Issue 5: Gaps in Community Care/Continuity of Care

Goal: Ensure that the minimum set of services, specified in statute (AS47.30.046), are available in all areas of the state on either an individual or community level.


A large portion of Alaska's population lives in very small population centers with minimal mental health services. This makes it very difficult to provide a continuum of care to individuals who suffer from psychiatric disorders. One way of providing that continuum is by training providers in home communities to provide individualized, wrap-around services for the beneficiary population. This care is expensive, but less expensive than trying to establish programs in rural settings. The system would have to adopt a payment method that allows the funds to follow the individual.

The Alaska Mental Health Board believes optimal treatment, favorable outcomes, and recovery are most likely to occur when comprehensive community support programs are provided in an atmosphere of respect, acceptance, and hope.

People with psychiatric disorders may require a variety of services from different providers. Continuity of care can best be achieved through case management. The case manager is responsible for the coherence and appropriateness of services. The level of service needed is directly related to the level of acuity of the person's illness. Every person should have a single service manager or management team who keeps informed about every aspect of the treatment and informs the consumer and others who need to know. When an individual is hospitalized, the manager should be kept informed and should communicate frequently with the inpatient treatment team. Whenever residence in a community is interrupted for any reason, continuity of care requires that the same service manager or management team retain responsibility for the individual's treatment unless the consumer or other members of the treatment team desire a change.


210. Ensure that funding is available for individualized care for individuals living in rural areas without necessary services.

211. Ensure that funding is available for programs to provide a minimum set of services in all smaller communities.

212. Training funds should be available for all publicly-funded community service providers to restructure their systems to: incorporate proven research finding with innovative models of care; provide access to services that consumers need; provide oversight and advocacy through well-trained care managers; and use an integrated consumer-centered systems approach that includes providing services in settings that are comfortable for the consumer.

213. Ensure that technical assistance is available to work with the home communities of individuals with psychiatric disorders to help develop needed services.
Responsible party (actions 1-4): Division of Mental Health and Developmental Disabilities, Alaska Mental Health Board

214. The Alaska Mental Health Board will advocate for client choice in case management, so that if available and desired, clients can select independent case managers.

215. The Alaska Mental Health Board will advocate for a comprehensive array of consumer services to be available for individuals who meet the priority definition and either have a Global Assessment Functioning scale score of 50 or below or who are at risk of declining to this level. These must include "new generation" medications, inpatient treatment, outpatient treatment with mobile capability, residential support services, transportation services, intensive case management, psychosocial rehabilitation, peer support, consumer-run services, and round-the-clock crisis services that are available seven days a week.
Responsible party (actions 5-6): Alaska Mental Health Board