew when they lived in at risk households.

and similarly, if you treat mothers' depression, mothers of young children, you do things to prevent both substance use disorders from developing, but also a variety of behavioral problems and early schooling. and so i think there is a lot of promise here and i think that that promise is what prompted the act to put in the provisions to make it really easy to access those types of services. also the untreated alcohol and drug problems drive medical costs in unwanted ways. they just drive up all kinds of healthcare costs. this illness is so co-occurring with a whole host of very expensive medical conditions. so once you develop a plan where there is benchmark coverage in every area of insurance, whether it's medicaid, the exchanges, the group health plans, you are raising the possibility of cutting down on an enormous amount of unwanted healthcare spending. just think one fetal alcohol syndrome birth

that was preventable. the acoa is also sprinkled with screening, early screening, and that's how we get out the population who is currently uninsured is to do the early screening and intervention, catch people's addiction earlier in the disease and then the benchmark plans provide for the treatment of it. we should be, if we did this thoroughly, able to cut down on other medical spending. that is major prevention stuff, in my book. that's just true also for mental health. early screening is the best tool we have, really, for prevention, i think. john? i think screening is incredibly important. however, i think trying to get primary care professionals to do screening in a way that really allows them to identify substance use or mental health conditions is critically important. i will just tell you this personal story and that is that i went in for my primary care visit,

the nurse came in, did a screening, asked me about drug use and i asked her how many people in the 10 years that she had been there had actually said yes and she said one. and she works for a very, very large healthcare organization. it is certainly something that will need further study and implementation actually, for people to actually do it. i know that sbirt, we have sbirt that does a great job of screening patients at every sector of the healthcare system for mental health and for addiction treatment. there's also another program that we have, which is the community transformation grants. john, do you want to talk a little bit about that and what they will do? sure, and they were released in may of this year. they are for states and local communities.

their primary focus obviously is on prevention, prevention of a variety of activities. one of those activities is around prevention of -sorry- focus on emotional health. within the emotional health category, there are a number of activities that are specifically focused on preventing alcohol use, substance use, and to promote emotional wellness. so will samhsa continue to do programs that will help communities integrate into these new aca framework? yes. as a matter of fact, we provided, as soon as they came out, information to our stakeholders that are representative of states and local communities in order for them to take advantage of those grant programs. and just so that we have touched base, let's review some of the places where individuals can go

and get help because there are so many pieces to this. richard, you were talking about the office of national coordinator? yes. inside of the department of health and human services there's an office that is in charge of all the health information technology and they give grants to states and they have worked with individual providers to sort of really bolster the expansion and the responsible use of health information technology. and they are very sensitive to the issues of behavioral health consumers that were brought up. and so it is really that office, the office of national coordinator for health information technology where people should contact with these issues. but john, there is also other offices that provide the consumer with information as to how to reach the exchanges, talk about the health homes, talk about all of the other components, correct?

yes. out of the office of the secretary, out of hhs, there is a web site, a very good web site around the affordable care act. and it is incredibly user friendly, provides information about the act. it is also being populated now with information that is state specific about what is being covered and insurance companies within those states. it's a rolling implementation so that as the secretary gets additional information, that information is put into that web site. incredibly interactive. samhsa also has a web site on health reform and within that web site we talk about parity, we talk about the health homes, we talk about the grant opportunities that i just talked about and a variety of other issues as well. final thoughts, deb, in terms of what consumers need to know and what they need to do?

well, the opportunity here is huge, but the challenge is how do we set it up so the law is enforceable? again, i am looking at benefit books that don't reflect the parity act yet and the aca is coming down the pike soon. well, it's already here. we have to find some way to catch all of this and put it down where the consumer opens a benefit book and there it is. patrick? and i think it actually even goes beyond that. i mean, i think in, and probably in the substance abuse community, but also in the mental health community, word of mouth is probably one of the best ways we have of getting information out. again, because we have these problems of- for instance, i worked in florida for a number of years and we knew that we only served about 49 percent of the people who really needed our services in the state and the rest were untreated completely. so how did we have access to even get a book to them?