Behavioral Health Gaps Analysis Report

Nevada Department of
Health and Human Services

DIVISION OF PUBLIC AND BEHAVIORAL HEALTH
2013
Comprehensive Gaps Analysis of
Behavioral Health Services
Prepared by Social Entrepreneurs, Inc.

Lisa Watson, MA
Kelly Marschall, MSW
Table of Contents
Acknowledgements _________________________________________________________________________________________ 1
Executive Summary _________________________________________________________________________________________ 2
Introduction _______________________________________________________________________________________________ 11
Methods of the Study
Context of the Study
Historical Context _________________________________________________________________________________________ 17
50 Year Retrospective of Behavioral Health in Nevada 1963 – 2013
Current Service System ___________________________________________________________________________________ 21
Primary Providers
Secondary Providers
Linkages and Coordination Efforts
Financing Behavioral Health Services
Profile of Behavioral Health Consumers ________________________________________________________________ 28
Age
Gender
Race & Ethnicity
Gaps Analysis ______________________________________________________________________________________________ 37
Prevalence, Utilization and Unmet Need
Situational Assessment ___________________________________________________________________________________ 53
SWOT Analysis
Strengths
Weaknesses/Gaps
Opportunities
Threats
Summary
Recommendations ________________________________________________________________________________________ 71
Appendix ___________________________________________________________________________________________________ 78
Appendix 1.1: Key Informant Interview Questions
Appendix 1.2(a): Consumer Survey Questionnaire (English)
Appendix 1.2(b): Consumer Survey Questionnaire (Spanish)
Appendix 1.3: Expanded Service System Description
Appendix 1.4: California Mental Health Timeline 1957-2013
Appendix 1.5: Summary of New Articles Published
Appendix 1.6: Cross-Tabulation Charts and Graphs
Appendix 1.7: Bibliography
NEVADA DIVISION OF PUBLIC AND BEHAVIORAL HEALTH
Gaps Analysis 2013
Acknowledgements
This report was developed by Social Entrepreneurs, Inc. under contract by the Nevada
Primary Care Office in the Division of Public and Behavioral Health. The following
individuals guided the planning and execution of the project:
 Dr. Tracey D. Green, Chief Medical Officer, Division of Public and Behavioral Health
 Richard Whitley, Administrator, Division of Public and Behavioral Health
 Laura J. Hale, Manager, Primary Care Office
The following are greatly acknowledged for sharing their time and expertise as key
informants.
Key Informant Organization
Kathryn Baughman State of Nevada –Rural Counseling and Supportive Services

Tim Burch Clark County Social Services (CCSS)
Dave Caloiaro State of Nevada – Division of Public and Behavioral Health Administration
Christy Craig Clark County Public Defender Office
Jodie Gerson State of Nevada – Southern Nevada Adult Mental Health Services (SNAMHS)
Tracey D. Green, MD State of Nevada – Chief Medical Officer
Stephanie Humphrey Nevada Public Health Foundation
Sheila Leslie Washoe Specialty Courts
Barry Lovgren General Public/Advocate
David Mee-Lee, MD Psychiatrist
Jeremy Matuszak MD University of Nevada School of Medicine
Betsy Neighbors State of Nevada – Lake’s Crossing
Cody Phinney State of Nevada – Northern Nevada Adult Mental Health Services (NNAMHS)
Kevin Quint Mental Health and Developmental Services Commission
Kevin Schiller Washoe County Social Services (WCSS)
Chelsea Szklany State of Nevada – Southern Nevada Adult Mental Health Services (SNAMHS)
Alyce Thomas A.T. Consulting, Coaching & Advocacy
Richard Whitley State of Nevada – Division of Public and Behavioral Health
Mike Willden State of Nevada –Department of Health and Human Services
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Gaps Analysis 2013
Executive Summary
Nevada is one of three states in the United States (US) that operates the public behavioral
health system for its vulnerable residents. In 2013, the Mental Health and Developmental
Services Division merged with the State Health Division to become the Division of Public
and Behavioral Health (DPBH). As a result, behavioral health services throughout the
State of Nevada are undergoing significant change.
The integration of public and behavioral health is aligned with recent research on brain
development. New information from the fields of neuroscience and behavioral medicine
has dramatically advanced understanding of mental functioning. The public health
approach to behavioral health considers those advances and:
 Recognizes the interrelatedness of behavioral health and physical health,

 Focuses on prevention and promotes behavioral health across the lifespan,
 Identifies risks that may contribute to illness or disability, as well as protective
factors that protect against the development of illness or disability and/or limit its
severity,
 Provides people with the knowledge and skills to maintain optimal health and
wellbeing, and
 Brings together individuals, communities and a variety of systems (health, human
services, schools, etc.) to work collaboratively toward better behavioral health for
all.1
The purpose of this report is to forward the efforts of the state as it implements an
integrated public and behavioral health system of care. The report identifies gaps in the
current service delivery system and promotes strategies that build upon a public health
approach to the prevention, intervention and treatment of behavioral health conditions.
Context of the Report

From March through August 2013, the State of Nevada faced a number of difficult
circumstances surrounding the operations of publicly supported behavioral health
services throughout the state. These circumstances included allegations of improper
discharge practices, excessively long wait times for clients at the state operated forensic
facility, and infractions within state psychiatric facilities that could jeopardize their
Center for Medicare & Medicaid Services (CMS) certification.
1 The Center for Disease Control and Prevention, www.cdc.gov.
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Gaps Analysis 2013
These situations have resulted in multiple investigations and state-requested

examinations to explore the challenges facing the Division and its operations.
While this report was commissioned prior to the unfolding of a behavioral health crisis
across the state, the circumstances surrounding the crisis offered a unique and
unprecedented opportunity to examine complex issues facing the system from a variety of
perspectives. As such, this report is written within the context of a system in constant
flux, facing significant scrutiny, and yet in the process of reform.
Current Service System

The current behavioral health system in Nevada is comprised of federal, state and local
resources with a variety of funding sources, priorities and mandates. Services throughout
the state differ based on target population, geographic region and funding source. As a
result, there are often different challenges for persons seeking behavioral health
assistance based on what services are available and where they are seeking services.
The most significant primary provider for public behavioral health services is DPBH.
Within the Division, there are four service delivery systems operated to protect, promote
and improve the physical and behavioral health of the people in Nevada. These systems
include Northern Nevada Adult Mental Health Services (NNAMHS), Southern Nevada
Adult Mental Health Services (SNAMHS), Rural Counseling and Supportive Services
(RCSS), and Lake’s Crossing Forensic Facility.
 NNAMHS is located in Sparks, Nevada, and is a comprehensive, community-based,

behavioral health system for adult consumers. Inpatient services are provided
through Dini-Townsend psychiatric hospital, located on the same campus as the
central NNAMHS site. Numerous outpatient services are available which include
the Washoe Community Mental Health Center, Outpatient Pharmacy, Program of
Assertive Community Treatment (PACT), Psychosocial Rehabilitation Program
(PRP), Consumer Peer Counseling, and Service Coordinator Services.
 SNAMHS provides both inpatient and outpatient services for adults living in Clark
County and in surrounding counties that may be closer geographically to this
agency rather than to a rural behavioral health center. Inpatient services are
provided through the Rawson-Neal psychiatric hospital on the central SNAMHS
campus. SNAMHS has eight behavioral health clinics serving the community and
rural southern Nevada. SNAMHS provides: Inpatient Services, Mobile Crisis,
Outpatient Counseling, Service Coordination, Intensive Service Coordination,
Medication Clinic, Residential Support Programs, Mental Health Court, and
Programs for Assertive Community Treatment (PACT) Teams.
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Gaps Analysis 2013
 RCSS has seven full service clinics, five partial service clinics, and one limited
service clinic that provide behavioral health services to both adults and children in
the rural areas of the state considered to be every county with the exception of
Washoe County, Clark County, Lincoln County and parts of Nye County. Satellite
Clinics provide all services offered by RCSS. Sub-satellite clinics offer many of the
same services with itinerant Clinics providing services less frequently. RCSS is the
only service system within DPBH to provide services to children and adolescents.
 Lake’s Crossing is a forensic facility that provides services aimed at determining
the legal competency of an individual to stand trial and restoration of legal
competency for trial purposes. Adult forensic services include clinical assessment,
forensic evaluation and short or long-term treatment for both pretrial detainees
and jail/prison inmates.
Financing behavioral health services through DPBH relies primarily upon state general
fund revenue with contribution from grants, and Medicaid insurance coverage. Each
service system, as described above, has its own budget established within the state
system, creating inflexibility to meet the needs of the system as a whole. This is
compounded by the lack of sufficient resources allocated to meet behavioral health needs
across the state, as indicated by Nevada’s per capita behavioral health spending which has
and continues to be significantly lower than the national average (Foundation, 2013).
This issue could be further impacted in the event that SNAMHS and/or NNAMHS loses
CMS certification, placing Medicaid reimbursements at risk. The ongoing crisis leaves the
Division in a difficult position as it implements integration of behavioral health into a
public health model of care, and prepares for the implementation of the Affordable Care
Act (ACA) in 2014.
Nevada has missed a number of opportunities over the

years to strengthen its behavioral health system in “Officials have known about
response to previous reforms. These opportunities go back solutions for decades,
to the adoption of the Community Mental Health Act of economic recessions and
1963 (CMHA), some 50 years ago. Since adoption of the budgetary constraints have
kept them from fully and
CMHA, other states shifted funding to local communities
consistently implementing
and divested their control in providing behavioral health mental health programming.”
services. Nevada continued to be the primary source for
The Las Vegas Sun,
behavioral health care for low-income adults throughout
August 2013
the state and low-income children in rural areas of the
state.
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Gaps Analysis 2013
To better understand how this difference in approach may have affected the development
of a comprehensive behavioral health system of care, a review of the Kaiser report,
“Learning From History: Deinstitutionalization of People with Mental Illness As Precursor
to Long-Term Care Reform,” specified circumstances that have had a negative impact on
the success of de-institutionalizing mentally ill persons. Those circumstances include:
 Housing: People with serious mental illness were moved to settings that were ill-
equipped and poorly supported to meet their needs.
 Essential services: The supports needed to successfully live independently in the
community were not available or provided.
 Outcomes: Mental health systems continued to measure success by effort, such as
bed days, instead of measuring the effect of services such as quality of life
indicators.
 Resources:
o State funds previously used for state institutions were not reinvested in
community programs.
o Federal funds for the community mental health centers program did not
adequately address need.
o Third-party health insurance policies and public programs, such as
Medicare, limited coverage for the treatment of mental illness.
Many of these circumstances have and continue to exist within Nevada. As specified in a
1979 review of the history of Nevada’s mental health system “three characteristics of
Nevada’s system are: (1) marked fluctuations in service capacity; (2) a lack of public
supervision or independent professional review of mental health programs; and (3)
absence of long-term planning. (Pillard, 1979) These issues remain. A proactive strategic
plan to establish a comprehensive and integrated public and behavioral health system of
care is critical to preventing behavioral health care needs from escalating and placing
additional burdens upon the state of Nevada.
In examining the current service delivery system this report relied upon quantitative
variables to establish who is being served and where gaps exist, and qualitative
information to identify why gaps exist.
Profile of Current Behavioral Health Consumers
Age of Behavioral Health Consumers

In Nevada, the largest category of consumers accessing care is between the ages of 25-44,
representing 38% of the service population. This is followed by consumers between the
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Gaps Analysis 2013
ages of 45-65, representing 35% of the service population. While persons age 25-64 make
up slightly more than half of the state’s population, they represent almost two-thirds of
the persons served by Nevada’s public behavioral health services. The system serves
significantly fewer very young (children up to age 12) and older adults (65+) compared to
the population distribution of persons in the state. Although DPBH is not the primary
agent responsible for providing services to children and adolescents, it will ultimately
bear the burden of treating these individuals in the event that early prevention and
intervention services are not adequate.
Penetration rates, as defined by the Substance Abuse and Mental Health Services
Administration (SAMHSA) is the “percentage of members using behavioral health
services.” This variable is commonly used to assess access to services. Penetration rates
particular to demographic profiles were compared against 2012 US averages to indicate if
Nevada was reaching subsets of people in a manner better, worse, or consistent with US
averages.
As Figure 1 demonstrates, Nevada is reaching approximately one for every two people
served on average nationally who require behavioral health services. The most
pronounced deficiencies pertain to the following age groups:
 Nevada served one child age 0-12, for every four served nationally
 Nevada served one adolescent age 13-17, for every four served nationally
 Nevada served one older adult age 75 and over, for every twelve served nationally
45 41.2
40
35
30 26.0 26.3
24.5
21.4 22.7
25
20
14.5 14.7
15 13
9.2 10.1 9.0
7.0
10
4.8
5 2.6
0.6
0
0-12 13-17 18-20 21-24 25-44 45-64 65-74 75+
NV Penetration rates per 1,000 population US (FY 2012)
Figure 1: Penetration Rates by Age Comparison
Whereas other states appear to be focused on early intervention and prevention, Nevada
appears to respond more to crisis in adulthood.
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Gaps Analysis 2013
Race of Behavioral Health Consumers

While the vast majority of consumers served reflect the racial demographics of the state,
there are variances particular to the Asian and African-American populations. In Nevada,
Asians represent 7.2% of the overall population in Nevada, but only 1.9% of the service
population. In contrast, African-Americans represent 8.1% of the population, but account
for 12.6% of the service population. While 26.5% of the population of Nevada is Hispanic,
they represent 12.5% of those served. National penetration rates for services to the
Hispanic population are 18.3 per 1,000 people in the population, but Nevada reaches only
4.9 per 1,000.
Unmet Need
Beyond understanding the consumer base of clients accessing public behavioral health
services, a thorough review of prevalence and usage data was conducted to establish an
estimate of unmet need in services to children and adults as well as within each region of
the state.
 Children’s Services: The Department of Children and Family Services (DCFS) is

responsible for providing behavioral health services to children and adolescents in
Washoe and Clark County, while DPBH is responsible for providing services in the
rural areas of the state. In Fiscal Year (FY) 2011-2012, there were a total of 12,399
children in the state that were Medicaid eligible and estimated to have a serious
emotional disturbance (SED). Of that total, the state provided services to 3,989 in
FY 2011-12, representing 32% of the estimated need. 2
o DCFS’s service population totaled 10,991, of which 2,927 were served,
representing approximately 27% of the estimated need.
o DPBH’s service population totaled 1,408, of which 931 were served,
representing approximately 66% of the estimated need. A total of 477
(34%) children were estimated to be in need of but not receiving services in
FY 2011-12.
 Adult Services: There were a total of 88,956 adults in the state of Nevada that were
Medicaid eligible and considered to have any mental illness or a severe mental
illness (AMI/SMI). Of that total, DPBH provided services to 25,522 in FY 2011-12,
representing 29% of the total of those estimated to be in need.
o Urban North: When considering the urban part of northern Nevada,
Washoe County, the estimated total adults in need were 14,239. DPBH
2 Sources of data and calculation is provided in the Unmet Need section of this report.
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provided services to 5,785 adults in FY 2011-2012, representing 41% of

those estimated to be in need.
o Urban South: When considering the urban part of southern Nevada,
considered to be Clark County, the adult population in need was estimated
to be 63,767. Of that total, DPBH provided services to 15,203 adults in FY
2011-12, representing 24% of those estimated to be in need.
o Rural: For rural Nevada, considered to be all counties except Washoe
County and Clark County, the estimated adult population in need for FY
2011-12 was 10,950. DPBH provided services to 4,534, representing 41%
of adults in need.
Gaps in Services
While statistics were combined with existing publications to identify what gaps exist in
the public behavioral health system, information gathered through key informant
interviews and consumer surveys was used to explain why gaps in services exist.
Representatives from DBPH indicated that data collection has not been uniform
throughout or between complimentary systems, making data analysis challenging.
Insufficient service options identified include inpatient and outpatient treatment

statewide, co-occurring disorder services for substance abusing mentally ill consumers,
substance abuse services for all populations, lack of youth services, lack of housing, care
management and wrap-around services to help those getting better to maintain stability,
and workforce concerns related to morale, compensation, recruitment and retention.
Quantitative and qualitative data indicates:
 Services are currently reaching people in their middle stages of life, with
insufficient resources for prevention or early intervention. Investing early and
often is a proven technique in service delivery both in terms of costs and
outcomes. “Intervening at the first sign of symptoms offers the best opportunity to
make a significant, positive difference in both immediate and long-term outcomes
for people affected by mental health issues.”3 As such, the federal Substance
Abuse and Mental Health Services Administration (SAMHSA) has designated
prevention as their first strategic priority (Steve Vetzner, 2013).
 Services are not sufficient to meet the needs of people later in life. Attention should
be paid to identifying and engaging older Nevadans who require behavioral
support services. Older adults require different treatment responses and supports
3 Retrieved from: http://www.sfgate.com/opinion/openforum/article/Mental-health-prevention-a-wise-investment-4028399.php
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Gaps Analysis 2013
such as transportation, home-based treatment options, and specialized outreach

efforts (Services W. S., 2013).
 A culturally competent framework to provide services to Nevada’s growing
minority population is needed. Particular interest should be paid to the over-
representation of African-American males in the service system, exploring the link
between this dynamic and their over-representation in the criminal justice system.
As identified in the report: Prevalence of Mental Illness in the Criminal Justice
System, “mentally ill individuals of African American origin were over-represented
among the CCDC detainees with mental illness while all other racial/ethnic
minorities were underrepresented. The rate of detained African Americans with
mental illness was 20.8% at CCDC in 2011, which significantly exceeded their
overall rate of less than 11% among the residents of Clark County.”
 Insufficient service reach is most pronounced in the southern region of the state,
as indicated by statistics that reveal only 24% of people eligible and needing
assistance are being served. Identifying the differences between the regions in
service populations, resources, and service deployment is critical for
understanding and addressing this reality.
 Treatment is a critical component of the continuum of care. To encourage the use
of services and minimize stigma, treatment should be available in the community
in the least restrictive environment possible. In addition to psychiatric
management, behavioral health treatment should include: counseling, medication
management, and linking individuals to other wrap-around services necessary for
them to remain stable. While DPBH has worked to make community-based
treatment more widely available, they lack sufficient funds to meet existing
demand.
 The system of care should be strengthened to promote community-based
organizations and include: inpatient, partial hospitalization, intensive outpatient,
outpatient, residential, adult day treatment, and mobile therapy options.
Specialized treatment facilities for youth with substance abuse disorders are
needed, and should include peer-supportive counseling to prevent relapse and
develop strategies for drug-free living.
 Discharge planning should consider housing, medication, and basic needs at a
minimum. No persons should be discharged to another level of care or from a
facility without a safe, stable environment to go to with assistance in making the
transition. Housing gaps include:
o long term transitional housing
o services for persons who are mentally ill and developmentally delayed
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Gaps Analysis 2013
o resources for persons who are under the age of 60 but experiencing mental
illness and dementia
o violent individuals with a mental illness
o sex offenders
o persons with co-existing medical and mental health and/or intellectually
delayed
Both quantitative and qualitative data support the conclusion that Nevada’s system is
crisis response driven. While efforts are currently underway to build a continuum of care
with an emphasis on community-based services, without sufficient resources, these
efforts will not be fully realized.
Recommendations
Nevada has an opportunity to implement a behavioral health
system that is community-based, comprehensive and “There is a consequence for
our whole community when
efficient. The gaps analysis is intended to assist the state in people need services and
understanding gaps and taking steps to address them. To do can’t get them. We have an
so, three focus areas are recommended. opportunity to intervene
early in the process and
1. Ensure accountability, credibility and high quality provide services or we can
leave it unaddressed and
services. that portion of the
2. Develop community and state capacity to implement populations is less happy,
no wrong door less productive and possibly
dangerous. We do no
3. Establish a vision and plan for the system of care and kindness by letting folks
secure the resources necessary to implement the plan suffer with their mental
illness.”
Strategies from research, key informants and best practices
Key Informant Comment
are provided for each focus area. Each is designed to address
one or more of the gaps, unmet needs and/or weaknesses or
threats from the situational analysis.
With leadership, vision, resources and a strategic approach, Nevada has an opportunity to
leverage the lessons learned by other states and to seize the moment to implement a
public health model for community-based services through the integration of the Division
of Public and Behavioral Health and the implementation of the Affordable Care Act.
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Introduction
Behavioral health services throughout the State of Nevada are undergoing significant
change. What used to be the Nevada Division of Mental Health and Developmental
Services (MHDS) is in the process of integrating within the Nevada State Health Division
(NSHD), creating a Division of Public and Behavioral Health (DPBH). Included in this
change is the merger of MHDS and the Substance Abuse Prevention and Treatment
Agency (SAPTA) into a behavioral health system. Part of this transition to a more
comprehensive “system of care” strategy includes the completion of a gaps analysis. The
Substance Abuse and Mental Health Services Administration (SAMHSA) suggests
identification of unmet needs and service gaps as part of a “strategic prevention
framework.”4 The framework relies upon a five-step planning process that consists of:
1. Completion of a Comprehensive Needs Assessment

2. Identification of Unmet Needs and Service Gaps
3. Development of a Strategic Plan
4. Implementation of Effective Community Prevention Programs, Policies and
Practices; and
5. Evaluation of Outcomes
4 Retrieved from: http://captus.samhsa.gov/access-resources/about-strategic-prevention-framework-spf.
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Gaps Analysis 2013
In recent years, new information from the fields of neuroscience and behavioral medicine
has dramatically advanced understanding of mental functioning. Increasingly, it is
becoming clear that mental functioning has a physiological underpinning, and is
fundamentally interconnected with physical and social functioning and health outcomes. 5
The integration of public and behavioral health aligns with research on brain
development. The public health approach to mental health:
 Recognizes the interrelatedness of mental health and physical health,

 Focuses on prevention and promotes mental health across the lifespan,
 Identifies risks that may contribute to illness or disability, as well as protective
factors that protect against the development of illness or disability and/or limit its
severity,
 Provides people with the knowledge and skills to maintain optimal health and
well-being, and
 Brings together individuals, communities and a variety of systems (health, human
services, schools, etc.) to work collaboratively toward better mental health for all. 6
The purpose of this gaps analysis is to forward the efforts of the state to implement a
system of care as Nevada integrates Public and Behavioral Health by identifying gaps in
the service delivery system. To accomplish that,
the gaps analysis includes a comprehensive
mapping and analysis of behavioral health services
in Nevada using the strategic prevention
framework. The report summarizes:
 The current behavioral health service

delivery system at the state and local level,
 Unmet needs related to behavioral health,
and
 Opportunities and recommendations for
systems improvement.
Figure 2: Strategic Prevention Framework Components
5The World Health Organization, The World Health Report 2001, Mental Health: New Understanding, New Hope, 2001.
6 The Center for Disease Control and Prevention, www.cdc.gov.
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Gaps Analysis 2013
Methods of the Study

Conducting a gaps analysis is simplified within a defined system of stable service delivery
components where consistent and reliable longitudinal data are available for analysis. In
those circumstances, the system at the point in time of the analysis is compared to the
defined system as planned or intended and the variance between the two systems and the
outcomes sought versus achieved are used to identify gaps. Unfortunately, these
circumstances did not exist during the development of this report.
Because of this, the report relies upon a variety of resources to assess gaps in Nevada’s
behavioral health system. Resources used to complete the gaps analysis included
qualitative data such as gathering the perspectives of system stakeholders and
consumers, a review of public documents, and a literature review of papers and studies
specific to Nevada’s system. Quantitative data such as state demographics, prevalence and
utilization statistics, as well as comparisons of national behavioral health statistics and
Nevada statistics was analyzed. The combination of qualitative and quantitative data was
used to complete the gaps analysis.
Qualitative Data Collection Efforts

Key informant interviews, group meeting participation, and consumer surveys were used
to gather input from consumers, behavioral health professionals, local and state program
administrators, school counselors, law enforcement, emergency health providers, and
other stakeholders to discern the resources in use and the gaps related to behavioral
health in their area of concern.
 Key Informant Interviews: Social Entrepreneurs, Inc. (SEI) worked with the staff of
the DPBH to identify key informants to interview. From May through September
2013, 19 key informant interviews were conducted by phone or in person. The
results of these interviews were woven throughout the report with direct quotes
found in quotations. A summary of the key informant questions can be found in
the Appendices.
 Media Scan: A number of interviews and reports relevant to the gaps analysis were
published in print and media during the period in which the gaps analysis was
completed. SEI reviewed media reports, including interviews, and used the results
to validate themes identified by key informant interviews. A summarized table of
this media scan can be found in the Appendix of this report.
 Group Meeting Participation: SEI attended two meetings with the Division’s
behavioral health quality assurance team, comprised of content experts in a
variety of areas including criminal justice, veterans, youth, homeless services, etc.
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Gaps Analysis 2013
Information was collected during these meetings to track issues and system-
change strategies as they were planned statewide.
 Consumer Survey: To inquire about program services availability, use of, barriers,
and gaps, SEI worked with 19 provider agencies throughout the state to distribute
consumer surveys to their clients. There were a total of 339 surveys collected in
both English and Spanish representing clients in the north, south and rural areas of
Nevada. The survey questions are included in the Appendices.
Quantitative Data Collection Efforts

Quantitative data such as estimated need, service provider capacity, and utilization rates
were collected and analyzed. Research from US sources was utilized to calculate unmet
needs.
 Demographic Profile of Behavioral Health Consumers and Penetration Rates: This

information was derived from the 2012 Uniform Reporting System (URS) by
SAMHSA Center for Mental Health Services (CMHS). CMHS operates the only
program in the nation that focuses on the development of data standards that
provide the basis for uniform, comparable, high-quality statistics on mental health
services, making it a model in the health care statistics field.
 Census Data: Population estimates from the 2010 US Census were used to describe
Nevada’s current population.
 Prevalence Statistics: The prevalence rates were based on national studies of the
prevalence of adults with serious mental illness (SMI) and children with serious
emotional disturbance (SED). The prevalence rates, separated by age, were applied
to the population statistics for each county in Nevada. Because the public mental
health system is intended to serve those persons who have low resources, the
prevalence rates were applied to the estimated Medicaid eligible population for
the State of Nevada.
 Utilization Statistics: Utilization statistics for services provided by what was
known formerly as MHDS, from the state AVATAR database, were provided by staff
of DPBH. Utilization statistics for services provided to children through the
Department of Children and Family Services (DCFS) came from an internally
developed state report titled: “Descriptive Summary of Children’s Mental Health
Services – Fiscal Year 2012.”
Public Document Review

Public documents such as the “Consultation Report on Rawson-Neal Psychiatric Hospital,”
“Nevada Division of Mental Health and Developmental Services Needs Assessment 2012,”
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Gaps Analysis 2013
and the “Joint Federal Mental Health and Substance Abuse Block Grant Application 2013”
were reviewed and information was leveraged to assist in the development of this report.
A bibliography of all reports reviewed is provided in the Appendices. Additionally, a
broad based internet scan for research, state reports, and US publications was conducted
to trace the history of mental health in the US and in Nevada, to identify alternative
approaches and best practices in providing mental health services and to put Nevada’s
system in context with other states in the US.
Context of the Study

This study took place during a significant time of transition and turmoil within the State
of Nevada related to behavioral health. The state was preparing for integration efforts
across multiple state departments and hosting the biennial legislative session tasked with
budget passage. Additionally, the state became the target of public scrutiny as a result of
a number of issues related to the care and treatment of behavioral health clients.
Integration Efforts
Integration of Mental Health and Developmental Services (MHDS) and the Health Division
into the Division of Public and Behavioral Health (DPBH) became official on July 1, 2013.
However, the development of a cohesive and integrated system is currently a work in
progress. While the name of the Division has changed, uniform policies and procedures
do not exist system wide, staffing resources and service provision continue to function in
silos, and data to quantify services provided and identify ongoing need are not reliably
captured.
2013-2015 Legislative Session

While efforts to integrate had been initiated, the resources necessary to fully launch
integration required passage of the 2013-2015 budget by a legislature that was in session
from February to June 2013. The required presence of Division leadership during the
legislative session further impacted the ability to move forward with implementation. In
addition, regulations that require separate budgets for SNAMHS, NNAMHS and RCSS
created inflexibility to meet the changing needs of the system as a whole.
Public Scrutiny
Beginning in March 2013, and current through the publication of this report, the State of
Nevada has faced a number of difficult circumstances surrounding the operations of
publicly supported behavioral health services throughout the state. These circumstances
included allegations of improper discharge practices, excessively long wait times for
clients at the state operated forensic facility, and infractions within state psychiatric
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Gaps Analysis 2013
facilities that could jeopardize CMS certification. These

situations have resulted in multiple investigations and
state-requested examinations to explore the challenges “Over the years, the state’s
facing the Division and its service operations. Included in mental health system has
reflected the same cycle
the Appendix of this report is a sample of news articles
endured by mental health
that were published during this timeframe. patients themselves,
oscillating between making
Each one of these situations influenced the other, progress and receding into
culminating in a behavioral health crisis that continues to crisis.
unfold. While this report was commissioned prior to the Las Vegas Sun,
unfolding of this crisis, the circumstances did offered a August 2013
unique and unprecedented opportunity to examine
complex issues facing the system from a variety of
perspectives. As such, this report is written within the context of a system in constant
flux, facing significant scrutiny, and yet ready for reform.
The following section of this report provides a historical context with detail of missed
opportunities and strategies other states have employed, as well as lessons learned over
the past 50 years. This current challenges facing the system, coupled with the integration
of the Division of Public and Behavioral Health and the implementation of the Affordable
Care Act provides an opportunity for systems reform for Nevada.
1882: Nevada’s First State Asylum
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Gaps Analysis 2013
Historical Context
Nevada is one of only three states in the nation that serves as the sole source provider for
public behavioral health services. The other two states are Alaska and South Carolina.
Historically, this had a tremendous impact on the method of service delivery and
influenced how systems change efforts are addressed. Many of the current issues
plaguing the system have their roots in past policies and practices.
The following info graphic provides a snapshot of major milestones within the behavioral
health system in Nevada spanning the last five decades, beginning with the adoption of
the Community Mental Health Act of 1963 (CMHA), which de-institutionalized mental
health care.
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Gaps Analysis 2013
50 Year Retrospective of Behavioral Health in Nevada 1963 – 2013

For comparison purposes, a similar timeline for the state of California can be found in Appendix 1.4.
Figure 3: 50 Year Retrospective of Behavioral Health in Nevada 1963-2013
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Gaps Analysis 2013
Over the past 50 years, many states ceased to serve as the primary provider of behavioral
health services for persons without insurance. Rather, they responded to the CMHA by
shifting funding to local jurisdictions, supporting community-based services, and over
time, closing institutions due to a lack of demand. See Appendix 1.4 for an info graphic
that illustrates how a state neighboring Nevada took a different path following the
adoption of the CMHA of 1963, with different results.
While many states now have a community-based service delivery system, it took time to
develop with lessons learned along the way. As noted by the Kaiser Family Foundation:
“The history of deinstitutionalization falls into several stages as policies and
objectives have changed over time. The early focus was on moving individuals out of
state public mental hospitals and from 1955 to 1980, the resident population in those
facilities fell from 559,000 to 154,000. Only later was there a focus on improving and
expanding the range of services and supports for those now in the community, in
recognition that medical treatment was insufficient to ensure community tenure. In
the 1990’s whole institutions began to close in significant numbers and there was a
greater emphasis on rights that secured community integration – such as access to
housing and jobs (pg.1).”
As noted in the Kaiser report, “Learning From History: Deinstitutionalization of People

with Mental Illness As Precursor to Long-Term Care Reform,” many systems made a
number of mistakes that impacted their success in de-institutionalizing mentally ill
persons. The description of those mistakes is informative for Nevada, as the state is
challenged by many of the same issues:
 Housing: People with serious mental illness were moved to settings that were ill-
equipped and poorly supported to meet their needs.
 Essential services: The array of supports needed to successfully live independently
in the community was not available or provided.
 Outcomes: Mental health systems continued to measure success by effort, such as
bed days, instead of measuring the effect of services such as quality of life
indicators.
 Resources:
o State funds previously used for state institutions were not reinvested in
community programs.
o Federal funds for the community mental health centers program did not
adequately address need.
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Gaps Analysis 2013
o Third-party health insurance policies and public programs, such as

Medicare, limited coverage for the treatment of mental illness.
With leadership, vision, resources and a strategic approach, Nevada has an opportunity to
leverage the lessons learned by other states and to seize the moment to implement a
public health model for community-based services through the integration of the Division
of Public and Behavioral Health and the implementation of the Affordable Care Act.
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Gaps Analysis 2013
Current Service System

The behavioral health system in Nevada is comprised of federal, state and local resources
that operate under a variety of funding sources, priorities and mandates. Services
throughout the state differ based on target population, geographic region and funding
source. As a result, there are often different challenges for persons seeking behavioral
health assistance based on services available and where they are sought. The system is
most developed in the urban areas of northern and southern Nevada, although more
linkages exist between urban and rural areas than in the past.
The system relies on a variety of providers. For the purpose of this report, they are
divided into three categories: 1) primary service providers, 2) secondary service
providers, and 3) linkage and coordination efforts. The following section summarizes
each category. A more comprehensive description can be found in the Appendices.
Primary Providers
The primary providers of behavioral health services in Nevada include the public
behavioral health system as operated by DPBH, non-profit/community-based
organizations, private practitioners and psychiatric hospitals, and federally qualified
health centers.
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Division of Public and Behavioral Health (DPBH)

The most significant primary provider for public behavioral health services is DPBH.
Within the Division, there are four service delivery systems operated to protect, promote
and improve the physical and behavioral health of the people in Nevada. These systems
include Northern Nevada Adult Mental Health Services (NNAMHS), Southern Nevada
Adult Mental Health Services (SNAMHS), Rural Counseling and Supportive Services
(RCSS), and Lake’s Crossing Forensic Facility.
 NNAMHS is located in Sparks, Nevada, and is a comprehensive, community-based,

behavioral health system for adult consumers. Inpatient services are provided
through Dini-Townsend psychiatric hospital, located on the same campus as the
central NNAMHS site. Numerous outpatient services are available which include
the Washoe Community Mental Health Center, Outpatient Pharmacy, Program of
Assertive Community Treatment (PACT), Psychosocial Rehabilitation Program
(PRP), Consumer Peer Counseling, and Service Coordinator Services.
 SNAMHS provides both inpatient and outpatient services for adults living in Clark
County and in surrounding counties that may be closer geographically to this
agency rather than to a rural behavioral health center. Inpatient services are
provided through the Rawson-Neal psychiatric hospital on the central SNAMHS
campus. SNAMHS has eight behavioral health clinics serving the community and
rural southern Nevada. SNAMHS provides: Inpatient Services, Mobile Crisis,
Outpatient Counseling, Service Coordination, Intensive Service Coordination,
Medication Clinic, Residential Support Programs, Mental Health Court, and
Programs for Assertive Community Treatment (PACT) Teams.
 RCSS has seven full service clinics, five partial service clinics, and one limited
service clinic that provide behavioral health services to both adults and children in
the rural areas of the state considered to be every county with the exception of
Washoe County, Clark County, Lincoln County and parts of Nye County. Satellite
Clinics provide all services offered by RCSS. Sub-satellite clinics offer many of the
same services with itinerant Clinics providing services less frequently. RCSS is the
only service system within DPBH to provide services to children and adolescents.
 Lake’s Crossing is a forensic facility that provides services aimed at determining
the legal competency of an individual to stand trial and restoration of legal
competency for trial purposes. Adult forensic services include clinical assessment,
forensic evaluation and short or long-term treatment for both pretrial detainees
and jail/prison inmates.
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Gaps Analysis 2013
Nevada Substance Abuse Prevention and Treatment Agency (SAPTA)

SAPTA currently funds private, non-profit treatment organizations and government
agencies statewide to provide the substance abuse related services and treatment levels
of care. In state fiscal year 2012-2013, SAPTA funded 22 treatment organizations
providing services in 68 locations throughout Nevada. Together, these providers had
11,907 treatment admissions. Services consist of intervention, comprehensive evaluation,
detoxification, residential, outpatient, intensive outpatient, and transitional housing
services for adults and adolescents, and opioid maintenance treatment for adults.
Non-Profit Community-based Organizations
Community-based organizations provide behavioral health, substance abuse and co-
occurring disorder counseling and supportive services. Community-based organizations
throughout the state vary in target population, approach, location, and accessibility.
These services are primarily grant funded and more prevalent in urban areas. There are
great differences in the sophistication and the capacity of these providers throughout the
state.
Private Psychiatric Providers
Private practitioners and psychiatric hospitals are concentrated primarily in Washoe and
Clark Counties. Access to these services often depends upon medical insurance.
Throughout rural Nevada, there is a significant shortage of mental health professionals.
Federally Qualified Health Centers (FQHC)

FQHCs provide services in the most medically underserved areas and/or to the most
medically underserved populations. Nevada is host to a total of 31 FQHC clinics of which
only two offer behavioral health services.
Secondary Providers
Beyond the primary providers, there are also
demands placed on a number of other systems “Over 13 percent of those with
throughout Nevada that respond to persons with behavioral health disorders
receive treatment outside the
behavioral health issues. Secondary providers such as health care system entirely,
specialty courts, emergency transport, hospital such as through human
emergency rooms, county law enforcement, primary services programs or the
care practitioners and rural community health and voluntary support network of
social service centers often provide services when self-help groups and
organizations“.
needed. While many do not see themselves as
providers of behavioral health services and are not (Garfield, 2011)
equipped to fully address the behavioral health
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Gaps Analysis 2013
problems they encounter, they are part of a continuum of services providing access to
care.
A secondary provider that has been impacted most significantly by the behavioral health
needs of its service population is the criminal justice system, including juvenile, state and
federal correctional facilities. As stated in the report, “Mental Illness and the Criminal
Justice System: Clark County, Nevada:”
“It has become increasingly commonplace for mentally ill individuals exhibiting
troublesome behaviors to be sentenced to criminal custody rather than receive
placement in psychiatric institutions. Unfortunately, the public and media
frequently regard jails and prisons, rather than psychiatric facilities, as the de facto
institutions responsible for the care of people with mental illness” (pg.3). One
explanation routinely offered for this dynamic involves the confluence of
deinstitutionalization efforts with the lack of supportive community-based
resources.
Linkages and Coordination Efforts

Nevada has numerous boards, commissions, collaboratives, and workgroups across the
state that seek to address systems improvement for consumers accessing behavioral
health services. These entities establish linkages and promote coordination critical to an
effective continuum of care. Because of the integration within the Division, some of these
entities are also in a state of transition.
Formal state-driven efforts have included the Commission on Mental Health and
Developmental Services, the Nevada Children’s Behavioral Health Consortium, the Nevada
Mental Health Planning Advisory Council, the Multidisciplinary Prevention Advisory
Committee (MPAC), the Substance Abuse Prevention and Treatment Agency (SAPTA)
Advisory Board, and SAPTA Community-based Coalitions.
Another example of a state-driven effort to create linkages within the Division includes
the 2012 establishment of a statewide Quality Improvement Team (QIT). The team
identified special populations such as veterans, youth, and persons involved in the
criminal justice system, and met regularly to identify special needs and resources
requiring coordination. In 2013, the QIT established workgroups for each special
population area and published white papers to capture and transfer knowledge
throughout the system.
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Gaps Analysis 2013
Local efforts to coordinate services exist regionally and

throughout the state in the form of coalitions, work groups,
task forces and alliances. For the most part, they are “There are models of
partnerships between law
population specific and designed to identify ways to serve
enforcement, courts, the state
consumers in a more comprehensive, coordinated manner. and social services all across
Some seek to implement evidence-based solutions to the state that have worked to
address community problems. The results of these efforts the benefit of the client. These
can be seen in the development of new community-based are not always formalized, are
often person or relationship
resources including community response teams, diversion
dependent and can quickly
programs, and multidisciplinary transition teams. These evaporate when a person
efforts exist on a continuum of formality, ranging from change position, a crisis
partnerships generated from formal operational occurs, or one agency stops
agreements to ad hoc working groups collaborating on participating.”
short-term issues. Key Informant
The effectiveness of these collaborations varies. Several

key informants describe that linkages throughout the system on behalf of behavioral
health consumers are largely dependent upon the personal relationship created between
people working within the system.
This complex system of primary and secondary service providers, supported by state and
local coordination efforts, serve a growing population of people needing behavioral health
services. While the service population has grown, the availability of qualified staff,
sufficient facilities, and resources to support community-based services is insufficient to
meet the demand, resulting in overcrowded emergency rooms, jails filled with mentally ill
persons, and long waiting lists for all types of services.
Financing Behavioral Health Services

Financing behavioral health services through DPBH relies upon three funding streams
which include:
1. General Fund Revenues currently makes up the largest portion of funding to

support public behavioral health services.
2. Grants both large and small make up another source of funding to support public
behavioral health services throughout the state. The largest of these grants is the
Mental Health Block Grant.
3. Public Insurance Products such as Medicare and Medicaid are the smallest
contributor to funding services in their current formation.
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Gaps Analysis 2013
All financial investments made to support DPBH behavioral health services are reporting
annually to the NASMHPD Research Institute, Inc. (NRI). NRI collects this information
from State Mental Health Agencies (SMHA) in an effort to meet state and national needs
for comparable information portraying public mental health systems.
The table below demonstrates that Nevada’s per capita behavioral health spending has
and continues to be significantly lower than the national average (Foundation, 2013).
PER CAPITA BEHAVIORAL HEALTH

FFY04 FFY05 FFY06 FFY07 FFY08 FFY09 FFY10
EXPENDITURES
$ per capita $54 $63 $61 $79 $81 $64 $68
Nevada
Rank 40 39 42 33 36 41 43
United States $ per capita $93 $100 $104 $113 $121 $123 $121
Figure 4: Per Capita Behavioral Health Expenditure 04-10
The following map illustrates how Nevada compares to the rest of the nation in per-
person behavioral health spending for FY2010 (Foundation, 2013).
Figure 5: Behavioral Health Spending Across the Nation FY 2010
Exacerbating the issue of low spending levels related to behavioral health services, was
the issue of the “great recession”, which hit Nevada particularly hard. This resulted in
further funding cuts to behavioral health. As noted in Nevada's MHDS 2012 Needs
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Gaps Analysis 2013
Assessment, Nevada ranked fifth of all states with the greatest proportion of cuts to
behavioral health from FY 2009 to 2012 (McKnight, 2012). These cuts were also
referenced in Nevada’s 2013 Joint Block Grant Application:
“MHDS suffered a total budget decrease of 12.5% for the 2011 through 2013
biennium and a 13.9% overall decrease in the General Fund appropriations. This
has resulted in a loss of approximately 150 positions Division-wide. The
eliminations occurred in agency programs in the north and south and in the
inpatient and outpatient treatment centers. The elimination of these positions
impacted services provided to Nevada’s consumers statewide and in all regions for
MHDS, Division of Child and Family Services (DCFS) and the Substance Abuse
Prevention and Treatment Agency (SAPTA). The cuts have raised concerns
regarding meeting client needs” (Block Grant Division of Mental Health and
Developmental Services Substance Abuse Prevention and Treatment Agency,
2013).
During the most current legislative session, Governor Sandoval requested and the
legislature approved a series of new funds to support additional staff within DPBH as well
as additional services for consumers such as comfort rooms, additional civil and forensic
beds, housing for Nevadans leaving jails and prisons, and the requirement of treatment
for co-occurring disorders. While these additional investments are welcome
enhancements, they are not tied to a comprehensive strategic plan to confront and
address some of the structural flaws within the existing service delivery model such as
insufficient resources to fill position,
professional staff, lack of community-based
programming, lack of housing, and
transportation barriers.
A proactive, strategic plan to implement an

integrated system of care approach to
behavioral health is not in place. Without
this type of vision, investments will continue
to be targeted to confront crises, and will
likely achieve only short-term gains.
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Gaps Analysis 2013
Profile of Behavioral Health Consumers

This section explores the profile of behavioral health consumers based on age, gender and
race. Additionally, age and race are cross-tabulated to establish a more comprehensive
picture of the profile of current consumers. The demographic profile of behavioral health
consumers is important to understand compared to the demographics of the state.
Comparing these two data sets shows where subpopulations are either underrepresented
or over-represented in services.
Additionally, penetration rates identify how well the State of Nevada is doing in reaching
consumers in need of behavioral health services. Penetration rate, is defined by SAMHSA
as the “percentage of members using mental health services.” (Dougherty Management,
Inc., 2002) Penetration rates particular to demographic profiles are compared against
2012 national averages to determine if Nevada is reaching subsets of people in a manner
better, worse, or consistent with national averages. This variable is commonly used to
assess access to services.
Age
In Nevada, the largest category of consumers accessing care is between the ages of 25-44,
representing 38% of the service population. This is followed by consumers between the
ages of 45-65, representing 35% of the service population.
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Gaps Analysis 2013
The chart below demonstrates the age distribution of consumers accessing behavioral
health care compared to the age demographic profile of the state.
45.0%
38.4%
40.0% 35.5%
35.0%
28.5%
30.0% 25.6%
25.0%
17.8%
20.0%
15.0% 6.8% 6.6%
7.9% 4.0% 7.3%
10.0% 5.8% 5.3% 4.7%
3.6%
5.0% 1.9%
0.3% 0.1%
0.0%
0-12 13-17 18-20 21-24 25-44 45-64 65-74 75+ Not
Available
% of NV Population % of Clients
Figure 6: Age of Clients Accessing DPBH Services Compared to Statewide Population Statistics.
This chart demonstrates that while persons between the ages of 25-64 make up slightly
more than half of the state’s population, they represent almost two-thirds of the persons
served in DPBH. The system, including DCFS and DPBH, serves significantly fewer very
young children (up to age 12) and older adults (65+) compared to the population
distribution of persons in the state.
Figure 7 demonstrates how Nevada compares to the national averaged efforts in reaching
individuals throughout the lifespan. On average, systems nationally reach consumers ages
13-17 with a penetration rate of 41.2 per 1,000 people in the population, in contrast to
Nevada, which has a penetration rate of 9.2 per 1,000 between the ages of 13-17.
45 41.2
40
35
30 26.0 26.3
24.5
22.7
25 21.4
20
14.5 14.7
15 13
9.2 10.1 9.0
7.0
10
4.8
5 2.6
0.6
0
0-12 13-17 18-20 21-24 25-44 45-64 65-74 75+

Figure 7: Nevada Penetration Rates by Age Compared to US Statistics
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Gaps Analysis 2013
Nevada serves one child (ages 0-12) for every four, on average, served nationally and one
senior (ages 75+) to every 12 served nationally.
For all age ranges, Nevada fails to reach the same amount of consumers as national
averages. The following represents the ratio of service reach between Nevada and
national averages (Nevada: National).
Ages Ages Ages Ages
0-12 Ratio (1:4) 18-20 Ratio (1:3) 25-44 Ratio (1:2) 65-74 Ratio (1:3)
13-17 Ratio (1:4) 21-24 Ratio (1:2) 45-64 Ratio (1:2) 75+ Ratio (1:12)
Figure 8: Ratio by Age Nevada: National
Because penetration rates are an indication of access, low penetration rates in Nevada
indicate a deficiency of service options including outreach, assessment and treatment.
This appears to be particularly true in relationship to services for the very young.
Whereas other states appear to be focused on early intervention and prevention, Nevada
appears to respond more to crisis in adulthood. Intervening earlier in the life span may
result in fewer persons requiring intervention and treatment later in life, which would be
a less costly and more effective service delivery system. “Intervening at the first sign of
symptoms offers the best opportunity to make a significant, positive difference in both
immediate and long-term outcomes for people affected by mental health issues.”7 As
such, the federal Substance Abuse and Mental Health Services Administration (SAMHSA)
has designated prevention as their
first strategic priority (Steve Vetzner,
2013).
While DPBH is not the primary agent
responsible for providing services to
children and adolescents, it will
ultimately bear the burden of treating
these individuals in the event that
early prevention and intervention
services are not adequate.
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Gaps Analysis 2013
Gender
Figure 9 demonstrates the gender
distribution of consumers accessing public
behavioral health services for FY 2011-12.
Female consumers make up the largest
demographic of individuals accessing care, Male
representing 53% of the service population. 47%
Male consumers represent the remaining Female
53%
47% of the service population.
Figure 10 shows the gender distribution of
consumers accessing behavioral health care
compared to the demographic of the state.
Figure 9: Gender of DPBH Clients FY 2011-12
60.0%
52.6%
49.5% 50.5%
50.0% 47.0%
40.0%
30.0%
20.0%
10.0%
0.4%
0.0%
Female Male Not Available
Figure 10: Gender of Clients Accessing DPBH Services Compared to Statewide Population Statistics
While there are fewer females than males in Nevada, more females use DPBH services.
This is consistent with national trends which identify females as accessing behavioral
health services with slightly more frequency than men (Center for Mental Health Services,
NASMHPD Research Institute, Inc., 2012).
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Gaps Analysis 2013
25.0 23.1
22.2
20.0
15.0
11.3
9.9
10.0
5.0
-
-
0.0
Female Male Not Available
NV penetration rates per 1,000 population US (FY 2012)
Figure 11: Nevada Penetration Rates by Gender Compared to US Statistics
Nationally averaged penetration rates for females account for 23.1 persons per 1,000
people in the population, compared to 11.3 persons in Nevada. Nationally averaged
penetration rates of services to men, (22.1 per 1,000) also exceed Nevada’s rate of 9.9 per
1,000.
Race & Ethnicity American Indian

or Alaska Native Asian
1%
Figure 12 shows the racial distribution 2%
Native Hawaiian
of consumers accessing public or Other Pacific
Black or Islander
behavioral health services for FY 2011- Not Available African 1%
More Than One 17% American
12. White consumers represent the Race 13%
2%
largest demographic accessing care,
representing 64% of those served.
Figure 13 demonstrates the racial

distribution of consumers accessing
behavioral health compared to the racial White
64%
demographic of the state.
Figure 12: Race of DPBH Clients FY 2011-2012
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Gaps Analysis 2013
66.2%
70.0% 64.5%
60.0%
50.0%
40.0%
30.0%
20.0% 12.6% 12.0%17.1%

1.2% 7.2% 8.1% 0.6%
10.0% 4.7%
1.1% 1.9% 0.6% 2.2%
0.0%
American Indian Asian Black or African Native Hawaiian White More Than One Not Available
or Alaska Native American or Other Pacific Race
Islander
Figure 13: Race of Clients Accessing DPBH Services Compared to Statewide Population Statistics
While the vast majority of consumers served reflect the racial demographics of the state,
there are variances particular to the Asian and African-American populations served. In
Nevada, Asians represent 7.2% of the overall population in Nevada, but only 1.9% of the
service population. In contrast, African-Americans represent 8.1% of the population in
Nevada, but account for 12.6% of the service population.
The table that follows demonstrates how Nevada compares to the national average in
reaching consumers according to race. It demonstrates that in every racial category,
Nevada lags behind in reach when compared to national averages.
40.0 34.7
35.0
30.0 24.4
21.9 20.4
25.0 18.4
20.0 15.7
15.0 8.5 8.9
7.4 5.4 6.3
10.0
-
5.0 2.7 -
0.0
American Indian Asian Black or African Native Hawaiian White More Than One Not Available
or Alaska Native American or Other Pacific Race
Islander
NV penetration rates per 1,000 population US (FY 2012)
Figure 14: Nevada Penetration Rates by Race Compared to US Statistics
The following represents the ratio of service reach between Nevada and national averages
(Nevada: Nation).
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Gaps Analysis 2013
American Indian or Alaskan Native Black or African American White

Ratio (1:3) Ratio (1:2) Ratio (1:2)
Asian Native Hawaiian or Other Pacific More than one Race

Ratio (1:2) Islander Ratio (1:2) Ratio (1:4)
Figure 15: Ratio by Race Nevada: National
On average, Nevada continues to serve one individual for every two served nationally.
This dynamic is most pronounced among American Indian / Alaskan Native populations
as well as amongst those of more than one racial heritage.
Ethnic Considerations
While 26.5% of the population of Nevada is Hispanic/Latino, they represent 12.5% of
those served, as identified below in Figure 16.
80.0% 73.5% 75.3%
70.0%
60.0%
50.0%
40.0%
26.5%
30.0%
20.0% 12.5% 12.2%
10.0%
0.0%
Hispanic/Latino Ethnicity Not Hispanic/Latino Not Available
Figure 16: Ethnicity of Clients Accessing DPBH Services Compared to Statewide Population Statistics
Figure 17 reveals that while national penetration rates for services to the Hispanic
population are 18.3 per 1,000 people in the population, Nevada reaches only 4.9 per
1,000. This is the most pronounced gap in service reach identified among racial/ethnic
groups when compared to national averages.
25.0 21.6
18.3
20.0
15.0 19.2
10.0
4.9
5.0
0.0
Hispanic/Latino Ethnicity Not Hispanic/Latino
Figure 17: Nevada Penetration Rates by Ethnicity Compared to US Statistics
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Gaps Analysis 2013
Nevada’s lack of resources, compounded with language barriers and lack of bilingual
professionals likely accounts for this disparity.
Cross-Tabulation
To further understand the profile of behavioral health consumers, cross-tabulations of the
following were calculated Race/Age, Ethnicity/Age, Race/Gender and Ethnicity/Gender.
These provide a picture of how target populations of consumers access the behavioral
healthcare system and help identify underserved groups in need of outreach. The
following is a narrative summation of what the cross-tabulation analysis reveal. All charts
associated with the analysis can be found in the Appendix of this report.
Race/Age
Cross-tabulations reveal that in most categories there is little difference between when
White, African American/Black, and American Indians/Alaska Native consumers access
services based on age. Approximately 15-19% of the behavioral health consumer base
between these three racial groups access
services prior to the age of 18.
Approximately 9-12% access services in
early adulthood, between the ages of 18-
24. The largest age range of consumers
makes up the two age categories 25-44
(36-37%) and 45-64 (32-38%). A very
small portion of the population age 65 and
over are accessing care at all, accounting
for just 1-2% of the total service
population.
Cross-tabulations of race and age

demographics reveal the following
variances within particular racial groups:
 Asian consumers tend to access the

bulk of services between the ages of
25-44, accounting for 49% of the
consumer base within that racial
category. Additionally, this
population has a very low percentage (10%) of consumers accessing services prior
to the age of 18.
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Gaps Analysis 2013
 Native Hawaiian/Other Pacific Islander consumers have the largest percentage of

all racial groups accessing services prior to the age of 18, with 29% of their
consumer base within this age category. 11% of their consumer base is between
the ages of 18-24, and 42% is between the ages of 25-44. This racial group has the
smallest population of consumers within the 45-64 age range, making up just 18%
of the consumer base within their racial category.
Ethnicity/Age
26% of the Hispanic consumer base access services prior to the age of 18. Only 12%
access services in early adulthood, between the ages of 18-24, while 38% access services
between the ages of 25-44. Hispanic consumers between the ages of 45-64 make up 23%
of their consumer population, and only 1% of their consumer base is over the age of 65.
Race & Ethnicity/Gender

Cross-tabulations of race/ethnicity and gender demographics reveal the following
variances within particular groups:
 African American/Black consumers are the only racial group in which men access
services more frequently than their female counterparts.
 Hispanic consumers access services equally amongst gender categories, with both
men and women each accounting for 50% of consumers within their ethnic
category.
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Gaps Analysis 2013
Gaps Analysis
This section compares information about the prevalence of serious emotional disturbance
(SED) among children, and any mental illness (AMI) and serious mental illness (SMI)
among adults against the numbers of individuals currently being served by DPBH to
develop an estimate of unmet need. Additionally, results of a survey which aimed to
identify how people access services, their satisfaction with services received and
identification of gaps in the service delivery model is presented.
This information helps define what gaps exist in the public mental health system. The
situational analysis component of this report will seek to explain why these gaps exist.
Prevalence, Utilization and Unmet Need

A multi-step formula was used to establish an estimate of unmet need related to
behavioral health services.
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Gaps Analysis 2013
Step 1: To identify the population in Nevada that need behavioral health support and are
eligible to receive it through public provisions, the following formula was used:
% OF POPULATION
( )
2010 ESTIMATED % OF PEOPLE IN NEVADA NEEDING
CENSUS
DATA
X
ELIGIBLE FOR
MEDICAID IN
NEVADA
X PEOPLE CONSIDERED
SED/AMI/SMI
= AND ELIGIBLE FOR PUBLIC
MENTAL HEALTH SERVICES
This component of the analysis took into consideration the following:
 2010 Census Data: Population statistics were taken from the 2010 US Census data.
 Percentage of Population Eligible for Medicaid in Nevada:
o Estimated Medicaid eligible population of children: The estimated Medicaid
eligible population for children was taken from the, “Medicaid Facts Sheet
for Nevada – September 2012," produced by the American Academy of
Pediatrics in conjunction with the Children’s Hospital Association.
o Estimated Medicaid eligible population of adults: The US average of the
Medicaid enrollees (16%) was applied to population statistics to determine
the Medicaid eligible population. This information comes from a
memorandum by the Public Consulting Group (PCG) to the State of Nevada
Department of Health and Human Services titled: “An Overview of Nevada’s
Publicly-Subsidized Health Coverage Programs,” produced on August 4,
2011.
 Percentage of People Suffering from SED/AMI/SMI:
o SED prevalence rate: Estimates of the number of children suffering from
serious emotional disturbances (SED) vary widely. A 5% prevalence rate
was used for the purpose of this analysis based on an expanded literature
review conducted by Brauner and Stephens in their article, “Estimating the
Prevalence of Early Childhood Serious Emotional/Behavioral Disorders:
Challenges and Recommendations.” In this article, the authors provided a
range of 5% to 26% based on their review of 10 studies conducted around
the issue (Brauner & Stephens, 2006). The 5% prevalence rate is also
referenced in the MHDS Needs Assessment 2012 Report (pg. 55).
o AMI/SMI prevalence rates: Estimated prevalence rates for adults suffering
from any mental illness (AMI) or severe mental illness (SMI) were taken
from the, “State Estimates of Substance Use and Mental Disorders from the
2009-2010 US Surveys on Drug Use and Health Report,” produced by the US
Department of Health and Human Services, Substance Abuse and Mental
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Gaps Analysis 2013
Health Services Administration, Center for Behavioral Health Statistics and

Quality (Services S. A., 2012).
Step 2: To identify the unmet need of people in Nevada that required behavioral health
services and were eligible to receive them through public provision, yet did not, the
following formula was used:
PEOPLE IN NEVADA
NUMBER OF PEOPLE WHO PEOPLE IN NEVADA NEEDING AND
-
NEEDING AND
ELIGIBLE FOR PUBLIC
BEHAVIORAL
ACCESSED PUBLIC
BEHAVIORAL HEALTH
SERVICES
= ELIGIBLE FOR PUBLIC BEHAVIORAL HEALTH
SERVICES BUT NOT RECEIVING THEM
(UNMET NEED)
HEALTH SERVICES
This component of the analysis took into consideration the following:
 DPBH (known as MHDS during the time of data collection) Service Utilization
Statistics: This information was obtained directly from Division staff.
 DCFS Service Utilization Statistics: This information was taken from DCFS
Descriptive Summary of Children’s Mental Health Services – Fiscal Year 2012
(Services, 2012).
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Gaps Analysis 2013
Children’s Mental Health Prevalence, Utilization and Unmet Need

The Division of Children and Family Services
(DCFS) is responsible for providing
behavioral health services to children and
adolescents in Washoe and Clark County,
while DPBH is responsible for providing
services in the rural areas of the state. Served,
3,989
In Fiscal Year (FY) 2011-2012, there were a
total of 12,399 children in the state that Unmet
were Medicaid eligible and estimated to Need,
8,410
have a serious emotional disturbance (SED).
Of that total, the state provided services to
3,989 in FY 2011-12, representing 32% of
the estimated need.
Figure 18: Children Served by State vs. Unmet Need in Nevada
Served,
2,927
DCFS’s service population totaled 10,991, of which 2,927
Unmet
were served, representing approximately 27% of the
Need,
8,064
estimated need.
Figure19: Children served by DCFS vs.

Unmet Need
Unmet DPBH’s service population totaled 1,408, of which 931 were

Need,
477 served, representing approximately 66% of the estimated
Served,
931
need. A total of 477 (34%) children were estimated to be in
need of but not receiving services in FY 2011-12.
Figure 20: Children served by DPBH

vs. Unmet Need
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Gaps Analysis 2013
Urban North
Served,
When considering the urban part of northern Nevada
Unmet
Need,
793 alone, considered to be Washoe County, the total service
1,060 population is estimated to be 1,853. Of that, DCFS
provided services to 793 in FY 2011-12, or 43% of those
in need.
Figure 21: Children Served vs. Unmet Need in
Washoe County
Urban South
Served,
2,265 In urban southern Nevada, considered to be Clark
County, the total service population is estimated to be
Unmet
Need, 9,138. Of that, DCFS provided services to 2,265 in FY
6,873 2011-12, representing 25% of children estimated to be
in need.
Clark County
Rural
Unmet
Need,
For all counties except Washoe and Clark, the total
477 service population is estimated to be 1,408. Of that,
Served,
931 DPBH provided services to 931 in FY 2011-12 or 66% of
children estimated to be in need.
Rural Nevada
Combined, 8,410 children were estimated to need but not receive services in FY 2011-12.
The tables that follow provide detail on those numbers.
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Gaps Analysis 2013
Children’s Mental Health Prevalence, Utilization and Unmet Need

Medicaid Eligible
Medicaid Eligible Total Served Total Served by Estimated
2010 Census Data SED Population Total Children
Region/County Population by State State MH Unserved Medicaid
(Age 0-17)8 (based on 5% Served Statewide
(37.36%)9 DCFS11 Authority12 Eligible Population
Prevalence Rate)10
Rural and Frontier
Churchill 6,128 2,289 114 0 75 75 39
Douglas 9,128 3,410 171 0 84 84 87
Elko 14,306 5,345 267 0 123 123 144
Esmeralda 144 54 3 0 0 3
Eureka 475 177 9 0 0 9
Humboldt 4,522 1,689 84 0 102 102 -18
Lander 1,573 588 29 0 31 31 -2
Lincoln 1,336 499 25 0 18 18 7
Lyon 12,524 4,679 234 0 191 191 43
Mineral 842 315 16 0 16 16 0
Nye 8,622 3,221 161 0 45 45 116
Pershing 1,247 466 23 0 25 25 -2
Storey 631 236 12 0 0 12
White Pine 2,170 811 41 0 81 81 -40
Carson City 11,741 4,386 219 0 140 140 79
Regional Subtotal 75,389 28,165 1,408 0 931 931 477
Northern
Washoe 99,179 37,053 1,853 793 0 793 1,060
Northern Subtotal 99,179 37,053 1,853 793 0 793 1,060
Southern
Clark County 489,207 182,768 9,138 2,134 131 2,265 6,873
Southern Subtotal 489,207 182,768 9,138 2,134 131 2,265 6,873
Nevada - Total 663,775 247,986 12,399 2,927 1,062 3,989 8,410
Figure 24: Children's Behavioral Health Prevalence, Utilization and Unmet Need
8Population statistics were taken from the Nevada Rural and Frontier Health Data Book – 2013 Edition using the 2010 Census data.
9The estimated Medicaid eligible population for children was determined by statistics provided in the Medicaid Facts Sheet for Nevada – September 2012, produced by the American Academy of Pediatrics in
conjunction with the Children’s Hospital Association.
10 5% prevalence rate identified by Brauner and Stephens in their article: Estimating the Prevalence of Early Childhood Serious Emotional/Behavioral Disorders: Challenges and Recommendations Public Health
Reports, Volume 121, pp 301-310. That 5% was applied to the Medicaid eligible population statistic to identify the consumer base for State Behavioral Health Services.
11 Utilization data was taken from the Division of Child and Family Services: Descriptive Summary of Children’s Mental Health Services Fiscal Year 2012 Report.
12 Utilization data was provided by Sean Dodge, Psy.D., Lead Clinical Psychologist for Public and Behavioral Health Rural Counseling and Supportive Services. The data represents utilization for FY 2011-12.
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Gaps Analysis 2013
Adult Mental Health Prevalence, Utilization and Unmet Need

Public behavioral health services to adults, age 18
and over, are provided through the following service
agencies:
Served,
 Northern Nevada Adult Mental Health 25,522
Services (NNAMHS)
 Southern Nevada Adult Mental Health Unmet
Services (SNAMHS) Need,
63,434
 Rural Counseling and Supportive Services
(RCSS) sites
Figure 25: Adults Served by DPBH vs. Unmet Need in Nevada

There are a total of 88,956 adults in the state of
Nevada that are Medicaid eligible and are considered to have any mental illness or a
severe mental illness. This is considered the service population that DPBH is responsible
to serve. Of that total, DPBH provided services to 25,522 in FY 2011-12, representing
29% of the total of those estimated to be in need. Over 60,000 adults were estimated to be
in need of but not receiving services in FY 2011-12. The tables that follow provide detail
on those numbers.
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Gaps Analysis 2013
Urban North
Unmet
Served,
5,785
When considering the urban part of northern Nevada,
Need, Washoe County, the estimated total adults in need were
8,454
14,239. DPBH provided services to 5,785 adults in need
in FY 2011-12, or 41% of those estimated to be in need.
Figure 26: Adults Served vs. Unmet Need in
Washoe County
Urban South
Served,
15,203 When considering the urban part of southern Nevada,
considered to be Clark County, the adult population in
Unmet
Need, need was estimated to be 63,767. Of that total, DPBH
48,564
provided services to 15,203 adults in FY 2011-12,
representing 24% of the total estimated to be in need.
Clark County
Rural
Served,
For rural Nevada, considered to be all counties except
Unmet
Need,
4,534 Washoe County and Clark County, the estimated adult
6,416 population in need for FY 2011-12 was 10,950. DPBH
provided services to 4,534, representing 41% of adults in
need.
Rural Nevada
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Gaps Analysis 2013
Adult Mental Health Prevalence, Utilization and Unmet Need

SMI Population Total Adults Estimated
2010 Census Data13 Medicaid Eligible AMI Population
(based on 5.29% Served by Unserved
Region/County Population (based on 21.96%
Prevalence State MH Population
18-64 65+ (16%)14 Prevalence Rate)
Rate)15 Authority16 (SMI/AMI)
Rural and Frontier
Churchill 14,652 3,742 2,943 156 646 449 353
Douglas 27,877 9,323 5,952 315 1,307 486 1,136
Elko 30,886 4,072 5,593 296 1,228 487 1,037
Esmeralda 428 195 100 5 22 0 27
Eureka 1,239 222 234 12 51 0 64
Humboldt 10,489 2,079 2,011 106 442 421 127
Lander 3,570 623 671 35 147 121 62
Lincoln 2,982 1,367 696 37 153 59 131
Lyon 30,477 8,081 6,169 326 1,355 778 903
Mineral 2,708 1,008 595 31 131 104 58
Nye 24,045 11,143 5,630 298 1,236 606 928
Pershing 4,528 729 841 44 185 78 151
Storey 2,494 671 506 27 111 0 138
White Pine 6,398 1,442 1,254 66 275 245 97
Carson City 34,261 9,415 6,988 370 1,535 700 1,204
Regional Subtotal 197,034 54,112 40,183 2,126 8,824 4,534 6,416
Northern
Washoe 273,032 53,550 52,253 2,764 11,475 5,785 8,454
Northern Subtotal 273,032 53,550 52,253 2,764 11,475 5,785 8,454
Southern
Clark County 1,250,003 212,545 234,008 12,379 51,388 15,203 48,564
Southern Subtotal 1,250,003 212,545 234,008 12,379 51,388 15,203 48,564
Nevada - Total 1,720,069 320,207 326,444 17,269 71,687 25,522 63,434
Figure 29: Adult Behavioral Health Prevalence, Utilization and Unmet Need
13 Population statistics were taken from the Nevada Rural and Frontier Health Data Book – 2013 Edition using the 2010 Census data.
14 16% Medicaid Eligible statistic was identified in a memo produced by Public Consulting Firm PCG to the State of Nevada Department of Health and Human Services titled: An Overview of Nevada’s Publicly-
Subsidized Health Coverage Programs produced on August 4, 2011.
15 SMI/AMI Prevalence determined by the US Survey on Drug Use and Health (NSDUH) available at: http://www.samhsa.gov/data/NSDUH/2k10State/NSDUHsae2010/NSDUHsaeCh6-2010.htm
16 Utilization data was provided by Sean Dodge, Psy.D., Lead Clinical Psychologist for Public and Behavioral Health Rural Counseling and Supportive Services. The data represents utilization for FY 2011-12.
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Gaps Analysis 2013
Consumer Surveys
Surveys were distributed throughout the state to social service providers that did not
provide behavioral health services. Providers included food pantries, family resource
centers and health and human service organizations. A total of 339 individuals completed
the survey. The demographics of the survey respondents are found in the following tables.
Gender (n=334) Number Percent

Male 185 55.4%
Female 149 44.6%
Figure 30: Consumer Survey Gender Breakout
More males filled out the survey compared to females with 185 men (55.4%) and 149
women (44.6%).
Age (n=333) Number Percent

0-12 0 0.0%
13-17 2 0.6%
18-20 5 1.5%
21-24 11 3.3%
25-44 98 29.4%
45-64 124 37.2%
65-74 39 11.7%
75+ 54 16.2%
Figure 31: Consumer Survey Age Breakout
The majority of respondents were adults between the ages of 25 to 64 (222 of 333 or
66.6%). This corresponds with the ages of persons most frequently served by DPBH. Two
respondents were under the age of 18 (0.6%) and 16 were young adults between the ages
of 18 and 24 (4.8%). There were 93 respondents over the age of 65 (27.9%).
Race/Ethnicity (n=331) Number Percent

White 225 68.0%
Hispanic 33 10.0%
Black/African American 40 12.1%
American Indian/Alaskan 10 3.0%
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Gaps Analysis 2013
Race/Ethnicity (n=331) Number Percent

Pacific Islander 3 0.9%
Asian 7 2.1%
Mixed Race 13 3.9%
Figure 32: Consumer Survey Race/Ethnicity Breakout
Out of 331 survey respondents who indicated race, 225 were White (68%) while the most
underrepresented were Pacific Islanders with three respondents or 0.9%. African
American/ Black respondents made up 12.1% of the survey respondents (40 of 331)
while Hispanics represented 10% (33). American Indian/Alaska, Pacific Islander, Asian,
and Mixed Race made up 10% or 33 of the surveys.
County (n=330) Number Percent

Carson City 13 3.9%
Churchill 15 4.5%
Clark 104 31.5%
Douglas 0 0.0%
Elko 2 0.7%
Esmeralda 0 0.0%
Eureka 0 0.0%
Humboldt 0 0.0%
Lander 0 0.0%
Lincoln 0 0.0%
Lyon 12 3.6%
Mineral 0 0.0%
Nye 0 0.0%
Pershing 0 0.0%
Storey 2 0.6%
Washoe 182 55.2%
White Pine 0 0.0%
Figure 33: Consumer Survey Region Breakout
The majority of survey respondents were from Washoe or Clark County with 182 of 330
from Washoe (55.2%) and 104 from Clark (31.5%). Forty-four respondents were from
Carson City, Churchill, Elko, Lyon, or Storey Counties (13.3%). Douglas, Esmeralda,
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Gaps Analysis 2013
Eureka, Humboldt, Lander, Lincoln, Mineral, Nye, Pershing, and White Pine Counties did
not return any surveys.
Types of Services Used Yes Percentage No Percentage

Yes No
Inpatient Care -- Hospitalization 80 27.8% 208 72.2%
Outpatient Care -- Community-Based Services 97 35.1% 179 64.9%
Psychiatry -- Access to a Therapist 77 27.6% 202 72.4%
Medication Management -- Use of Prescription Psychotropics 70 25.6% 203 74.4%
Support Group Participation 57 21.3% 210 78.7%
Dual Diagnosis Services 41 15.6% 221 84.4%
Case Management -- Support services to help with ancillary 71 26.7% 195 73.3%
needs (goals establishment linkage to other services, etc.)
Figure 34: Consumer Survey - Services Used
Question six on the survey asked respondents if they have used any of the listed services.
A majority of the services were not utilized by the respondents while the most utilized
service was Outpatient Care with 35.1% or 97 respondents. The least utilized was Dual
Diagnosis Services with 41 or 15.6% of respondents indicating they had used that service.
Degree to Which their Need Was Met Always Usually Sometimes Never
met my met my met my met my
needs needs needs needs
Inpatient Care -- Hospitalization (n=60) 46.7% 18.3% 26.7% 8.3%
Outpatient Care -- Community-Based Services (n=69) 33.3% 29.0% 29.0% 8.7%
Psychiatry -- Access to a Therapist (n=55) 30.9% 18.2% 32.7% 18.2%
Medication Management -- Use of Prescription 45.6% 19.3% 17.5% 17.5%

Psychotropics (n=57)
Support Group Participation (n=40) 32.5% 32.5% 20.0% 15.0%
Dual Diagnosis Services (n=24) 50.0% 4.2% 12.5% 33.3%
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Gaps Analysis 2013
Case Management -- Support services to help with 33.3% 29.2% 22.9% 14.6%
ancillary needs (goals establishment linkage to other
services, etc.) (n=48)
Figure 35: Consumer Survey - Needs Met
For those who had received services, respondents were asked to indicate the degree to
which their needs were met. No clear patterns of satisfaction in having needs met were
evident, but Inpatient Care, Medication Management, and Dual Diagnosis Services rated
the highest in needs met. At the same time, Dual Diagnosis Services also rated the highest
in never having needs met. More than half of those respondents who answered the
question indicated “always” or “usually” to indicate the services met their needs.
Psychiatry or access to a therapist was the lone exception with more than 50% indicating
the service never or sometimes met their needs.
Issues
180 166 160 158
122
160 121 125 131
140 128 122 120 113 127
114 107
120 100 104
100 76
80 68
60
40
20
0
Yes No
Figure 36: List of Issues
Respondents were given a list and asked to indicate whether the issue was a concern or
barrier for them. Lack of transportation received the highest number of responses (160).
Lack of medical insurance, costs of services, long waiting lists and not knowing where to
get help were also rated as high concerns. In addition, not enough services available and
not enough service providers each were cited by more than 100 respondents as a
concern.
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Gaps Analysis 2013
Significance of Behavioral health Care for Your Community? (n=277)

200
62.5%
180
160
140
120
100
80
18.4%
60 15.5%
40
3.6%
20
173 51 10 43
0
This is a big issue - there are a This is a moderate issue - there This is a minor issue - there This is not an issue - services
lot of needs that remained are ongoing needs, but are system improvements being provided are sufficient
unaddressed services are available needed, but they are minor to meet the needs of people
and do not affect the critical
health issues of individuals
Figure 37: Significance of Behavioral Health Care for Your Community
62% of those who responded indicated that behavioral health concerns were a big issue
in their community with a lot of needs that remain unaddressed.
How well current system responds to behavioral health care needs of your
community? (n=236)
70 28.0%
60
19.9%
50 17.8%
40
11.9% 11.9%
30 9.7%
6.8% 7.2%
20 5.9%
3.4%
10 47 14 28 8 66 28 16 23 17 42
0
Responds in 2 3 4 5 6 7 8 9 Responds in
the best the worst
way way
possible possible
Figure 38: Response to Behavioral Health Care Needs
Respondents varied in how well they rated the current system in responding to the
behavioral health care needs of the community.
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Gaps Analysis 2013
Respondents were asked to list other issues they felt were important to understand. From
the open-ended responses, the following issues were listed most frequently.
Biggest Issues
Jobs 6
Insensitive or improperly trained caregivers 10
Not enough food 11
Transportation to medical facilities 11
Lack of affordability /Insurance 22
More services 30
Proper housing before and after treatment/homelessness 31
0 5 10 15 20 25 30 35
Figure 39: Biggest Issues
The surveys received from Nevadans validate that housing, lack of services, lack of
providers, and transportation for access to services are the biggest challenges they face.
They also show that people view behavioral health concerns as a large problem in their
communities and they don’t feel the problem is being addressed. When they were the
recipient of services, they indicated that services met their needs, with the exception of
access to psychiatry or a therapist. This is supported by the key informant results found in
the next section.
Summary
The profile of behavioral health consumers in Nevada, where they are served, and trends
of service penetration, when compared to national averages, indicate that Nevada’s
current system and approach to providing behavioral health services does not meet the
needs of Nevadans, with a pronounced deficiency in Southern Nevada. Nevadans of all
ages, both genders, and all racial and ethnic considerations are underserved. It is
estimated that over 8,000 children and more than 60,000 adults in Nevada need but are
not able to receive behavioral health care.
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Gaps Analysis 2013
Data indicates:
 Services are currently reaching people in their middle stages of life, with
insufficient resources for prevention or early intervention. “Intervening at the first
sign of symptoms offers the best opportunity to make a significant, positive
difference in both immediate and long-term outcomes for people affected by
mental health issues.”17 As such, the federal Substance Abuse and Mental Health
Services Administration (SAMHSA) has designated prevention as their first
strategic priority (Steve Vetzner, 2013).
 Services are not sufficient to meet the needs of people later in life. Attention should
be paid to identifying and engaging older Nevadans who require behavioral
support services. Older adults require different treatment responses and supports
such as transportation, home-based treatment options, and specialized outreach
efforts (Services W. S., 2013).
 A culturally competent framework to provide services to Nevada’s growing
minority population is needed.
o Particular interest should be paid to the over-representation of African-
American males in the service system, exploring the link between this
dynamic and their over-representation in the criminal justice system. As
identified in the report: “Prevalence of Mental Illness in the Criminal Justice
System”, “mentally ill individuals of African American origin were over-
represented among the CCDC detainees with mental illness while all other
racial/ethnic minorities were underrepresented. The rate of detained
African Americans with mental illness was 20.8% at CCDC in 2011, which
significantly exceeded their overall rate of less than 11% among the
residents of Clark County.”
o Hispanics/Latinos are significantly underrepresented in service delivery.
Attention should be paid to how to reach this population.
 Insufficient service reach is most pronounced in the southern region of the state,
as indicated by statistics that reveal only 24% of people eligible and needing
assistance are being served. Identifying the differences between the regions in
service populations, resources, and service deployment is critical for
understanding and addressing this reality.
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Gaps Analysis 2013
Situational Assessment
With a clear understanding of what gaps exist within the behavioral health system of
care, a situational assessment was conducted to explore why the gaps exist and to identify
opportunities to leverage existing strengths within the system. The following section
provides a situational assessment using the strengths, weaknesses, opportunities and
threats (SWOT) method. This is followed by a summary of the findings related to that
assessment. Throughout this entire section of the report, the analysis is largely shared in
the words of key informants.
SWOT Analysis
The SWOT method of analysis identified the following aspects affecting the Division:
 Strengths: the assets, resources, or capabilities that have the greatest positive
impact on the success of the organization and its ability to achieve its mission.
 Weaknesses: the aspects of the organization that are considered to be important
internal weaknesses– deficiencies in resource or capabilities, or other liabilities,
that hinder the ability of the organization to achieve its mission.
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Gaps Analysis 2013
 Opportunities: the external factors that offer a genuine opportunity to benefit the
organization. This may include environmental factors that allow the organization
to expand its services, or apply its capabilities to benefit a different part of the
community.
 Threats: the external conditions, trends, and other forces that are at least
moderately likely to hurt the organization in some manner if not addressed.
Information was compiled by qualitative data collection methods and themes were
identified. The areas noted by multiple stakeholders as strengths, weaknesses,
opportunities or threats are highlighted under the appropriate area below.
Strengths
Innovative Practices
Research and key informants indicate there
are a number of innovative practices that are
occurring at varying stages across the state.
Some projects cited by key informant
include, “the Health Home Pilot Project, the
Community Health Worker Program, Project
Echo, Community Triage Centers and
WHAM 18 to name a few.” There are a subset
of practices that have had a measurable impact on mental health services and should be
understood as they present opportunities for state-wide implementation. Each of the
following was identified as system strengths by a number of key informants. Descriptions
of services were obtained from public sources.
Mental Health Court

Mental Health Court is a collaborative effort between DPBH and the criminal justice
system. This program provides the opportunity for people with misdemeanor and minor
felony criminal charges who would benefit from psychiatric treatment to be diverted from
the standard criminal justice system if they participate in treatment. It is a service
coordination model with a caseload of 25 consumers per coordinator, ensuring
18WHAM stands for Whole Health Action Management (WHAM), the SAMHSA-HRSA Center for Integrated Health Solutions (CIHS) new
peer support curriculum. According to SAMHSA, WHAM is designed to train "peers teaching skills to better self-manage chronic
physical health conditions and mental illnesses and addictions to achieve whole health and resiliency."
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Gaps Analysis 2013
consumers obtain benefits, comply with court ordered treatment, medication and
substance abuse recovery.
Mobile Crisis Team (MCT) in Las Vegas at SNAMHS

This specialized unit works with Las Vegas area hospital emergency departments. The
Team is comprised of Licensed Clinical Social Workers (LCSWs) who travel to local
emergency rooms to evaluate patients on involuntary holds and, when feasible, develop
safe discharge plans to allow the ER to discharge the person back to the community. This
service averts unnecessary psychiatric hospitalizations, saves ER personnel time and
reduces the numbers of psychiatric patients in the ER.
Mobile Outreach Safety Team (MOST) at NNAMHS

This is a specialized program, staffed with two Licensed Clinical Social Workers (LCSWs,
in collaboration with local law enforcement agencies (Reno, Sparks, Washoe County) to
offer psychiatric services to the homeless mentally ill and those with mental illness who
bring themselves to the attention of law enforcement. This helps prevent increasing
numbers of persons with mental illnesses from being incarcerated and assists with
enrolling them in appropriate services. Also noted was the “Crossroads Program,” which
provides long-term housing and support for persons considered, “frequent flyers” that are
identified by the MOST team.
Project for Assistance in Transition from Homelessness (PATH)

This program targets homeless, or those at risk of becoming homeless. Individuals access
mental health services, apply for housing assistance, and/or maintain current housing.
This program is funded through a grant from SAMHSA. DPBH contracts with three private
providers throughout the state to meet the program objectives.
Telemedicine Services
Teleconferencing therapy, psychiatric consults and medication management at RCSS have
been implemented since 2011, to better serve people in frontier and rural Nevada who
have limited access to services and face transportation barriers. This pilot project
included purchasing and installing equipment in remote locations and hospitals across
Nevada to connect consumers to providers. One key informant described equipment
placed at China Springs. “Now we don’t need to discharge children with mental health
issues as they can have psychiatric care there and their families can come see them.”
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Gaps Analysis 2013
Evidence-based Practices
DPBH has implemented the Program for Assertive Community Treatment (PACT) in
northern and southern Nevada that provides intensive support to people with mental
illness who have a history of high use of emergency, hospital and law enforcement
services. The teams work in an interdisciplinary manner to support consumers living in
the community, adherence to their medication regime and employment rehabilitation.
Key informants noted repeatedly the implementation of evidence-based practices within
DPBH as a strength.
DCFS currently implements the following best practice approaches in their deployment of
behavioral health services to children and adolescents:
 Trauma-Focused Cognitive Behavioral Therapy

 Parent-Child Interaction Therapy
 Motivational Interviewing
 Dialectical Behavior Therapy
 Aggression Replacement Training
 Positive Behavioral Supports
 Wraparound
Resource Development
Leadership has charged the staff of DPBH with securing grants for additional resources.
They have supported grant writing training for staff to better position the Division to
secure new sources of funding. One state employee noted, “We have written more grants
in the last 60 days than I can remember in the past 10 years.”
These efforts have financially strengthened the system. Nevada recently received notice
that the state is likely to be awarded a new Cooperative Agreements to Benefit Homeless
Individuals (CABHI) grant, which will include capacity building and supports including
treatment for homeless individuals. The state was awarded an expansion of the Maternal,
Infant and Early Childhood Home Visiting Program grant, which provides prevention and
early intervention services to at risk families. In addition, the state received a technical
assistance award to implement a PEER counseling project. These projects help augment
the system of care currently in place. The state is also awaiting word on other grants
submitted.
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Gaps Analysis 2013
Additional revenue development activities have centered on how to draw down

additional federal funding for existing services rendered. Staff at SAPTA-funded
programs have been trained on how to bill Medicaid to increase reimbursement for
services.
New funding was approved during the 2013 legislative session and the Interim Finance
Committee to expand or reconfigure existing services to include:
 11 new full time positions and 12 new contract positions for SNAMHS
 SNAMHS renovation of building 3A for 21 Civil Psychiatric beds
 5 new comfort rooms at Rawson-Neal
 SNAMHS Drop-In Center opened September 23 rd
 42 forensic beds and 16 civil beds in building 3 at SNAMHS
 20 new full time positions at Lake’s Crossing
 10 new Forensic Psych beds at Lake’s Crossing
 New Behavioral Health Center opened July 2013; expanded hours pending staff
coverage
Quality of Care
Key informants noted that the following enhance the quality of services provided:
 “The state formulary provides good coverage for services/medications.”

 “Outpatient and group services are delivered well by qualified staff.”
 “System of care principles and values are embraced by system partners that serve
children.
 “Staff of DPBH are passionate, dedicated and talented.”
 “Use of evidence-based practices,” within DPBH was also acknowledged by key
informants.
Regardless of region, key informants indicated that,
 “State behavioral health staff reach out to homeless shelters, jails, social services,
any place where mentally ill people are,”
 “This is more effective than when the client has to go to the state to access
services.”
 There is acknowledgement that, “this has happened much more frequently lately,”
with the state acting in a, “flexible,” “nimble way,” to reduce barriers to services.
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Gaps Analysis 2013
 The Division has, “a good training series that orients staff” to evidence-based
services.
 One key informant noted that, “therapists are unbelievably good.” and
 “Medications are good.” and
 “Use of state of the art evidence-based practices, are in place.”
Statewide Collaboration
Parts of the system in northern and southern Nevada were described as:
 [Its] “Working much better these days between jail, cop on the street, public
defender and court.”
 “There is good cooperation with the pharmacy board.”
 “Parole and probation are much more collaborative now. “
Weaknesses/Gaps
Key informants identified a number of
weaknesses that need to be addressed to
strengthen the system.
Workforce
Key informants noted that there, “are not
sufficient staff resources.” “Psychiatrists are
difficult to recruit and retain and quality
psychiatrists even more difficult.”
 “Morale” at DPBH has been impacted by the continual, “flood of surveyors,

inspectors, reporters and requests for public information.”
 “The volume of consumers in southern Nevada means training is less of a priority
than in other parts of the state because of the size of caseloads and the backlog in
paperwork.”
 In addition, “compensation” and
 The “credibility of the system” were both cited as barriers to recruiting a highly
qualified workforce to fill positions.
 Psychiatric coverage was described as “spotty” throughout the state. “There are
some areas with no psychiatrists at all.”
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Gaps Analysis 2013
 “Child psychiatrists” were also identified as a gap by key informants.

 The rural telemedicine mental health project was seen as, “a strength” but key
informants noted that, “psychiatrists often combat burnout by feeling satisfaction
in patients outcomes but, the program is structured to use psychiatrists for
consults but transfer the case to Rural Clinics which is frustrating for the
psychiatrists participating in the program.”
This perspective is supported by statistics derived from the, “Nevada Rural and Frontier
Health Data Book - 2013 Edition,” which depicts every county in Nevada, with the
exception of Clark, having a shortage of mental health professionals (pg.177-179).
Provider Network
Nevada’s system of community-based providers is, “actually weaker than it was prior to
the recession.” Key informants noted that,
 “A number of nonprofits have ceased operation” and/or, “eliminated essential

community services.”
 The “private mental health provider community hasn’t evolved like other states”
because of the state operated system.
 So, community-based clinics and services, “haven’t emerged to extend the safety
net” of services.
 Formal systems, “aren’t in place to ensure reliability of practice” across the
continuum of services.
 “Referral relationships are dependent on knowing the right person to reach,
reaching them and hoping they have a resource.”
Resources
Key informants noted a lack of capacity and long waiting lists for all services across the
system of care including:
Outpatient Services
 “Individual counseling” is a gap because, “A lot of folks [clinicians] don’t believe in
individual therapy.”
 “Long term safe, outpatient civil commitment with wrap around services.”
 “Outpatient for those who don’t need the same level of support.”
 “Peer support groups”
 “Youth and transgender options”
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Gaps Analysis 2013
Inpatient Services
 “Forensic inpatient beds for those who have not
been deemed competent.” “Nevada currently has one of
 Residential services for: the most restrictive civil
o Co-occurring disorder services commitment laws in the
o Mental health and substance abuse services country. The state forces
individuals to deteriorate to
for juveniles the point of dangerousness
o Substance abuse treatment beds statewide before help can be provided. In
 In southern Nevada, “people are sent to the Nevada, there are almost ten
emergency room for medical clearance before they seriously mentally ill persons
in jails and prisons for every
can be admitted to the hospital, rather than clearing
one person in a hospital.”
them medically at Rawson-Neal.”
Testimony provided in favor
 As stated earlier in this report, there are primary,
of AB 287, April 8, 2013 by
secondary, and linkage agencies that play a role in Kristina Ragosta, Esq.,
the deployment of behavioral health care. Some of Treatment Advocacy Center
those partners, outside of the state operated system
pose challenges to the system. For example, in northern Nevada, there were a
number of stories of persons who “were a danger to themselves or others, picked
up by the police, taken for a 72-hour hold and then discharged when they clearly
weren’t safe to return home.” 19
 Even the most sophisticated service providers describe the, “impossibility of
getting an involuntary commitment in northern Nevada.”
Culturally Competent Services

 There were gaps in efficacy of the providers within the state to provide culturally
and linguistically appropriate services for special populations with Latinos and
transgender individuals identified as two particular populations that are
underserved.
Supportive Services
 Transportation was identified as a challenge along the continuum of services.
 “Lack of transportation to access services,” coupled with, “costly” transportation
options to, “transport persons from rural or southern Nevada to northern Nevada
to access Lake’s Crossing,” which was noted more than once as a weakness.
19 See section of the report which describes the passage of AB 287, which could help address this issue.
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Gaps Analysis 2013
 “There is a lack of supportive housing for those who can’t live independently but
don’t need to be locked up.”
 “Affording safety and security with some supervision but without confinement is
what is most often needed but lacking.”
 “Resources that include some supervision but that are less intensively supervised
are needed” at all levels.
 “Housing resources” were identified in all regions as a gap.
 Often, “housing with some level of support or supervision” was identified as a gap.
The housing gaps noted include:
o long term transitional housing,
o services for persons who are mentally ill and developmentally delayed.
o resources for persons who are under the age of 60 but experiencing mental
illness and dementia
o violent individuals, including sex offenders
o persons with co-existing medical and mental health and/or intellectual
challenges
Wrap-around Care
 “There is a lack of resources to provide structure for those in need.”
 “Most acute cases need support to remember to take medication, to check in, to
ensure they are managing finances, that they are connected to supports.”
 “For those in mental health court, for a year, they receive intensive support. Once
they are discharged, that support often ends.”
Competing Priorities
Key informants noted a number of policies have been recently established or modified.
Additionally, investigations and information requests have required attention and focus
that can at times divert attention from daily responsibilities. Key informants from DPBH
noted it is challenging to implement changes:
 “when also responding to investigations, an incessant number of public

information requests,”
 “the need to respond to law suits regarding waiting lists” or discharge practices
and federal” inspections of its residential mental health facilities.”
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Gaps Analysis 2013
Opportunities
There are a number of developments in
process or planned that provide
opportunities to strengthen Nevada’s
system of care.
Consolidation of Public and

Behavioral Health
Consolidation of health, substance abuse
and mental health was seen as an
opportunity by many key informants:
 “It will integrate public and behavioral health services by leveraging existing
capacity.” Implementing a patient-centered system of care for prevention, early
intervention and access to treatment will greatly strengthen the system of care.
 This provides an opportunity to, “foster collaboration” and,
 “Allow the system to meet the needs” of persons with both behavioral health
and/or health problems, including mental illness, substance abuse disorders and
chronic diseases, such as hypertension, diabetes and kidney disease.
Under this public health model of delivering behavioral health services, DPBH has the
opportunity to focus more on data-driven, population-based needs and service
opportunities. Key informants referenced a number of positive changes underway
related to the merger. They include:
 “training SAPTA providers to bill Medicaid,”

 “out-posting staff in emergency rooms to provide access to behavioral health
assessments,”
 “implementing telemedicine resources and equipment in rural Nevada” to give
access to psychiatric consultations therapy and medication management,
 “implementing a system of care including shared policies and procedures Division-
wide,” and
 “pursuing new grants to bring resources to Nevada” to meet gaps in services.
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Gaps Analysis 2013
System of Care
Establishment of and, “consistently applied” “The Division leadership has a clear vision
statewide systems are planned as of July 1, 2013. of the importance of addressing basic
In addition, a number of changes can positively needs to have any chance of stabilizing
and providing holistic care.”
impact the system of care:
o “Full implementation of AVATAR,” the management information system designed to
ensure uniform data collection across the state.
o Statewide policies and procedures for NNAMHS, SNAMHS, and RSCC. “Outpatient
mental health services are being standardized across the state.”
o “The new outpatient service delivery model is based on overlapping, blending and
coordinating efforts with multiple service agencies.”
o Implementation of Quality Improvement Programs. A focus on, “meeting accreditation
standards is an opportunity statewide” and at the time of investigations had been
extended to Lake’s Crossing and RCSS.
o Investments are currently being made to expand urgent care and medical clearance
practices. In order to more effectively manage the flow of individuals seeking
psychiatric services, “SNAMHS facility is co-locating a walk-in clinic to provide medical
clearance and behavioral health services.”
o “Northern Nevada Adult Mental Health facility is expanding medical clearance hours.”
o “The Division is expanding mental health court diversion programs” for consumers in
the criminal justice system whose charges are due to their mental illness.
o Nevada may be awarded the Cooperative Agreements to Benefit Homeless Individuals
for States (CABHI) grant. The grant will enhance or develop the infrastructure and
treatment service system to increase capacity to provide accessible, effective,
comprehensive, coordinated/integrated, and evidence-based treatment services with
permanent supportive housing and peer supports to the homeless population.
o The CABHI grant proposal also included funding for a data patch to link data across
management information systems (MIS) within DPBH.
o Emergence of Nevada’s Green Zone Initiative for veterans was cited by several key
informants. Within Nevada’s state government, the Green Zone Initiative will provide
an interagency approach to veteran education, employment, and wellness benefits.
Access to behavioral health services is a key focus of the Initiative.
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Gaps Analysis 2013
The Affordable Care Act (ACA)

Key informants noted:
 The ACA could, “save the state substantial General Fund dollars for pharmacy
expenditures, outpatient services, and substance abuse prevention and treatment.”
 “Medicaid can be billed for more of the services currently provided.”
 In addition, there is a greater focus and coverage for prevention and wellness
services. However, “the system must meet CMS standards to bill Medicaid” and
recent events indicate, “problems in doing so.”
 “Certification is the priority.”
 The ACA is intended to improve access to quality care and needed health services.
“Better access, improved coverage, and support for prevention” all provide an
opportunity to, “achieve better health outcomes, higher quality of care, and, critical
to the health of Nevadans, a reduction in health disparities.”
New Regulations
The passage of AB 287 impacting Nevada’s law on Civil Commitments was identified by
key informants as a real opportunity. The bill would create a system of "outpatient civil
commitment" for mentally ill patients with a history of repeat interactions with law
enforcement. It allows judges to consider a doctor’s recommendation for treatment and
order that offenders be compliant with doctors’ orders, which may include medication
management.
Threats
Threats are conditions external to DPBH that
may impact its ability to achieve its mission.
The following threats were identified that
pose challenges to the system if not
adequately addressed.
Credibility
Given the media attention, the investigations
and the problems with data and
documentation, key informants noted a
number of threats:
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Gaps Analysis 2013
 “Loss of accreditation,”
 “Certification,” “Multiple data systems including home
 “Media attention,” and grown systems are a problem in
quantifying actual need. Everyone has
 “Ongoing investigations make it difficult to
to use the same forms, the same
promote positive changes and threaten processes, the same criteria and the
existing resources. “ same data system (Avatar). This has
not been the case.”
They also threaten to, “divert the focus of DPBH
efforts” on integrating into a public health model,
with a comprehensive community-based service delivery system.
Loss of Funding
While additional investments were made during and after the 2013 legislative session,
Nevada:
 “Stands to lose millions of dollars in funding” should lawsuits move forward or

 “Medical reimbursements be denied,”
 Inability to bill Medicaid due to the “patient dumping” scandal and the recent
audits by CMS is a concern.
Staffing Shortages
Key informants noted that, “many upper level professionals are turning over because of
morale, pay, and the current environment.”
 The dual pressures of, “providing high quality services while doing so in a more
efficient manner” has led to some of the staff turnover.
 Multiple key informants noted turn-over, stating “when staff leaves, it is often
difficult to find replacements and positions go unfilled,” for extended periods of
time.
 As one key informant noted, “state services are so underfunded. How are we going
to recruit and retain talent?”
Housing
Housing is considered a critical component that is, “a gap for many” of the DPBH
consumers. Key informants noted that,
 “Not in my back yard (NIMBY) syndrome” is a challenge to addressing the housing
needs of all types of consumers within the system.
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Gaps Analysis 2013
 “Locating a place to provide housing” for vulnerable populations often results in a

public outcry within neighborhoods.
 This makes it, “difficult for public officials to approve zoning or permits for group
housing options.”
 In addition, the oversight of group housing was questioned by several key
informants, one described, “Cases of fraud and the inability of the state to invest
resources to prevent fraud.”
Substance Abuse Services

One key informant raised a number of issues related to, “the provision of substance abuse
treatment services,” and concerns of how the state may not be doing enough to provide
adequate services according to federal regulations.
“Issues have, “been raised repeatedly in
open meetings” but have not received the
Other Concerns scrutiny of the “patient dumping” crisis.
Another concern expressed was specific to the merger These issues threaten to be the next wave
of mental health and substance abuse services. As one of criticisms to be leveled against the
key informant put it: Division”.
 “I worry that instead of fully integrating

substance abuse and mental health that the good parts of mental health will feel
the impact.”
 Another asked, “How is integration between substance abuse and mental health
going to look or is substance abuse going to be forgotten?”
 Key informants noted that, “there are so many changes happening at lightning
speed, something is bound to fail.”
 Another stated, “I worry about the Affordable Care Act and its impact on the
system when new consumers now have a payer source, are there sufficient
providers and how will it impact the Division’s bottom line?”
Summary
The key informant interviews indicate a number of strengths, weaknesses, opportunities
and threats that DPBH should consider as it plans for the future. The steps taken by DPBH
to this point are seen as positive and the leadership and the staff are considered by many
to be strengths. The weaknesses identified are known to DPBH and steps have been taken
to begin to address the needs. However, without sufficient resources, a true continuum of
care that addresses the gaps in services identified by key informants can’t be put in place.
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Gaps Analysis 2013
One key informant claimed. “While changes are planned, and many changes had been
made, the system at this point in time, “is inadequate.”
Insufficient System of Care

According to one key informant, Nevada’s behavioral health system, “doesn’t meet
minimum needs. We do what we can but we lack sufficient resources, infrastructure and
supports to truly help everyone who needs help.”
Key informants note that access to services depends on

geographic location and what mental state a person is in “The legislative Interim
when presenting for care. Some described the criminal Finance Committee approved
justice system as, “the main referral source” or portal for $2.1 million in emergency
accessing the state behavioral health system, saying, “For mental health funding…after
spending hours criticizing
those who haven’t committed a crime, it is difficult to
Nevada's inadequate
access services.” As one key informant put it, “You have to treatment of mentally ill
be homicidal, suicidal or out of meds to be seen. The wait residents and visitors.
list at some clinics is between 60 and 90 days for an Legislators said the state of
appointment. Your only option is to walk in and wait all Nevada’s mental health system
appears to have reached crisis
day.” levels. Failures in the system,
According to one key informant, “[the system] historically they said, have led to
overcrowding in emergency
has not focused on prevention or early intervention but on
rooms, backlogs and delays in
treating those in crisis which is a costly and more harmful jails, loss of accreditation for
approach to care.” one major state hospital,
difficulties in recruiting
Key informants described that some even have a “bad quality staff because of pay
outcome after getting to the right door.” One noted that, that's not competitive, and
“the front door is broken.” Community-based organizations inefficient, expensive practices
question whether, “The state people understand how of moving mentally-ill inmates
between Southern and
difficult it is to get mental health services.” One noted that,
Northern Nevada
“the greatest challenges and variances occur when
Las Vegas Review Journal
someone needs hospitalization.” Another stated, “There
August 6, 2013
are no resources in rural Nevada and people often end up
in the emergency room, in jail, or being transported to
Reno in handcuffs, in the back of a squad car, or by helicopter.”
One key informant said, [In northern Nevada] “even trying to get someone into the
hospital that is clearly in need is a challenge.”
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Gaps Analysis 2013
Another noted, “At NNAMHS, the barriers from the inside are horrendous. One person can
erect a barrier, by not asking an evaluation using the right questions.” That being said,
“The system in Northern Nevada is leaps and bounds ahead of the rest of the state. In
southern Nevada, the volume is so much greater, it is constantly crisis driven and the lack
of beds leads to premature discharges, with a push to get folks out of a bed as soon as
possible.” Another key informant stated that, “southern Nevada is a magnet for people
from out of state who get into trouble, spend all their money and then are stranded here
after a long weekend of drinking or worse.” A number expressed the opinion that, “The
demand in the south is greater and harder to serve.”
Accountability and Credibility

Key informants within the state
system indicated that uniform
systems including policies, The National Alliance on Mental Illness gave
procedures and data collection were Nevada a “D” grade on report cards in 2006
not employed across the three and in 2009.
regions in Nevada but were being
implemented beginning in July. For “In a state with high rates of severe
the first time, “all agencies will use depression and other serious mental illnesses
the same paperwork and processes.” — as well as suicides — a strong commitment
Prior to July 2013, NNAMHS, is needed to restore and expand the mental
SNAMHS and RSCC all had, “their health safety net,” the 2009 report said.
own processes and paperwork
“Without one, Nevada will find its emergency
systems.”
rooms and criminal justice system
Data collection also varied by region overwhelmed — and costs being shifted to
with, “multiple management other sectors of state and local government.”
information systems in use” but not
Las Vegas Review Journal, April 14, 2013
applied in a consistent manner. In
addition, some clinicians were
described as, “creating and keeping
their own spreadsheets” to track data they felt they needed. There was “little confidence”
from key informants within the state in the, “quality or accuracy of data” that had been
collected. Waiting list data was an example provided multiple times as something that,
“should be, but isn’t known.” As one state key informant noted, “we have a credibility
problem.” This alluded to data but also to the investigations, documentation problems and
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Gaps Analysis 2013
resulting impact on accreditation and certification. Key informants from the state readily
identified, “conditional problems that need to be addressed.”
Leadership
Leadership at DPBH is viewed by external stakeholders as being, “data driven, outcome
oriented,” and “wanting to use evidence-based approaches” and “promoting outreach to
communities to increase access services. Sentiments ranged from, “cautiously optimistic”
to “enthusiastic” about the leadership of DPBH and the, “changes they plan and have
already made.” Leadership within the Division is doing what it can to strengthen the
existing system and to improve outcomes but, “don’t have the resources to be successful.”
“They are seeking resources when possible and trying to use resources more wisely.”
However, at this time, the system is, “woefully inadequate.”
Collaboration and Coordination with State, Regional & Local Partners

In addition, key informants identified a need for collaboration. One noted that, “essential
collaboration across systems is relationship based.” Another said that in term of
collaboration, “This is worse in Southern Nevada. The system is far too person
dependent.” As one key informant stated, “there are models of partnerships between law
enforcement, courts, the state and social services all across the state that have worked to
the benefit of the client. These are not always formalized, are often person or relationship
dependent and can quickly evaporate when a person changes position, a crisis occurs, or
one agency stops participating.”
This is a critical issue as, “persons with behavioral health needs don’t only impact the
mental health system.” Rather, they often are also, “accessing local health and human
resources,” and “are involved in the criminal justice system” and may be “accessing health
care through local emergency rooms or clinics.”
Linkages, collaboration and transitions between “The counties need to be at the table with
systems, “aren’t institutionalized in a way that the state and have an honest
affords consumers ‘no wrong door’ for accessing conversation about roles and
responsibilities. That hasn’t happened
services.” Several key informants noted, “We
because the state often doesn’t show up
need no wrong door.” One said “the client doesn’t at local meetings and the county, “is
care if you work for the state or the county, they afraid if they dip their toe in the
just know they need help and aren’t getting it,” swimming pool to try and solve an issue
and “ they will end up owning the pool.”
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Gaps Analysis 2013
One key informant noted that, “the largest gap continues to be persons coming out of
prison as the Department of Corrections provides its own mental health services but is
less concerned about what happens when that person returns to the community.” There is
“less collaboration with the non-psychiatric community and substance abuse providers
and mental health.” There are plans to strengthen this collaboration within DPBH but that
coordination of services is not fully in place.
One key informant was “positive about the changes underway within DPBH but assert
that policies and procedures, collaboration and linkages, are not enough to make
behavioral health services available, accessible and sufficient” to meet Nevada’s needs.
Without a “fundamental financial investment in services and supports” at the community
and state level, “the system may improve but will never be able to meet the needs.”
There are opportunities to collaborate
with the counties and coalitions and task
forces to extend the safety net of services
in Nevada. Restoring credibility by
attaining federal certification and national
accreditation of services, partnering to
create a “no wrong door” approach to
services and securing resources should all
be priorities for DPBH.
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Gaps Analysis 2013
Recommendations
Nevada has an opportunity to implement a behavioral health system that is community-
based, comprehensive and efficient. The gaps analysis is intended to assist the state in
understanding gaps and taking steps to address them. To do so, the following three focus
areas are recommended. The strategies listed below the focus areas come from research,
key informants and best practices. Each is designed to address one or more of the gaps,
unmet needs and/or the weaknesses or threats from the situational analysis.
Ensure Accountability, Credibility and High Quality Services:

 Ensure that policies and procedures are clearly articulated and understood
across the state. From the point of first contact on, processes for assessment,
referral, admission, treatment, discharge planning and transition should be
clear, coherent and consistently implemented.
 Ensure that outcome-based, measurable criteria are in place to document and
later describe those receiving services, what the service delivery cycle entailed,
how waiting lists and discharges were managed and the outcome of services.
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Gaps Analysis 2013
 Collect and report data uniformly across services and within DPBH using one
shared data system. Use data to make decisions about how future resources are
allocated.
 Establish performance-based targets of penetration rates for all levels of care,
by region, provided by both the state and community-based providers.
 Implement the recommendations from the consultation report on the Rawson-
Neal Psychiatric Hospital system-wide, as appropriate, with a focus on the ten
recommendations provided.
 Ensure that substance abuse services meet the regulations and standards that
apply to them.
 Seek accreditation and certification to demonstrate credibility and quality.
1. Develop Community and State Capacity to Implement No Wrong Door.

 Educate the public about the value of identifying and seeking care for
behavioral health issues before a person escalates to the point of criminal
justice involvement. Work to reduce the stigma related to mental illness and
confront individuals’ desires to, “solve it on my own.”
 Ensure that the community is aware of services and how to access them and
that services are accessible, available and supportive in every community.
 Identify and engage community partners throughout the state to include
county commissioners, county social service agencies, and county and city
managers.
 Define with community partners’ roles and responsibilities to collaborate,
coordinate and care for Nevadans in need of behavioral health prevention,
intervention and treatment.
 Define a shared approach to building the capacity of community-based
organizations to provide services to people in need in their communities.
 Create a plan to build the capacity for services focused on prevention and early
intervention and for culturally appropriate services for special populations.
 Support the development and enhancement of behavioral health services for
children ages 0-17 and those ages 65+.
 Promote a culture of shared ownership with regional, county and local partners
where all staff promotes collaboration, coordination and communication with
counties and community-based agencies and between public health workers
and behavioral health staff.
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Gaps Analysis 2013
 Develop and formalize partnerships that effectively facilitate referrals and

transitions across systems so that there truly is no wrong door or point of
contact within the Division and throughout Nevada.
 Provide cross-training between behavioral health and public health staff to
maximize resources and advance knowledge of all services within all programs
and staff of DPBH.
 Promote recruitment and retention, and publicize loan repayor programs to
retain professionals who receive their education and training within Nevada.
 Use technology to provide training and promote evidence-based practices
within the system of care.
2. Establish a vision and plan for the system of care and secure the resources
necessary to implement the plan.
 Define the system of care essential for Nevada including sufficient providers,
substance abuse and co-occurring disorder services, housing, transportation,
wrap around support and case management. (Note: a description of the
components can be found at the end of this section.)
 Convene state, county and local providers to define roles and responsibilities
for each component of the system of care.
 Quantify the funds needed, based on target penetration rates to meet demand
and identify all funding sources at the federal, state and county level that can be
accessed to support the system of care.
 Transition some state services to local communities as possible and
appropriate and reallocate funding to support the system of care.
 Pursue a diversified funding approach with all partners (hospitals, law
enforcement, state, county and other) to support the system of care including:
o Continue to pursue new grants to support components needed to
implement the system of care.
o Leverage federal dollars and matching funding programs.
o Establish systems to obtain reimbursement for services.
o Request revisions to regulations to maximize flexibility and efficiency in
how state funding can be allocated and reallocated based on demand and
need for services, deploying state resources in a strategic manner.
o Evaluate feasibility of a dedicated funding stream to support behavioral
health services.
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Gaps Analysis 2013
o Invest additional resources in prevention and intervention as available

from treatment savings.
 Evaluate the system of care based on outcomes and indicators agreed to by all
parties.
When designing a system of care, a number of specific components are needed and
detailed below.
Prevention/Education:
Implement high-impact prevention and use combinations of scientifically proven, cost-
effective, and scalable interventions targeted to the right populations in the right
geographic areas. Include screening and assessment to identify concerns early and
provide needed support. Link with other formal systems to help identify and address
behaviors that may be an indication of a concern such as school expulsions. Design an
education and prevention program to confront myths about behavioral health, explain the
signs of mental illness and substance abuse and inform the public on how they can help
persons at risk.
Identification, Outreach and Access:

Build on the MOST and MCT team concepts to develop identification mechanisms that will
establish linkages with community-based entities (including group homes, churches,
police, emergency rooms, inpatient facilities, pharmacists, primary care physicians, public
housing facilities, senior centers, child care settings, etc.) capable of identifying and
referring people in need of services prior to law enforcement involvement.
Incorporate mental health screenings in health check-ups, with referral to a behavioral

health assessment for follow-up. Design effective outreach to engage individuals in their
own environments including school, work, home, or other settings including health care.
Convene a planning team comprised of state, county and local health and human service
providers to map an effective process for identification, outreach, and access that defines
roles, responsibilities, and agreements between state and local government and that
identifies local access points based on the capacity of local providers and service delivery
systems.
Assessment and Evaluation:

Identify resources and approved assessment processes that are appropriate to the
person's culture and level of acculturation, and utilize assessment tools that are valid and
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reliable. Establish standards for access to assessment that promote prevention and
intervention rather than delaying access until an individual reaches crisis status.
Behavioral Health Treatment:

Treatment is a critical component of the continuum of care. To encourage the use of
services and to minimize stigma, treatment should be available and provided within an
individual's community, in the least restrictive environment possible. In addition to
psychiatric management, behavioral health treatment should include: counseling,
medication management, and linking individuals to other wrap around services necessary
for them to remain stable.
The system of care should be strengthened to promote community-based organizations

and include: inpatient, partial hospitalization, intensive outpatient, outpatient, residential,
adult day treatment, and mobile therapy options. Specialized treatment facilities for youth
with substance abuse disorders are needed, and should include peer-supportive
counseling to prevent relapse and develop strategies for drug-free living.
Discharge planning should consider housing, medication and basic needs at a minimum.
No persons should be discharged to another level of care or from a facility without a safe,
stable environment to go to with assistance in making the transition.
Housing:
Any system of care for persons with behavioral health needs must emphasize safe and
stable environments. Affordable housing should be made available for low-income
individuals and families. It should also include an appropriate range of supportive
housing options.
Clustered apartments such as those implemented through the Crossroads program should
be replicated to provide services and supports in a cost efficient manner. A variety of
more structured residential settings are needed for a small number of more seriously
disabled individuals who require a greater degree of attention, supervision or structure.
This may include housing specific for subpopulations such as persons with dementia
under the age of 60, youth with a behavioral health disorder and other disability, and
adults in need of structure and support in order to remain independent.
Coordination with Health Care:

Create systems and linkages to ensure a high level of integration of physical and
behavioral health care, using a public health model approach to a continuum of care.
Ensure individuals are connected to both medical and behavioral health services, and
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facilitate the coordination of care. This includes ensuring primary care practitioners are
skilled in identifying behavioral health and substance abuse problems and in making
referrals for treatment and ensuring that treatment is available at the time of the referral.
Care Management:
Care management should be available to the most severely impacted consumers to ensure
they receive the services they need. Depending on individual needs and preferences, care
managers could be a single person or a team who assumes responsibility for maintaining
a long-term, caring and supportive relationship with the individual. All care managers
should be trained in behavioral health and be skilled in working within behavioral health,
public health and human service systems.
Crisis Response Service:

Ensure crisis assistance is in place to immediately respond to persons in crisis and
members of their support system and is available 24-hours a day, 7 days a week. This can
be done by building upon programs that are working in both northern and southern
Nevada including the MOST teams and the MCT teams. These services could be replicated
in some manner in the other counties in Nevada.
Protection and Advocacy:

Persons with behavioral health/substance abuse problems are particularly at-risk as
victims of violence or abuse, but may be afraid or unable to report crime and abuse. They
also may have difficulty caring for themselves. Law enforcement, social service providers
and emergency responders should be linked to crisis intervention teams to identify and
provide protection for vulnerable populations.
The following secondary components are also essential to supporting a system of care
and can be provided by community-based organizations on a community by community
basis.
Peer Support:
Peers are one of the most influential groups for people with behavioral health issues and
provide a "non-treatment" approach most persons prefer. Faith-based groups, community
organizations, veteran groups, senior centers and other informal support systems can
help identify at-risk children and adults and help them maintain their treatment.
Social Rehabilitation:
Social rehabilitation services help consumers gain or regain practical skills needed to live
and socialize in the community. Activities should be age and culturally appropriate and
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tailored to individual needs and preferences. Social rehabilitation should include

assistance in developing interpersonal relationships and leisure time activities/interests
that provide a sense of participation in a community. Employment and volunteer
opportunities should be available through community-based organizations for those who
choose and are able to work or volunteer in the community.
Summary
Nevada has an opportunity to strengthen the behavioral health system by taking a public
health approach to behavioral health. As research indicates, this opportunity would
advance the field of practice, build on brain development research, and create
community-based solutions to prevent crises and:
 Recognize the interrelatedness

of behavioral health and
physical health,
 Focus on prevention and
promotes behavioral health
across the lifespan,
 Identify risks that contribute to
illness or disability and in some
cases protect against the
development of illness or
disability or limit the severity,
 Provide Nevadans with the
knowledge and skills to
maintain optimal health and
wellbeing, and
 Bring together individuals, communities and the systems throughout the state to
work collaboratively toward better behavioral health for all.
This would strengthen the current service delivery system and promote strategies that
build upon a public health approach to the prevention, intervention and treatment of
behavioral health conditions. The integration of the Division, awareness of the scope of
the problem, and the implementation of the ACA, make this an opportune time to build
the system of care that Nevadans need.
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Appendix
1.1 Key Informant Interview Questions
1.2 Consumer Survey Interview Questionnaire
1.3 Expanded Service System Description
1.4 California Mental Health Timeline: 1957-2013
1.5 Summary of News Articles Published
1.6 Cross-Tabulation Charts and Graphs
1.7 Bibliography
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Appendix 1.1: Key Informant Interview Questions

 Please describe your target population, geographic area served, any mandates and
the services you offer related to persons with mental health concerns in Nevada.
Location, Priority Populations, Services Offered
 Describe the steps your organization has in place to assess and admit people for
services? How are they referred to you? List major referral sources
 What is the average length of stay or service cycle?
 Do you discharge plan with consumers? How does that work?
 Do you have data you could provide on number of admissions, length of stay,
number of discharges and where consumers are discharged to?
 What are the major challenges when discharge planning?
 What resources are available and what resources are not available but needed for
mental health?
 How do you educate the public about the services available through your
organization?
 Is your organization engaged in any public awareness campaigns around mental
health issues? Anti-stigma campaigns, outreach to specific populations, etc.
 How does your agency collaborate with mental health, substance abuse, and or
other agencies to meet the needs of consumers? Is there a process for interagency
collaboration? Which agencies participate? Who should be at the table but isn’t?
 Are there opportunities for improving collaboration?
 What are areas of ongoing strengths within the mental health system of care in
Nevada?
 What do you anticipate as possible challenges related to the reorganization of the
Mental Health services system within Nevada?
 What opportunities or concerns do you think the Affordable Care Act will have on
mental health services/systems in Nevada?
 What are the most critical issues that Nevada needs to address to meet the mental
health needs of its population?
 Where do gaps exist within the system, and how do those gaps affect the end user?
Are there any gaps that are particularly pronounced based on region?
 What are the major barriers to accessing services within the mental health system?
Geographic isolation, service provider capacity, transportation, etc.
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 Who needs mental health services and does not receive them? What are the
consequences of people needing services and not receiving them? To themselves
as well as within the context of the community
 What policy level changes are needed to improve the mental health system at the
local, regional and/or state level?
 What practical changes are needed to improve the mental health system and
promote wellness and recovery for consumers at the local, state and regional
level?
 If you had a wish list, what other changes would you like to see happen?
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Appendix 1.2(a): Consumer Survey Questionnaire (English)

People can get counseling, treatment or medicine for many different reasons, such as:
 For feeling depressed, anxious, or “stressed out”
 Personal problems (like when a loved one dies or when there are problems at work)
 Family problems (like marriage problems or when parents and children have trouble getting
along)
 Needing help with drug or alcohol use
 For mental or emotional illness
Any of these reasons can lead to someone needing behavioral health care. We are collecting information to help
the state understand what kind of behavioral health care services are needed to support Nevada residents. We
are also trying to identify what prevents people who need assistance from getting the help they require.
Respondent Profile Questions

1. ***What is your gender? 4. ***What county do you live in?
 Male
 Carson City  Lincoln
 Female
 Churchill  Lyon
 Clark  Mineral
2. ***What is your age?  Douglas  Nye
 0-12  Elko  Pershing
 13-17
 Esmeralda  Storey
 18-20
 Eureka  Washoe
 21-24
 Humboldt  White Pine
 25-44  Lander
 45-64
5. ***Which of the following best describes you?
 65-74
 Current behavioral health care client
 75+
 Former behavioral health care client
 Friend/family member of someone who has received
3. ***What is your race/ethnicity? behavioral health care services
 White  Parent of a child currently receiving behavioral health care
 Hispanic services
 Black/African  Parent of a child formerly receiving behavioral health care
American services
 American  Someone in need of behavioral health care services but not
Indian/Alaskan currently receiving them
 Pacific Islander  Someone in recovery
 Asian  Not sure
 Mixed Race
 Other
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6. *** There are a variety of behavioral health care services that can be provided to help people
live a meaningful life. Please indicate which of the following type of services you or someone
you know have used and the extent to which it served your/their needs.
Have you If you answered yes, please indicate to what
used this extent you believe the level of care received was
Type of Services Used service? sufficient to meet the need?
Sometimes
Always met Usually met Never met
No Yes met my
my needs my needs my needs
needs
Inpatient Care – Hospitalization
Outpatient Care –
Community-Based Services
Psychiatry –
Access to a therapist
Medication Management – Use of
Prescription Psychotropics
Support Group Participation
Dual Diagnosis Services
Case Management – Support Services to

help with ancillary needs (goals
establishment, linkage to other services,
etc.)
7. *** There are a number of reasons that people may not receive the assistance they need. We
want to understand why people who need services may not be able to access care. Please
indicate which of the following you believe prevents you or other people from accessing
services and the severity of the issue.
If you answered yes, please indicate to what extent you
Is this an
believe this issue prevents you/others from accessing
Barriers to Services issue?
care.
Medium
No Yes Big Problem Little Problem Isolated Issue
Problem
No local services available
Lack of transportation
Lack of medical insurance
Cost prohibitive
Long wait lists
Not enough services available
Not enough service providers
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8. *** How significant of an issue is behavioral health care for your community?
 This is a big issue – there are a lot of needs that remain unaddressed
 This is a moderate issue – there are ongoing needs, but services are available
 This is a minor issue – there are system improvements needed, but they are minor and do not
affect the critical health issues of individuals
 This is not an issue – services being provided are sufficient to meet the needs of people.
9. *** On a scale of 1-10, how well do you think the current system responds to the behavioral
health care needs of your community?
 1 – Responds in the best way possible  6

 2  7
 3  8
 4  9
 5  10- Responds in the worst way possible
10. ***What do you think the state should focus on to address the behavioral health care needs of
your community? Please list them in order of importance.
Most important issue to address gaps in services:
Second most important issue to address gaps in services:
Third most important issue to address gaps in services:
Thank you for taking the time to complete this survey. Your input is valuable and appreciated!
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Appendix 1.2(b): Consumer Survey Questionnaire (Spanish)

Las personas pueden recibir servicios de consejería, tratamiento o medicamentos por varias razones, tales como”
 Depresión, Ansiedad, Estrés

 Problemas personales (la muerte de un ser querido o problemas en el trabajo)
 Problemas familiares (de matrimonio, o cuando los padres y los hijos tienen problemas
llevándose bien)
 Problemas con el uso de alcohol y drogas
 Enfermedades mentales o emocionales
Cualquiera de estas razones puede llevar a alguien a necesitar cuidado de salud del comportamiento Estamos
recopilando información para ayudar al estado a entender qué tipo de servicios de salud del comportamiento
son necesarios para apoyar a los residentes de Nevada. También estamos tratando de identificar qué es lo que
impide que las personas reciban la ayuda que necesitan.
c preguntas sobre el perfil del participante

11. *** ¿Cuál es su género? 14. *** ¿En cuál condado vive?
 Masculino
 Carson City  Lincoln
 Femenino
 Churchill  Lyon
 Clark  Mineral
12. *** ¿Cuál es su edad?  Douglas  Nye
 0-12  Elko  Pershing
 13-17  Esmeralda  Storey
 18-20
 Eureka  Washoe
 21-24
 Humboldt  White Pine
 25-44
 Lander
 45-64
15. *** ¿Cuál de las siguientes situaciones es la que mejor lo
 65-74 describe?
 75+  Cliente actual de cuidados de salud del comportamiento
 Ex cliente de cuidados de salud del comportamiento
13. *** ¿Cuál es su raza/etnicidad?  Amigo/familiar de alguien que ha recibido servicios de
 Blanco cuidado de salud del comportamiento
 Hispano  Padre de un niño que actualmente recibe servicios de
 Afro- Americano cuidado de salud del comportamiento
 Indio  Padre de un niño que recibió servicios de cuidado de salud
Americano/Alaska del comportamiento
 Islas del Pacifico  Persona con necesidad de servicios de cuidado de salud del
 Asia comportamiento pero que no los recibe actualmente
 Raza Mixta  Persona en recuperación
 Otro  No estoy seguro / No Aplicable
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16. ***Hay una variedad de servicios de cuidado de salud del comportamiento que pueden proporcionarse
para ayudar a las personas a tener una vida significativa. Por favor indique cuál de los siguientes
servicios ha utilizado usted o alguien que usted conoce y el grado al que sirvió a sus necesidades.
Si contestó sí, indique en qué medida cree que el
¿Utilizó usted
nivel de atención que recibió fue suficiente para
este servicio?
Tipo de Servicio satisfacer sus necesidades
Algunas
No Si Siempre Usualmente Nunca
veces
Paciente Interno – Hospitalización
Paciente Externo –
Servicios a través de la comunidad
Psiquiatría –
Acceso a terapeuta
Administración de Medicamentos –
Uso de prescripciones Psicotrópicos
Participación en Grupos de Apoyo
Servicios de Diagnóstico
Manejo de caso – Servicios de apoyo para
ayudar con necesidades auxiliares
(establecimiento de metas, vinculación con
otros servicios, etc.)
17. ***Hay un número de razones por las que la gente no puede recibir la asistencia que necesita.
Queremos entender por qué las personas no pueden acceder esa atención. Por favor, indique cuál de
las siguientes razones usted cree que sea la que impide que usted u otras personas tengan acceso a los
servicios y la gravedad del problema.
Si contesto que si, por favor indique hasta qué punto
¿Es esto un
usted cree que este problema le impida a usted y a otras
problema?
Barreras a los Servicios personas tener acceso a servicios.
Gran Problema no Problema Problema
No Si
Problema tan Grande Pequeño Aislado
No hay servicios locales disponibles
Falta de transportación
Falta de seguro médico
Costo muy elevado
Largas listas de espera
No hay suficientes servicios
disponibles
No hay suficientes proveedores
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18. *** ¿Qué tan importante es para su comunidad el problema del cuidado de la salud del
comportamiento?
 Es un gran problema –hay muchas necesidades que se mantienen sin resolver
 Es un problema moderado - existen necesidades pero hay servicios disponibles
 Es un problema mínimo - se necesitan mejoras en el sistema, pero son menores y no afectan los
problemas críticos de salud de las personas
 No es un problema – los servicios proporcionados son suficientes para atender las necesidades de las
personas.
19. ***¿En la escala de 1-10, qué tan bien cree usted que el sistema actual responde a las necesidades de
cuidado de salud del comportamiento de su comunidad?
 1 – Responde de la mejor manera posible  6

 2  7
 3  8
 4  9
 5  10- Responde de la peor manera posible
20. ***¿En qué cree usted que el estado deba enfocarse para atender las necesidades del cuidado de salud
del comportamiento de su comunidad? Por favor enumérelos por orden de importancia.
Problema más importante para resolver la falta de servicios:
Segundo problema más importante para resolver la falta de servicios:
Tercer problema más importante para resolver la falta de servicios:
Gracias por tomarse el tiempo de completar esta encuesta. ¡Valoramos y apreciamos su opinión!
Por favor, devuelva esta encuesta a la persona que venga con su próxima entrega.
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Appendix 1.3: Expanded Service System Description

The behavioral health system in Nevada is comprised of federal, state and local resources
with a variety of funding sources, priorities and mandates. Services throughout the state
differ based on target population, geographic region and funding source. As a result, there
are often different challenges for persons seeking behavioral health assistance based on
what services are available and where they are seeking services. The system is most
developed in urban areas comprised of northern and southern Nevada, although more
linkages exist between urban and rural areas than ever before.
Beyond the formal, known systems, there are also behavioral health demands placed on a
number of other systems throughout Nevada that respond to persons with behavioral
health issues. While not primary behavioral health providers, these systems must be
considered when identifying where gaps in services exist. Providers such as emergency
transport, hospital emergency rooms, county law enforcement, primary care practitioners
and rural community health and social service centers often provide behavioral health
services when needed. While many do not see themselves as a provider of behavioral
health services and are not equipped to address the behavioral health problems they
encounter, they are part of a continuum of services that provides access to care.
Primary Behavioral Health Providers
The primary providers of behavioral health services in Nevada include the public
behavioral health system as operated by the Nevada Division of Public and Behavioral
Health (DPBH), non-profit/community-based organizations, private practitioners and
psychiatric hospitals, and federally qualified health centers.
Nevada Division of Public and Behavioral Health
DPBH, formerly known as Mental Health and Developmental Services (MHDS), provides
the majority of behavioral health services throughout the state. Within the Division, a
number of agencies and service sites exist that provide behavioral health and substance
abuse treatment to children, families, and adults. Those agencies are listed below.
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Southern Nevada Adult Mental Health Services (SNAMHS) has clinics and locations in
various communities within Clark County and a centralized inpatient hospital. The variety
of community-based clinics offers easy access throughout Clark County. SNAMHS is
licensed by the State of Nevada. The facility is certified by the Centers for Medicare and
Medicaid Services (CMS) and was accredited by the Joint Commission until July 2013.
SNAMHS provides both inpatient and outpatient services for people living in Clark County
and persons living in surrounding counties that may be closer geographically to this
agency rather than to a rural behavioral health center. SNAMHS has eight behavioral
health clinics serving the community and rural southern Nevada. SNAMHS provides:
Inpatient Services, Mobile Crisis, Outpatient Counseling, Service Coordination, Intensive
Service Coordination, Medication Clinic,
Residential Support Programs, Mental
Health Court, and Programs for Assertive
Community Treatment (PACT) Teams.
Rawson-Neal Psychiatric Hospital is a state

hospital operated by SNAMHS which was
established to diagnose, treat and
reintroduce behavioral health patients into
the community. The facility opened in 2006
and is licensed to serve 289 adult suffering
from severe mental illness. It currently is
budgeted to serve 190 individuals. In 2013,
the budget was expanded to add 21 beds to
building 3A of the facility.
Northern Nevada Adult Mental Health

Services (NNAMHS) occupies part of 92
acres deeded to the State in the 1800's for
the benefit of the mentally ill and NNAMHS
developmentally disabled. Located adjacent
SNAMHS
to the Truckee River in Sparks Nevada, it
shares grounds with Lake's Crossing Center, RCSS
the State Forensic Hospital, and Sierra
Regional Center, the treatment center for
Figure 40: DPBH Behavioral Health Service Location
the developmentally disabled.
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In recent years NNAMHS has developed from the only state hospital in Nevada to a
comprehensive, community-based, behavioral health system supported by an acute care
psychiatric inpatient hospital. The agency is fully licensed and is certified by the Joint
Commission on Accreditation of Health Care Organizations (JCAHO) and the Centers for
Medicare & Medicaid Services (CMS). Its primary service area is northern Nevada.
Numerous outpatient services are available that include the Washoe Community Mental
Health Center, Outpatient Pharmacy, Program of Assertive Community Treatment (PACT),
Psychosocial Rehabilitation Program (PRP), Consumer Peer Counseling, and Service
Coordinator Services.
Dini-Townsend Hospital is a state psychiatric in-patient facility operated by NNAMHS.

The facility opened in 2001 and has the capacity to serve 70 adults suffering from severe
mental illness. It currently is budgeted to serve 30 individuals. In addition, there are 2
(10 bed) annexes at Dini-Townsend that are used for Lake’s Crossing consumers.
Lake’s Crossing is a forensic facility that provides services focusing on determining the
legal competency of an individual to stand trial and restoration of legal competency for
trial purposes. Forensic services include clinical assessment, forensic evaluation and
short or long-term treatment for both pretrial detainees and jail/prison inmates. Lake’s
Crossing is not certified through the Centers for Medicare and Medicaid Services, and is
not accredited. The facility has the capacity to serve 66 individuals waiting to stand trial.
Rural Counseling and Supportive Services (RCSS) is the one agency within the DPBH that
provides outpatient services/programs throughout rural Nevada. Today RCSS has seven
full service clinics, five partial service clinics, and one limited service clinic that provide
behavioral health services to more than 4,577 consumers throughout the 76,391 square
miles of Nevada with the exception of Washoe County, Clark County, Lincoln County and
parts of Nye County. Satellite Clinics provide all services offered by RCSS. Sub-satellite
clinics offer many of the same services with itinerant Clinics providing services less
frequently. Rural Counseling and Supportive Services Centers continue to provide a
comprehensive array of services to the seriously mentally ill (SMI adult) and seriously
emotionally disturbed (SED children) populations.
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The table that follows provides a summary of individuals served by NNAMHS, SNAMHS
and RCSS in Nevada in FY 2011-12.
RURAL
RURAL CLINICS
SERVICE TYPE SNAMHS NNAMHS CLINICS STATEWIDE
NORTH
SOUTH
Outpatient Counseling 5,506 2,673 4,463 1,246 13,888
Med Clinic 11,712 4,778 2,290 638 19,418
Service Coordination 1,227 1,392 762 361 3,742
PACT 138 96 - - 234
Mental Health Court 113 311 52 - 476
Inpatient Treatment 5,005 1,337 - - 6,342
Figure 41: Individuals Provided Behavioral Health Services by DPBH as MHDS (2011-12)
Nevada Substance Abuse Prevention and Treatment Agency (SAPTA) – SAPTA currently
funds private, non-profit treatment organizations and government agencies statewide to
provide the substance abuse related services and treatment levels of care. In state fiscal
year 2012-2013, SAPTA funded 22 treatment organizations providing services in 68
locations throughout Nevada. Together, these providers had 11,907 treatment
admissions. Services consist of intervention, comprehensive evaluation, detoxification,
residential, outpatient, intensive outpatient, and transitional housing services for adults
and adolescents, and opioid maintenance treatment for adults.
In state fiscal year 2013, SAPTA supported services including 2,162 detoxification
admissions, 2,205 residential treatment admissions, 6,259 outpatient, and 1,281
intensive outpatient admissions. Adolescents accounted for 9.6% of total admissions.
There were 1,077 individuals needing treatment that had to wait for admission an
average of 17 days (Agency, 2013).
Battle Mountain Dayton Fallon

 Lyon Council on AOD  New Frontier
 Vitality Unlimited
Cottonwood Counseling Elko Fernley
 New Frontier  Lyon Council on AOD
 American Comprehensive  New Frontier
Counseling Center  Vitality Unlimited Gardnerville
 Cinper Evaluation Center
Ely  Tahoe Youth & Family Svs.
 Community Counseling
Center-CC Hawthorne
 John Glen Evaluation  New Frontier
Center  New Frontier
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Gaps Analysis 2013
Henderson Las Vegas (Cont.) Reno

 Bristlecone Family
 ABC Therapy  New Beginnings Resources
 Choices Group, Inc Counseling Center  Center for Behavioral
 Family & Child Treatment  Restoration Counseling Health
(FACT) Service  Family Counseling Services
 Henderson Assessment  Solutions Recovery, Inc. of No. NV
Center  WestCare Nevada (3)  Footprints
 Mission Treatment  Vitality Unlimited
Centers, Inc. Laughlin  Lynne Daus Evaluation
 Westcare Nevada Inc  Community Counseling Center
Center  Nevada Urban Indians
Incline Village Lovelock  Northern Nevada
Evaluation Center
 Sierra Recovery Center  New Frontier
 Quest Counseling and
Las Vegas Mesquite/Moapa Consulting, Inc.
 Reno Sparks Tribal Health
 Mesquite Mental Health
 ABC Therapy Center
Center
 Adelson Clinic  Ridge House (The)
 Moapa Mental Health
 B.D.D. Counseling Center  Silver State Substance
 Bridge Counseling  WestCare Nevada Inc. - Abuse Evaluations
Associates Harris Springs  Step 1, Inc.
 Center for Addiction  Step 2, Inc.
Medicine  WestCare Nevada Reno
North Las Vegas
 Center for Behavioral Community Triage Center
Health  Center for Behavioral S. Lake Tahoe
 Choices Group, Inc. Health (2)
 Sierra Recovery Center
 Clark County Court  Family & Child
Education Program Treatment (FACT) Silver Springs
 Community Counseling  North Las Vegas
Center Municipal Court  Lyon Council on AOD
 Family & Child Treatment  Options Diversionary Sparks
(FACT) Program
 Salvation Army  Evergreen Evaluation and
 Help of Southern Nevada Education Center
 Las Vegas Indian Center, Owyhee  Life Change Center
Inc.
 Shoshone Paiute Tribes Tonopah
 Las Vegas Municipal
of Duck Valley
Court  New Frontier
Reservation
 Las Vegas Recovery
Center Pahrump Virginia City
 LRS Systems, Ltd.
 Mesa Family Counseling  Community Counseling
 Lyon Council on AOD
 Mission Treatment Center
(Community Chest)
Centers, Inc.  WestCare Nevada
 Nevada Homes for Youth Pioche West Wendover
 Nevada Treatment Center
 New Frontier  New Frontier
Winnemucca Yerington
 New Frontier
 Vitality Unlimited Silver  Lyon Council on AOD Figure 42: SAPTA Services Sites
Sage
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Nevada Division of Children and Family Services

The Division of Children and Family Services (DCFS) provides a broad range of services
through State-operated, community-based behavioral health centers and community
providers. These centers are organized within Northern Nevada Child and Adolescent
Services (NNACS) and the Southern Nevada Child and Adolescent Services (SNACS)
agencies. Services consist of comprehensive evaluation, community-based individual,
group, and family therapy, medication management, clinical and intensive targeted case
management, and early childhood behavioral health services. Additionally, DCFS provides
treatment homes, residential treatment and psychiatric hospitalization to children and
adolescents needing intensive behavioral health support. Services provided are primarily
to children and adolescents residing in the Northern and Southern part of the state as
DPBH provides behavioral health services to this population in the rural areas. The only
exception is the WIN home-based model which provides services statewide.
Below is a summary of children/adolescents served by DCFS in FY 2011-12.
SERVICE TYPE NNCAS SNCAS RURAL STATEWIDE

Early Childhood MH Services (0-6) 238 803 1,041
Community-Based Outpatient Services 362 862 1,224
WIN Wraparound Services 182 267 96 545
Treatment Homes 112 49 - 158
Residential Treatment Care - 102 - 102
Psychiatric Hospitals 182 - 182
Figure 43: Individuals Provided Behavioral Health Services by DCFS (FY2011-12)
Non-profit and Private Practice Providers

Non-profit and private practice behavioral health providers throughout the state vary in
their approach, location, and accessibility. A sample of this community is provided below
to provide a general understanding of the varying types, organizational structures, and
service provision that exist in Nevada. The extent to which these services are available
depend upon the medical coverage that individuals hold.
Northern Region
 Northern Nevada HOPES is a non-profit community health center. In addition to

primary care, the organization also provides behavioral health services in their
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community health center located in downtown Reno, NV. Services provided

include behavioral health and substance abuse counseling, individual and group
therapy.
 Behavioral Health Services (BHS), a division of Carson Tahoe Health, provides a
diagnosis/multi-disciplinary team approach to treating seniors, adults, adolescents
and children experiencing behavioral and addictive disorders. It provides a broad
range of inpatient and outpatient services that includes individual, group and
family counseling, support groups, medical model detox services, and a 14-21 day
addictive disorders rehabilitation program. BHS has two locations both situated in
Carson City, one providing inpatient care and the other providing outpatient care.
 HealTherapy of Nevada provides non-traditional behavioral health services
utilizing horses with children, adolescents and adults. The program has two
locations in northern Nevada, one in Carson City and the other in Reno. Staff of the
program includes a psychiatrist, licensed clinicians, family resource specialists,
and therapeutic equestrian instructors.
Southern Region
 Heads Up Guidance and Wellness Centers of Nevada provide community-based

health care focused on the behavioral health needs of traditionally underserved
populations. Therapists and clinicians assist individuals, couples, children and
families providing basic skills training, psychosocial rehabilitation, mental
emotional release therapy, play therapy, neuro-linguisitic programming,
hypnotherapy, medication management, and group therapy/day treatment.
Services are provided at their Las Vegas location.
 Compass Behavioral Health provides behavioral health and prevention/early
intervention services to young children and adolescents in the Las Vegas area.
Services include basic skills training, psychosocial rehabilitation services,
individual therapy, play therapy, and group therapy.
 Nevada Behavioral Solutions provides comprehensive treatment for the child,
adolescent, and adult with behavioral and emotional problems. Services are
available in three locations including Las Vegas, North Las Vegas, and Pahrump
and include psychosocial rehabilitation, psychiatry, therapy, basic skills training,
and a day treatment progressive behavioral program.
 Liaison Behavioral Health and Community Outreach: provides behavioral
healthcare to adolescents and adults. Services are offered through their office
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located in Henderson, NV and include residential treatment foster care, individual

and family counseling, group counseling, rehabilitative treatment (psycho-social
rehabilitation & basic skills training), anger management (individual & group),
stress management, and HIV/STI support groups & education.
Rural Region:
 Alliance Family Services (AFS), Inc. offers outpatient healthcare services to

children, adolescents, and adults. Services include diagnostic evaluations,
consultations, medication management, individual, couples and family counseling.
Services are provided out of their clinic in Fernley, Nevada.
Statewide Resources:
 Mojave Mental Health Services is a clinical practice out of the University of Nevada
School Of Medicine. There are two clinics in Las Vegas and one in Reno. Services
vary by site, and include medication management, therapy, day treatment and
targeted case management for children, adolescents and adults.
 WestCare provides a wide spectrum of health and human services in both
residential and outpatient environments. Services include substance abuse and
addiction treatment, homeless and runaway shelters, vocational counseling and
behavioral health programs. These services are available to adults, children,
adolescents, and families. WestCare is host to multiple locations throughout
Nevada offering different
service options.
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It is important to note, that while services such as these exist, that the workforce to
support these types of service delivery is deficit in most parts of the state. As the
following map shows, the State of Nevada suffers from a significant shortage of
behavioral health
providers in all
counties except
Clark. The map is
taken from the,
“Nevada Rural and
Frontier Health Data
Book - 2013
Edition,” that depicts
every county in
Nevada except Clark
with a shortage of
mental health
professionals
(pg.177-179).
Figure 44: Mental Health Provider Shortage Area
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Psychiatric Care Hospitals

The following table represents the facilities across the state that provide acute psychiatric
care, including care capacity.
NUMBER OF PSYCHIATRIC
REGION FACILITY
HOSPITAL BEDS
Rural
Carson City Carson Tahoe Regional Medical Center 46
Henderson Seven Hills Behavioral Institute 94
Northern
Reno Willow Springs Center 116
Reno BHC West Hills Hospital 95
Sparks Northern Nevada Medical Center 21
Southern
Las Vegas Spring Mountain Sahara 30
Las Vegas Spring Mountain Treatment Center 82
Las Vegas Red Rock Behavioral Hospital 28
Las Vegas Desert Willow Treatment Center 58
Las Vegas Monte Vista Hospital 162
Las Vegas North Vista Hospital 60
Figure 45: Hospitals Providing Psychiatric Care (Office of Public Health Informatics and Epidemiology, 2013)
Federally Qualified Health Centers
Federally Qualified Health Centers (FQHC) provide services in the most medically
underserved areas and/or to the most medically underserved populations. They are
intended to increase access to care by providing low to no cost services and will often
provide transportation and translation supports to consumers. Nevada is host to a total
of 31 FQHCs, of which only 2 offer behavioral health services.
HAWC Community Health Centers provide behavioral health services through their two
clinic sites located in Virginia City and Reno. Services provided include behavioral health
evaluation, diagnosis, therapy and case management. In 2011, HAWC provided
behavioral health service to 231 consumers (UDS Summary Report 2011, 2013).
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Secondary Behavioral Health Providers

Beyond the primary behavioral health providers outlined above, there are a number of
other systems that come into contact with people requiring behavioral health
intervention. These systems, while not intentionally designed to deal with the complex
issues surrounding behavioral healthcare, are increasingly being tasked with serving this
vulnerable population.
Veteran’s Administration Services

The Veteran’s Administration plays a key role in providing mental health services in
Nevada. For those in northern Nevada, the VA Sierra Nevada Health Care System
(VASNHCS) provides alcohol and drug treatment and other mental health services to
veterans. Special services not available within VASNHCS are supported through referrals
to community hospitals and VA medical centers in San Francisco and Palo Alto. Mental
health care is also available through community clinics such as the VA Sierra Foothills
Outpatient Clinic in Auburn, the VA Carson Valley Outpatient Clinic in Minden, and the VA
Lahontan Valley Outpatient Clinic in Fallon.
For those in the southern part of the state, the VA Southern Nevada Healthcare System
(VASNHS) provides health care and mental health services. The system includes a
community-based outpatient clinic in Pahrump, as well as a federal medical center as part
of a VA/Department of Defense (VA/DoD) joint venture that is a US model for sharing
agreements. Finally veterans who meet the definition of homeless defined in The
McKinney Homeless Assistance Act may apply for VASH vouchers that provide shelter for
those with mental illnesses, substance abuse, or physical disabilities. These vouchers are
often distributed from HUD through local nonprofits in communities across the state.
Specialty Courts
Nevada has 46 specialty court programs: 29 urban and 17 rural programs. These 46
programs include 17 adult drug courts including, diversion and child support, 3 family
drug courts, 3 mental health courts, 6 juvenile drug courts, 2 prison re-entry courts, 6 DUI
courts, 5 hybrid DUI/drug courts, 1 prostitution prevention court, 1 veterans treatment
court, and 2 habitual offender courts. They are located all across the state and organized
into regions including Eastern, Central, Clark, 5th Judicial, Washoe and Western Region.
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Mental Health Courts

The Washoe County Mental Health Court was the first in the state, hearing its first case in
November 2001. In 2012, the Washoe County Mental Health Court served a total of 199
new participant admissions.
The Clark Region Mental Health Court was established in December 2003. Of all the
Mental Health Courts located throughout the state, this is the only program to host a
competency court, used to determine whether an individual will be held against their will.
Located within the Eighth Judicial District, this Mental Health Court served a total of 31
new participant admissions in 2012.
The Carson City Mental Health Court, established in 2005, handles misdemeanor cases as
well as felony cases transferred from the First Judicial District Court. In 2012, the Carson
City Mental Health Court served a total of 30 new participant admissions.
Department of Corrections Services
The Nevada Department of Corrections plays a crucial, yet unofficial role in addressing
behavioral health needs in the state. The Department recognizes behavioral health
problems as an everyday challenge to new and current inmates, and recognizes its role in
a Nevada Revised Statute that states: “The goal of Mental Health services in the
Department is to provide for the detection, diagnosis, treatment, and referral of inmates
with mental health problems, and to provide a supportive environment during all stages
of each inmate’s period of incarceration.”
The Department of Corrections is composed of 10 conservation camps, 7 correctional

facilities, 1 restitution center and 1 transitional center. Each major institution provides
behavioral health services by licensed health professionals while other campuses provide
varying degrees of treatment services.
Northern Nevada Correctional Center hosts the Regional Medical Facility for the Nevada
Department of Corrections. This facility provides in-patient medical and behavioral
health services. In addition there is the Medical Intermediate Care and Structured Care
Units for inmates whose medical and behavioral health situations are stable but who
require additional staff monitoring.
Southern Desert Correctional Center offers the most programs of any of the facilities in
Nevada to include: anger management, stress management, fitness and wellness,
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Inside/Out Dads, domestic violence, Toastmasters, gang awareness, conflict resolution,

victim empathy, commitment to change, SOS Help for Emotions, Thinking for Change,
relationships, sex offender treatment, stress and anxiety management. Additionally,
Southern Desert offers “New Beginnings” a re-entry program, forklift certification and
OSHA certification in cooperation with the local Teamsters Union. SDCC offers “TRUST” a
therapeutic community and “Re-Entry,” a unit to prepare inmates for reintegration back
into the community.
INMATE LICENSED TREATMENT

FACILITY
POPULATION MEDICAL STAFF SERVICES
Conservation Camps
Carlin Conservation Camp 150 
Ely Conservation Camp 150 
Humboldt Conservation Camp 152 
Jean Conservation Camp 240  
Pinoche Conservation Camp 196-238 
Stewart Conservation Camp 360 
Three Lakes Valley Boot Camp 75
Three Lakes Valley Conservation Camp 192
Tonopah Conservation Camp 152 
Wells Conservation Camp 150 
Correctional Facilities
Ely State Prison 1150  
Florence McClure Women’s Correctional Center 950 
High Desert State Prison 4176 
Lovelock Correctional Center 1680  
Northern Nevada Correctional Center 1619  
Southern Desert Correctional Center 2149  
Warm Springs Correctional Center 532  
Other
Northern Nevada Restitution Center 103 
Casa Grande Transitional Center 400 
Figure 46: Department of Corrections Service Population & Behavioral Health Services
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A Statewide Prisoner Reentry Coalition exists in Nevada to identify challenges for inmates
who are released from prison with substance abuse and mental health disorders, which
may have gone undiagnosed or untreated.
School Based Services

Many school districts employ
school psychologists and school
counselors to provide a variety
of services to their student
population which include
academic counseling, special
education assessments and
supports, as well as behavioral
health interventions. The degree
to which behavioral health
counseling occurs is dependent
upon the staffing resources,
community resources, and the
needs of each school districts’
student population. Some
innovative practices occurring at school sites around the provision of behavioral health
services include:
School Based Health Centers (SBCHs) are designed to provide health education,
preventative care, and comprehensive physical and behavioral health care services for
students on the school campus. There are 12 SBHCs in Nevada, all of which are located in
Clark County. While none of the sites currently offer comprehensive on-site services, with
a pronounced deficit related to the provision of behavioral health care, there is an
acknowledgment of this and efforts being made to address it.
Lyon County School District – There is a cooperative agreement between Lyon County
School District and Silver Springs Mental Health Center to provide behavioral health
outreach services in four Dayton area schools.
White Pine County School District – There is a cooperative agreement between White
Pine County School District and Ely Mental Health Center to provide group counseling
sessions at school sites. A psychologist from Ely Mental Health co-facilitates with school
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site counselors weekly group counseling sessions with students and the counselors refer
to the behavioral health center for ongoing care and treatment of the students who
present with behavioral health needs.
Hospitals and Emergency Medical Facilities

“Due to a lack of available
Hospitals and emergency medical facilities have alternatives, 79 percent of
increasingly become a place where people with hospital emergency
behavioral health issues are accessing care. The lack of departments report having to
“board” psychiatric patients
adequate community-based resources to serve people
who are in crisis and in need of
with behavioral health issues will continue to exacerbate inpatient care, sometimes for
this issue. eight hours or longer.”
According to a report by the Nevada Disability Advocacy (SAMHSA, 2009)

& Law Center, “Individuals on involuntary mental health
holds wait on average four days in hospital emergency rooms because state law requires
they must be medically screened. The state psychiatric hospital, administered by
Southern Nevada Adult Mental Health Services, does not have the equipment or personnel
to conduct such screenings. While individuals are being held in community hospital
emergency rooms, they receive little to no psychiatric care.” (Nevada Disability Advocacy
& Law Center, 2005)
Linkages and Coordination

State Driven Efforts
Nevada is host to numerous boards, commissions, collaboratives, and workgroups across
the state charged with addressing systems improvement for consumers accessing
behavioral health services. These entities are tasked with establishing linkages and
coordination that is critical to an effective continuum of care.
Formal Boards, Committees & Coalitions
Some Commissions will be reorganized as part of the integration of DPBH. Commission

prior to July 1, 2013 included the following.
Commission on Mental Health and Developmental Services (Commission on MHDS): The

Commission on MHDS is a ten member, legislatively created body, appointed by the
Governor and designed to provide policy guidance and oversight of Nevada’s public
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system of integrated care and treatment of adults and children with behavioral health,
substance abuse and developmental disabilities-related conditions. The Commission also
promotes and assures the protection of the rights of all consumers in this system and has
oversight and accountability function for both MHDS and DCFS.
Local Advisory Boards: The Commission on MHDS has created advisory boards in Washoe
and Clark Counties and makes appointments to these boards from stakeholders in the
community. The boards serve to provide information to the Commission regarding
service needs, public input, and other issues pertaining to mental health.
Nevada Children’s Behavioral Health Consortium: The Nevada Children’s Behavioral
Health Consortium was developed in response to the need for a statewide governance
body. The mission of the Consortium is to provide Nevada’s children and their families
with timely access to an array of behavioral health treatment services and support that
meet their needs in the least restrictive environment; and to deliver such services through
a system of care. To develop financing strategies to support quality service delivery. To
provide a mechanism by which system stakeholders can act in concert to ensure that
children’s needs are met. The Consortium works as a statewide voice for the common
themes articulated by the three regional consortia.
 Washoe County Children’s Mental Health Consortium

 Rural Regional Children’s Mental Health Consortium
 Clark County Children’s Mental Health Consortium
The Nevada Mental Health Planning Advisory Council (MHPAC): Nevada’s MHPAC was
established in 1989 by an Executive Order of the Governor with the goal of serving as an
advocate for individuals experiencing chronic mental illnesses, children and youth
experiencing serious emotional disturbances, and other individuals experiencing mental
illnesses or emotional problems. The members of the Council work in a variety of ways to
improve the way services are provided to consumers, to help bring more money into the
State system, to promote awareness of mental health issues, and to provide education and
training opportunities. MHPAC has created a Consumer and Family Member Advocacy
Committee to assist in their functions. The MHPAC has three federally mandated duties
which include; 1) To review the Community Mental Health Block Grant Plan and to make
recommendations; 2) To serve as an advocate for adults with Serious Mental Illness
(SMI), children with Severe Emotional Disturbance (SED), and other individuals with
mental illnesses or emotional problems; and 3) To monitor, review, and evaluate, not less
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than once each year, the allocation and adequacy of mental health services within the
state.
Prior to July 2013, MHDS was in the processes of “transforming” its Mental Health
Planning and Advisory Council (MHPAC) into a Behavioral Health Planning and Advisory
Council (BHPAC). In doing so, membership of the Council will be increased to include
consumers and family members of substance abuse and co-occurring-related disorders.
Populations of persons having substance abuse and co-occurring disorder services will be
advocated for and additional services related to these populations will be developed and
delivered.
Multidisciplinary Prevention Advisory Committee (MPAC): The MPAC is a volunteer

working group responsible for providing strategic and operational guidance to MHDS and
SAPTA. The MPAC advises SAPTA in the development and implementation of a
comprehensive statewide substance abuse prevention strategy that will optimize all
substance abuse prevention funding streams and resources, with specific focus on the
utilization of data, state and local level strategic planning, and underage drinking. The
MPAC serves as the Policy Consortium under a new federal grant, the Strategic Prevention
Framework State Enhancement Grant, and is responsible for grant oversight, input and
recommendations on the Capacity Building/Infrastructure Enhancement Plan and the
Five-Year Strategic Plan.
Substance Abuse Prevention and Treatment Agency (SAPTA) Advisory Board: The SAPTA
Advisory Board serves in an advisory capacity to the Agency Director of SAPTA and the
SSA. Its purpose is to ensure the availability and accessibility of treatment and prevention
services within the State. It consists of fifteen members who serve for two year terms and
are chosen from SAPTA funded prevention and treatment programs. The chairperson is
elected by the membership and serves as the chief executive of the Board and provides
general supervision, direction and control of affairs of the Board. The Board meets at least
quarterly, and the chairperson presides at all meetings.
SAPTA Community-based Coalitions: In state fiscal year 2012, SAPTA funded 11

community-based coalitions and one statewide coalition serving all 17 Nevada counties.
By convening key stakeholders, service providers and citizens, each coalition creates
comprehensive community prevention plans and implement sustainable prevention
efforts. In state fiscal year 2012, the coalitions managed 65 direct service providers who
served 27,068 participants with funds from various grants.
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Workgroups
In November 2012, MHDS established a statewide Quality Improvement Team in an effort

to recognize and improve quality and to work in collaboration as MHDS integrates with
the Nevada State Health Division (NSHD). This team consists of individuals from MHDS
mental health agencies, SAPTA and the NSHD. The Quality Improvement Team identified
special populations with specific needs to be addressed and created work groups for each.
The workgroups identified by focus area are:
 Adolescent/Young Adults
 Older Persons
 Race and Ethnic Disparities: Native Americans
 Veterans/Military
 Addictions/Co-occurring Disorders
 Criminal Justice/Law Enforcement
 Homelessness
Each workgroup consists of internal (MHDS and SAPTA) and external (community at
large) subject matter experts. The teams were tasked with examining the population
being addressed, and identifying the following:
 Data that supports that population’s service needs and recommendations

 What specifically is the need?
 What resources already exist?
 What resources need to be developed?
 Is there a cost factor to address the specific needs? If so, what is the approximate
amount?
 Reasonable time required for implementation
Local Efforts
There are a number of coordinating efforts occurring between service organizations in an

attempt to serve consumers effectively. To establish a comprehensive list of formal and
informal coordination efforts would be exhaustive, so a summary list is provided below:
 Operational agreements between state-operated behavioral health agencies and

county law enforcement to establish community response teams (CIT, MOST,
FACT).
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 Operational agreements between state operated behavioral health agencies, law

enforcement, community-based providers and court systems to implement
diversion programs through Mental Health Courts.
 Working relationships between state operated behavioral health agencies and
local private and public hospitals to provide acute behavioral health care.
 Working relationships between counties and private therapists to provide
community-based behavioral health care.
 Working relationships between UNR School of Medicine and RSCC to provide
telemedicine to remote communities.
 Formal collaboration between rural clinics and juvenile justice programs to
integrate behavioral health case management services into discharge planning for
youth with behavioral health needs.
 Formal collaboration between rural behavioral health, community coalitions and
local school districts to implement an evidence-based behavioral health and
suicide screening tool.
 Formal collaboration between DCFS, counties, school districts, and community-
based providers to provide wraparound services to children, adolescents and their
families throughout the state.
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Appendix 1.4: California Mental Health Timeline 1957-2013
Figure 47: California Mental Health Timeline 1957-2013
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Appendix 1.5: Summary of New Articles Published
Beginning in March 2013, a number of events unfolded that significantly impacted the
deployment of behavioral health services in the state. Allegations that patients were
inappropriately discharged from SNAMHS psychiatric hospital in southern Nevada and
bused to California led to a series of investigations, including internal and external audits.
Officials in San Francisco formally filed suit against Nevada, while others throughout the
state of California threatened to and still may follow their lead. The charges of “patient
dumping” highlighted the impact of budget cuts that began in 2007 and contributed to
ongoing public scrutiny. While new developments were noted on a weekly if not daily
basis, the timeline of events is summarized as follows:
Timing Event
March 1, 2013 “From a mental hospital in Las Vegas, he’s dispatched by bus to
Sacramento” is published in the Sacramento Bee, detailing James
Flavy Coy Brown’s discharge from Southern Nevada Adult Mental
Health Services Psychiatric Hospital to the Greyhound Bus Station
with a ticket to Sacramento, CA. 20
April-May 2013 Both Rawson-Neal and Dini-Townsend, inpatient facilities
providing psychiatric care, are investigated by the Centers for
Medicare and Medicaid Services, (CMS). 21
April-May 2013 Governor Sandoval’s office and the Nevada Department of Health
and Human Services request the National Association of State
Mental Health Program Directors retain consultants to review
conditions at Rawson-Neal Psychiatric Hospital (RNPH) in Las
Vegas, examining all areas of hospital policy and practice. 22
April 2013 Nevada modified policy to transport discharged patients when
transporting them out of state. 23
May 2013 CMS reports structural problems at Rawson-Neal facility. Both
Rawson-Neal and Dini-Townsend are cited with a number of
deficiencies that could jeopardize Medicare funding. 24
May 2013 A consultation report on Rawson-Neal Psychiatric Hospital is
issued to the state, outlining strengths and 10 recommendations
including the need for additional funding for services and staffing.
June 2013 The legislature approves a DHHS budget with a $23.4 million
addition to the state’s behavioral health system.
20 Retrieved from http://www.sacbee.com/2013/03/01/5227505/from-a-mental-hospital-in-las.html.

21 Retrieved from: http://www.10tv.com/content/stories/apexchange/2013/08/23/nv --psychiatric-hospitals.html.
22 Retrieved from: http://carsonnow.org/story/04/29/2013/nevada-governor-sandoval-says-firings-discipline-action-taken-mental-
health-bus-pro.
23 Retrieved from: http://www.lasvegassun.com/news/2013/apr/24/health-officials-reverse-policy-busing-mentally-il/.
24 Retrieved from: http://www.sacbee.com/2013/05/09/5406543/federal-probe-cites-major-problems.html.
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Timing Event
July 2013 Southern Nevada Adult Mental Health Services (SNAMHS)
relinquishes its accreditation from The Joint Commission on
Accreditation of Healthcare Organizations.
August 2013 CMS issues a survey report saying Rawson-Neal was out of
compliance with conditions for participating in Medicare, stating,
“deficiencies…substantially limit the hospital's capacity to render
adequate care to patients" and "adversely affect patient health and
safety."
August 2013 The Interim Finance Committee approved $2.1 million to open 22
beds at the Rawson-Neal Facility.
August 2013 The Legislature approved adding 10 beds to Lake’s Crossing, which
are estimated to be available in November 2013. In August,
Nevada’s Interim Finance Committee approved $3 million in
funding to renovate the Stein Hospital in Las Vegas, adding 58 beds.
However, renovations will take until 2015 at which time there will
be 42 beds added for patients in legal custody. The others 16 beds
would be used as overflow beds for the Rawson-Neal facility.
September 2013 The San Francisco City Attorney files a class-action suit against the
State of Nevada, Rawson-Neal Psychiatric Hospital and state mental
health administrators.25
September 2013 The Clark County Public Defender’s office, again sues the state for
failing to meet agreed upon time frames for persons being held in
detention while waiting for court ordered psychiatric evaluations
at Lake’s Crossing, the only forensic psychiatric facility in the state
for persons who in need of competency evaluation.
25 Retrieved from http://www.sacbee.com/2013/09/10/5723995/san-francisco-files-class-action.html.
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Appendix 1.6: Cross-Tabulation Charts and Graphs
Cross-Tabulation
To further understand the profile of behavioral health consumers, cross-tabulations of the
following were calculated Race/Age, Ethnicity/Age, Race/Gender and Ethnicity/Gender.
These provide a picture of which target populations of consumers access the behavioral
healthcare system and help identify underserved groups in need of outreach. The
following is a narrative summation of what the cross-tabulation analysis reveal. All charts
associated with the analysis can be found in the Appendix of this report.
When analyzed by race and gender only African American/Black males ages 25-44 access
services more frequently than their female counterparts.
Race/Age
This figure groups consumers by category-based on race and age.
8,000
7,070
6,796
7,000
Number Served
6,000
5,000
2,224
4,000
1,568
3,000 1,590 176 188 261 422

38 1,189
31 48 1,084
75 303 77
2,000 16
26 571 135 26
18 0
6 2
409 13 1,365 411 0
129 71 1,238 49
1,000 209 30 2
19 282 2
22 1
32 12 276 0
31 38
28 186 3
0 15 0
24 118 15
0-12 105 1
13-17 0
4
18-20 1
21-24 0
25-44
45-64
65-74
75+
Not
Available
Age
Figure 48: Cross Tabulation of Race and Age of Behavioral Health Consumers
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White Consumers 65+

2% 13-17
The White population makes up the 0-12 6%
majority of behavioral health 9%

18-24
consumers with most between the 45-64 9% Male
38% 46%
ages of 45-64, followed closely by ages
Female
25-44. Consistent with known trends, 54%
women make up the majority of 25-44
36%
consumers.
Figure 49: White Population of Figure 50: White Population of
Behavioral Health Consumers Based Behavioral Health Consumers
on Age Based on Gender
65+
1%
13-17
Black or African American Consumers 0-12 6%
11%
For Black or African Americans in 45-64
Female
Nevada, consumers between the ages 34% 18-24 47%
11%
of 25-44, followed closely by ages 45- Male
53%
64, most frequently utilize services
with men making up the majority. 25-44
37%
Figure 51: Black Population of Figure 52: Black or African

Behavioral Health Consumers Based American Population of Behavioral
on Age Health Consumers Based on
Gender
65+ 0-12 13-17

Asian Consumers 3% 3% 4%
18-24
Asians in Nevada access services most 8%
often between the ages of 25-44,
followed by the age range 45-64. 45-64
33%
Male
44%
There is a marked difference between
Female
this population and the White and 56%
25-44
Black/African American groups in 49%
that they tend to have lower access
levels of services at a very young age. Figure 53: Asian Population of Figure 54: Asian Population of
Women make up the majority of Behavioral Health Consumers Based Behavioral Health Consumers
consumers.
Page 110
Gaps Analysis 2013
65+ 0-12
0% 6% 13-17
5%
Multi-racial Consumers
45-64
Consumers who identify as multi- 21%
Male
racial are most often between the ages 18-24
20%
44%
of 25-44 and female. Female
56%
25-44
48%
Figure 55: Multi-racial Population of Figure 56: Multi-racial Population

Behavioral Health Consumers Based of Behavioral Health Consumers
65+
1%
13-17
American Indian or Alaska Native 0-12 9%
10%
Consumers 45-64
Male
American Indian or Alaska Native 32%
18-24 44%
consumers are also most often 12% Female

56%
between the ages of 25-44 and female.
25-44
36%
Figure 57: American Population of Figure 58: American Indian or

Behavioral Health Consumers Based Alaska Native Population of
on Age Behavioral Health Consumers
Based on Gender
65+
2%
Native Hawaiian or Other Pacific 0-12
45-64 16%
Islander Consumers 18%
Male
Native Hawaiian or Other Pacific 13-17
11%
44%
Islander consumers are also most 18-24 Female

often female and between the ages of 25-44
11% 56%
25-44. 42%
Figure 59: Native Population of Figure 60: Native Hawaiian or

Behavioral Health Consumers Based Other Pacific Islander Population
on Age of Behavioral Health Consumers
Based on Gender
Page 111
Gaps Analysis 2013
Ethnicity/Age
Figure 61 groups consumers by category based on ethnicity and age.
9,000
8,000
8,420
7,000 8,355
6,000
Number Served
5,000
4,000
3,000
209 1,367
2,000 550 206 1,154
207
406 303
1,531
1,000 170 276 1,366
1,073 60
1,352 823 12
0 665 26
36
0-12 10
13-17 0
18-20 451
51
21-24 2
25-44
45-64
65-74
75+
Not
Available
Age
Figure 61: Cross Tabulation of Ethnicity and Age of Behavioral Health Consumer
65+
1%
Hispanic Consumers 0-12

45-64 15%
The bulk of Hispanic Consumers are 23%
13-17
between the ages of 25-44, 11% Male
representing 38% of the service 18-24
Female
50%
50%
population within that ethnic group. 25-44

12%
Men and women equally access 38%
services.
Figure 62: Hispanic Population of Figure 63: Hispanic Population of
Behavioral Health Consumers Based Behavioral Health Consumers
Page 112
Gaps Analysis 2013
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(DPBH):
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Appelbaum, K. L., & Dvoskin, J. A. (2013). Consultation Report on Rawson-Neal Psychiatric Hospital.
National Association of State Mental Health Program Directors.
B. A., N., & D.M., M. (2012). The Impact of Psychiatric Patient Boarding in Emergency Departments. (R.
W. Derlet, Ed.) Emergency Medicine International, 2012, 5.
Block Grant Division of Mental Health and Developmental Services Substance Abuse Prevention and
Treatment Agency. (2013). Nevada State Health Division.
Brauner, B. C., & Stephens, C. B. (2006). Estimating the Prevalence of Early Childhood Serious
Emotional/Behavioral Disorders: Challenges and Recommendations. Public Health Reports,
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Brauner, C. B., & Stephens, C. B. (2006). Estimating the Prevalence of Early Childhood Serious
Emotional/Behavioral Disorders: Challenges and Recommendations. Public Health Reports,
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Caloiaro, D. (2013). 2013 State Mental Health and Substance Abuse Profiling System. Health-Mental
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Consulting Group.
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Reporting System Mental Health Data Results. Substance Abuse & Mental Health Services
Administration (SAMHSA).
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Centers for Disease Control and Prevention. (MMWR 2013). Mental Health Surveillance Among
Children US 2005-2011. 62(2).
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Consortium Annual Plan 2008.
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Consortium 10-Year Strategic Plan 2010-2020.
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Efforts: Strategies to Support and Sustain Local Initiatives. Bureau of Justice Assistance Office of
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Sun.
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Johnson, B. (2013). 2013 State Mental Health and Substance Abuse Profiling System. Financial
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Continuity.
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Nevada Department of

Health and Human Services

Prepared by Social Entrepreneurs, Inc.

Gaps Analysis 2013

Kathryn Baughman State of Nevada –Rural Counseling and Supportive Services

Gaps Analysis 2013

 Recognizes the interrelatedness of behavioral health and physical health,

Context of the Report

1 The Center for Disease Control and Prevention, www.cdc.gov.

Gaps Analysis 2013

These situations have resulted in multiple investigations and state-requested

Current Service System

 NNAMHS is located in Sparks, Nevada, and is a comprehensive, community-based,

Gaps Analysis 2013

Nevada has missed a number of opportunities over the

Gaps Analysis 2013

Profile of Current Behavioral Health Consumers

Age of Behavioral Health Consumers

Gaps Analysis 2013

NV Penetration rates per 1,000 population US (FY 2012)

Figure 1: Penetration Rates by Age Comparison

Gaps Analysis 2013

Race of Behavioral Health Consumers

 Children’s Services: The Department of Children and Family Services (DCFS) is

Gaps Analysis 2013

provided services to 5,785 adults in FY 2011-2012, representing 41% of

Insufficient service options identified include inpatient and outpatient treatment

Quantitative and qualitative data indicates:

3 Retrieved from: http://www.sfgate.com/opinion/openforum/article/Mental-health-prevention-a-wise-investment-4028399.php

Gaps Analysis 2013

such as transportation, home-based treatment options, and specialized outreach

Gaps Analysis 2013

Gaps Analysis 2013

1. Completion of a Comprehensive Needs Assessment

4 Retrieved from: http://captus.samhsa.gov/access-resources/about-strategic-prevention-framework-spf.

Gaps Analysis 2013

 Recognizes the interrelatedness of mental health and physical health,

 The current behavioral health service

Figure 2: Strategic Prevention Framework Components

Gaps Analysis 2013

Methods of the Study

Qualitative Data Collection Efforts

Gaps Analysis 2013

Quantitative Data Collection Efforts

 Demographic Profile of Behavioral Health Consumers and Penetration Rates: This

Public Document Review

Gaps Analysis 2013

Context of the Study

2013-2015 Legislative Session

Gaps Analysis 2013

facilities that could jeopardize CMS certification. These

1882: Nevada’s First State Asylum

Gaps Analysis 2013

Gaps Analysis 2013

50 Year Retrospective of Behavioral Health in Nevada 1963 – 2013

Figure 3: 50 Year Retrospective of Behavioral Health in Nevada 1963-2013

Gaps Analysis 2013

As noted in the Kaiser report, “Learning From History: Deinstitutionalization of People

Gaps Analysis 2013

o Third-party health insurance policies and public programs, such as