nadd pre conference workshop policy updates in addressing challenges in health care reform for...

NADD Pre Conference Workshop Policy Updates in Addressing Challenges in Health Care Reform for Individuals with Intellectual/Developmental Disabilities and Co-Occurring Mental Illness

November 18, 2015

9:00 AM to 12:15 PM

Focus

This Pre Conference Workshop provides an update, one year after the 2014 NADD Public Policy Position Statement was announced and discussed, on planned and taken action steps on ensuring the nation’s growing use of public and private managed care services meet the needs of individuals across all age groups who have an intellectual/developmental disability (IDD) and co-occurring mental illness.

Before We Get Started

Who’s here?

Your questions or topics of particular interest?

PresentersModerator and NADD Public Policy Position Statement: Eileen Elias, MEd Disability Services Center Director, JBS International, North Bethesda, MD & NADD Public Policy Committee Chair

Planning Subcommittee One ChairChristine Carter, MSW

Chief Operations Officer, Smoky Mountain Center

Managed Care Organization, Asheville, NC

Planning Subcommittee Two ChairVicki Gottlich, J.D., L.L.M., Director, Center for Policy and Evaluation, Administration for Community Living (ACL), Washington, DC

Presenters continued

Planning Subcommittee Three ChairDavid Miller, MPAff, Project Director, National Association of State Mental Health Program Directors (NASMHPD), Alexandria, VA

Planning Subcommittee Four ChairJeff Keilson, MA, Senior Vice President, Advocates, Inc., Framingham, MA

Overview & Update on Health Policy Committee’s Strategic Action Plan

Important Issues about this Population• Extremely diverse • MH issues often misunderstood, diagnostic

overshadowing• Medical issues often precipitate crises• Overuse of medication, side effects• Poor match between person and environmental

demands• High incidence of trauma, often overlooked• Risk for institutionalization, incarceration,

homelessness

Stress for families can be unrelenting

• Long and painful searches for services• Many do not receive appropriate treatment• Poor coordination across needed multiple

systems • Families may stay home, become isolated• Secondary MH issues for parents, siblings• Custody relinquishment (and divorce)

sometimes a covert requirement to access public services

Key Services- Often Hard to Find

• Comprehensive evaluation • Disability-specific expertise at the clinical and

programmatic level• Expanded service array including respite,

occupational therapy, alternative communications

• Preventative supports instead of symptom management

• Effective crisis prevention

NADD US Health Policy Committee Position Statement & Strategic Plan - Overview

•Addressing the needs of individuals with IDD and co-occurring MI is a primary NADD concern. •State authorities are uneven in supporting community-based services and inclusion of families and advocates in planning. •Priority attention to the impact of managed care and stakeholder’s roles.

NADD US Health Policy Committee Position

Statement & Strategic Plan – Overview continued •The NADD US Health Policy Committee is meeting these challenges through its action step planning process with the four subcommittees resulting from the October 14, 2014 Policy Discussion Meeting. •Each subcommittee’s processes and products to date will be presented and discussed today.

Pre Conference Meeting Goal

Understanding how persons with co-occurring Intellectual/Developmental Disabilities and mental illness service needs and quality of care in today’s health care reform environment occurs in support of successful community-based living. This involves attention to primary and long term supports, mental health and physical health care.

Educational Objectives

Objective One: Identify Subcommittee One’s outcomes to date from collecting and analyzing available IDD and co-occurring mental illness data demonstrating costs and cost savings to spur governmental attention to enhanced community services and adoption of best practices.

•Objective Two: Identify how Subcommittee Two is addressing coordination across federal agencies, such as ACL/NIDLRR, CDC, CMS, NIH, SAMHSA, facilitated by ACL, including resource enhancement and managed care organization policies on behalf of individuals with IDD and co-occurring mental illness.

Educational Objectives continued

Objective Three: Identify how, through Subcommittee Three, coordination of service and system needs of individuals with IDD and co-occurring mental illness is occurring by three state learning communities facilitated by Georgetown University Technical Assistance Center for Children’s Mental Health on behalf of the National Association of State Mental Health Program Directors and SAMHSA.

Educational Objectives continued

Objective Four: Identify through Subcommittee Four, how information is being collected and analyzed on managed care organizations’ actions and lessons learned from effective programs and state-MCO contract specifications to help address this population’s individual and system needs.

NADD Public Policy Position Statement

• NADD’s Public Policy Position Paper titled “Including Individuals with Intellectual/Developmental Disabilities and Co-Occurring Mental Illness: Challenges that Must Be Addressed in Health Care Reform”

• Located at (http://thenadd.org/about-nadd/nadd-position-papers/).

• Over thirty organizations officially endorsed the NADD Public Policy Position Paper.

http://thenadd.org/about-nadd/nadd-position-papers/

NADD Public Policy StatementIn order to advance the Public Policy Statement, NADD held a Strategic Planning Meeting on October 20, 2014 including high level representatives from the following organizations: (1) family members; (2) non-profit disability association executives; (3) federal government including the Center for Medicaid and Medicare Services (CMS), SAMHSA, and Administration for Community Living (ACL), and the National Institutes of Health (NIH) ; (4) 3rd party insurers and managed care organizations (MCOs); (5) NADD Public Policy Committee members; (5) service providers; and (6) other pertinent stakeholders from both the public and private sectors.

Policy Statement Overview

• The nation’s response to the service needs of individuals of all ages with co-occurring IDD (e.g., autism) and mental illness is of concern.

• Nationally, State IDD and Mental Health (MH) authorities are responsible for funding and monitoring needed services, yet support and funding is uneven.

• An increasing number of publicly funded programs are hard pressed to provide the levels of assistance, therapy, primary care, long-term medical oversight and individualized supports that people with this co-occurring condition need to live, work, and lead regular lives in the community.

Prevalence of IDD/MI

It is important to recognize that this group makes up approximately one-third (32.9%) of the total number of individuals with IDD served by state developmental disability (DD) agencies nationwide. The National Core Indicators data document the stability of this rate over time but specified data on the Policy’s target population is lacking.

Prevalence of IDD/MI

Service Challenges•Improvements in services for people with IDD/MI have been achieved by many states during the past decade by expanding supports furnished under the CMS Home & Community-Based Medicaid Waiver programs and state funding of improved crisis services and increased access to mental health services. •While advances have been made, state DD and MH authorities and service systems continue to struggle to provide effective and appropriate treatments and supports on a consistent and comprehensive basis. •State efforts to establish and maintain coordinated systems of care for people with this co-occurring condition have been significantly hampered by administrative and funding barriers that diffuse responsibilities and by the limited use of best practice models.•Dramatic declines in state revenues coupled with personnel reductions and a faltering economic recovery, have eroded the capacity of state agencies to maintain services. In many areas, waiting lists have grown and access to needed supports are delayed, deferred, or discontinued.

State ActionsSeveral states and private providers are looking for ways to stretch funding by coordinating services and improving support outcomes using:

– Home and community-based services under the Section 1915(c) Medicaid waiver program and the 1915(i) state plan option.

– Self-directed personal care through the new 1915(j) state plan services or using the 1915(k) Community First Choice personal care option to assist individuals with living in their homes.

– Federal programs such as Money Follows the Person (MFP) and the Balancing Incentive Payment (BIP) programs, which provide increased federal financing to states moving people from institutions to home and community-based settings.

– New federal strategy, the Health Home, to improve the coordination of primary, acute, mental health, and long-term services and supports for individuals with two or more chronic conditions.

http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Long-Term-Services-and-Support/Home-and-Community-Based-Services/Home-and-Community-Based-Services-1915-c.html

http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Long-Term-Services-and-Support/Home-and-Community-Based-Services/Home-and-Community-Based-Services-1915-i.html

http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Long-Term-Services-and-Support/Home-and-Community-Based-Services/Self-Directed-Personal-Assistant-Services-1915-j.html

http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Long-Term-Services-and-Support/Home-and-Community-Based-Services/Community-First-Choice-1915-k.html

http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Long-Term-Services-and-Support/Balancing/Money-Follows-the-Person.html

http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Long-Term-Services-and-Support/Balancing/Balancing-Incentive-Program.html

http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Long-Term-Services-and-Support/Integrating-Care/Health-Homes/Health-Homes.html

http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Long-Term-Services-and-Support/Integrating-Care/Health-Homes/Health-Homes.html

State Actions•Some states are pursuing managed care as one of several strategies to decrease expenditures and improve service coordination.

•Managed care approaches have been used to organize the delivery of acute health care and mental health services for some time.

• The effective application of this model to long-term supports including Medicaid waiver-based programs furnished to people with IDD is limited.

•Persons with IDD may receive MH services through managed programs such as Health Homes.

Manage Care Implications• Managed care proponents state that the approach offers

benefits to states:

– Enables policymakers to more closely align program expenditures with treatment and service outcomes

– Improves administrative and operational efficiencies

– Reduces costs over time.

•Changing the structure and functioning of state IDD and MH service systems to adopt to either public or privately administered managed care is a complex undertaking.

Managed Care Implications•The National Council on Disabilities’ recent report underscores the importance of the state’s role in managing Medicaid service delivery if the plans are operated by states, other public agencies, county governments, nonprofit organizations, or for-profit corporations.

– The authors recommend that states retain staff with knowledge and expertise of disability services including community long-term services and supports, provide effective management and oversight and ensure high quality of care through MCO contracts and obligations.

– The authors identify 24 policy-related issues and offer several recommendations for both federal and state policymakers.

Managed Care Implications•Managed care systems are designed to reduce expenses while maintaining quality and improving outcomes.

•Service costs and utilization are controlled through highly structured contracts among the state as the purchaser, the health plan(s), and the service providers.

•Contracts between the state agency and the MCOs should specify funding mechanisms, service delivery arrangements, family/consumer and other stakeholders roles, and the nature of the relationships of the various parties.

Managed Care Implications•Specific contract provisions are implemented through separate but related administrative protocols described in operations and policy manuals.

– Written by the state, these documents should identify MCO obligations with respect to the to be purchased and provided services and supports.

– States must clearly identify the nature and scope of services to be furnished to people with this co-occurring disability including service coordination, provider qualifications, oversight, quality management, cost-effectiveness, and steps to ensure coordinated care occurs among state agencies, providers, and others.

MCOs and States Attention re Individuals with IDD and Co-Occurring MI

•People with co-occurring IDD and MI disorders needs are very heterogeneous, and their support needs change over their lifetime.

•Individuals with IDD and co-occurring MI disorders require a flexible array of services to help them effectively reside in the community.

•States’ managed care funding models need to be designed to promote this flexibility and to support providers’ ability to structure services around the needs of the individual – children and adults.

Strategic Planning Recommendations1. Community Living

2. Knowledge and Expertise

3. Person-Centered Services

4. Workforce Competencies and Training

5. Readiness

6. Review Funding

7. Support for Families

8. Inter-Systems Service Coordination

9. Specifications in State Contracts with MCOs

10.Specifications for Public and Private Insurance Benefits and State Contracts with MCOs

11.Support to Develop Proven Models of Care and Treatment

Thank you!

132 Fair Street, Kingston NY 12401 – www.thenadd.org – (800) 331-5362

http://www.thenadd.org/

Research Validating the Costs of

Serving the Dually Diagnosed Population

Subcommittee One

Christina Carter, MSW,

Chief Operations Officer, Smoky Mountain Center Managed Care Organization

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NADD Subcommittee: Costs/Cost SavingOctober 2014Action Steps

1. Collect data on cost/cost savings from - START Ohio

& New York

2. Collect data from cost/cost savings from -Smoky Mountain LME/MCO North Carolina

3. Review NASDDDS Data -National Core Indicators

4. Identify and assess other available data - e.g., NADD Research Committee recent report

5. Identify utilization data on psychotropic medication, inpatient services, quality of life, work force, ER Services

6. Assess/project cost information

7. Provide analysis and recommendations report 32

Synchronicity

• NADD Subcommittee Costs/Cost Saving

Identify outcomes from collecting and analyzing available IDD and co-occurring behavioral health data demonstrating costs and cost savings to educate governmental entities and bring attention to

enhanced community services and adoption of best practices.

• Smoky Mountain Quality Improvement ProjectA Quality Improvement Project was initiated at Smoky Mountain LME/MCO in February 2015 for improvement in the detection, assessment and treatment of mental health disorders in individuals with Intellectual/Developmental Disabilities.

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Data: National Core Indicators

Nationwide

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Data: National Core Indicators

North Carolina

35

North Carolina & Smoky Mountain LME/MCO

• North Carolina’s General Assembly issued legislation to move the public system to a manage care model in 2010

• Smoky Mountain Local Management Entity/Manage Care Organization transitioned to a managed care model of publically funded MH/SU/IDD services in July 2012.

• There are 8 managed care organizations that contract with the N.C. Division of Medical Assistance to operate the N.C. Medicaid 1915(b)/(c) Waiver.

• Smoky Mountain LME/MCO (Smoky) manages care for a 23-county region in western NC.

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Framework for Smoky Interest

• Routine review of service authorization requests and Individual Support Plans demonstrated serious inadequate supports to address co-occurring conditions.

• Concerns included inadequate assessments and improper diagnostics to verify co-occurring disorders

• Lack of appropriate clinical interventions

• Lack of staff education in providing services & supports

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Framework for Smoky Data

• The sample came from persons being served within the 1915 (c) NC Innovations Waiver. NC Innovations is the Home and Community Based Waiver.

• Selection of data was made from across the 23 counties managed by Smoky

• At the time of the selection, 1570 people were participating in the NC Innovations Waiver.

• A sample of 211 NC Innovations participants were randomly selected

• 52% were confirmed to have a co-occurring mental health diagnosis

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Randomized Selected Sample

• From the sample of 211 people:

• 20 people were randomly selected who are diagnosed with IDD and a co-occurring mental health disorder

• 20 additional people selected who are diagnosed with an IDD or related condition

• Total sample size of 40 people.

• The cost data for the 40 person sample was pulled from paid Medicaid paid claims between 1/1/14 and 1/1/15

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Research Assurances

• During the course of reviewing the data, it was noted that two people in the co-occurring group were diagnosed with MH conditions either “by report” or “by history” NOT sound diagnostics

• In an effort to include only those persons appropriately diagnosed with mental health conditions, those two people were removed and 2 other people were chosen randomly.

• To prevent cost outliers potentially skewing the data:

• Two additional people were selected for each category

• The individual at the bottom and at the top of cost variance were removed

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Sample DetailData did not control for age, gender, race, physical health status, or residential setting.

• IDD only group ranged in age from 11-73

• Co-occurring group ranged in age from 16- 61

• Co-occurring group included (but was not limited to) the following MH diagnoses

• OCD, Schizoaffective Disorder, GAD, MDD, Disruptive Behavior Disorder, Anxiety and NOS, PTSD, ADHD, Bipolar, Depression

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Sample Detail

• Cost information included all services that Smoky manages (costs related to MH/SU/IDD services)

• Data did not include medications, non-psychiatric hospitalizations, or other medical costs.

(A second research study will cover this and additional aspects of costs)

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Sample Detail-Co-occurring

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58 Female Obsessive Compulsive Disorder Caucasian

H2015 - Community Networking Service - Ind Mild Intellectual Disability $5,269.22

H2016HIU2 - Level 4 AFL-Residential Supports Schizoaffective Disorder, Bipolar Type $59,780.68

H2025 - Supported Employment - Ind $3,856.24

T2021 - Day Support - Individual $27,025.19

T2025 - Specialized Consultative Service $1,300.00

$97,231.33

175008 45 Male Obsessive-Compulsive Disorder, Major Anxiety Caucasian

90791 - Psychiatric Diagnostic Evaluation Total Adjustment Disorder with Anxious mood $94.04

90837 - PSYCHOTHERAPY 60 MN Mild Intellectual Disability $820.27

99213 - Op Visit Exp Est Pat 15 M Total Eating Disorder NOS secondary to Prader-WIlli $297.72

H2015 - Community Networking Service - Ind $3,386.55

H2016HI - Level 4-Residential Supports Total $48,202.14


Total $89,938.52

Sample Detail Co-occurring

• Note: Many individuals diagnosed with a co-occurring disorder did not have claims for MH services, but may have higher level of IDD Supports

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58 Female Obsessive Compulsive Disorder Caucasian

H2015 - Community Networking Service - Ind Mild Intellectual Disability $5,269.22

H2016HIU2 - Level 4 AFL-Residential Supports Schizoaffective Disorder, Bipolar Type $59,780.68

H2025 - Supported Employment - Ind $3,856.24


T2025 - Specialized Consultative Service $1,300.00

$97,231.33

Sample Detail-IDD

• Examples of IDD only data

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16 Male Congenital Quadriplegia African American S5125 - Personal Care Services Severe Intellectual Disability $28,044.54 S5150 - Respite - Non-inst Individual $7,724.22 Total $35,768.76

31 Female Profound Intellectual Disability Caucasian

T2014U2 - Level 2 AFL - Residential Supports $46,522.90


T2021HQ - Day Support Group $1,582.08

Total $54,639.68

20 Male Autistic Disorder Caucasian H2025 - Supported Employment - Ind Moderate Intellectual Disability $15,615.53 S5125 - Personal Care Services $6,717.92 S5150 - Respite - Non-inst Individual $2,324.90 S5150HQ - Respite - Group $2,930.40 T2013 - In Home Skill Building: Individual $10,805.80 T2021HQ - Day Support Group $17,264.64 Total $55,659.19

Data summary

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Group N Sum Mean Standard Deviation

Co-occurring MH/IDD

20 $1,282,614.92

$64,126.4155

$16,778.80649

IDD only 20 $959,905.78

$47,995.2890

$15,833.90298

• T-difference -3.127• Mean cost difference of $16,135.45

Data Summary

• 30.6306% difference

• T-difference -3.166

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IDD Co-Occurring MH/IDD

Difference

Sum $959,905.78 $1,282,614.92 322,709.14

Mean $47,995.289 $64,130.746 16,135.45

Conclusions Drawn from Data Review

• It generally costs more to support individuals with co-occurring conditions

• There are opportunities to utilize best practices to address co-occurring needs from prevention level to acute level

• Integrated care and inter-disciplinary collaboration are critical

• Training is required to grow expertise on evidence-based treatment of individuals with co-occurring IDD/MH in the provider community

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Smoky InitiativesCurrent Initiatives

• QIP for diagnosis and treatment of IDD/MH for Innovations participants.

• Integrated care planning proposal approved created to improve coordination of care between medical healthcare, IDD providers & behavioral health providers

• NADD Training- Train the trainer scheduled for 3 days in December – targeted toward comprehensive MH/SU providers, identified IDD providers, and select Smoky staff

• IDD Advisory Committee- Advising C3@356 Project – BH Urgent Care, Facility Based Crisis ( Adult & Child), Peer Support Specialists(including IDD), Living Room Model, Outpatient, Psychiatric, etc.

• IDD Learning Community lead by Joan Beasley (provider and MCO representatives working on building and sharing knowledge around co-occurring MH/IDD)

• NC START trainings with Joan Beasley ( internal & external)

• Integrated Care Initiatives----Dually Diagnosed Medical Health Home

• Smoky Care Coordination ---- Clinician's & RN’s

• IDD Medical Health Home (specializing in dually diagnose)

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Gratitude

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NADD Public Policy InstituteTitle Goes HereVicki Gottlich, Esq.

Director, Center for Policy & EvaluationAdministration for Community Living

Department of Health and Human ServicesSubcommittee Two

Title 2 Goes HereFederal Agency Coordination

• October 2014 NADD public policy forum

• Goal: ensure that individuals with co-occurring IDD and mental illness receive the quality of care necessary for successful community based living.

• Recommended priority: enhance coordination among federal government agencies that assist individuals with IDD and MI or that conduct research to assist this population.

Title 2 Goes HereHerding Cats

• Gathering representatives from HHS “Op Divs” proved challenging

• Size of the federal bureaucracy• Resources – staff and finances• Policy priorities• Timing

• Getting commitments to work together remains a challenge

• Initial first step - information on programs and resources currently available through HHS agencies

• Project under way• Presentation discusses some of the findings

Title 2 Goes Here

Examples of Existing Programs and Resources

Administration for Community Living (ACL) – focusing on community living for people across the life span

• University Centers for Excellence in Developmental Disabilities Education, Research & Services (UCEDDs)

• State Protection & Advocacy Systems (P&As)• State Councils on Developmental Disabilities (Councils)• Independent Living Administration• Aging and Disability Resource Centers (ADRCs)• Lifetime Respite Care Program and Family Support services• National Institute on Disability, Independent Living, and Rehabilitation Research

Title 2 Goes HereExamples of Existing Programs and Resources

Substance Abuse and Mental Health Services Administration

• Center for Integrated Health Solutions• Behavioral Health Treatment Services Locator• National Center for Excellence for Infant and Early Childhood Mental

Health Consultation• The Caring for Every Child’s Mental Health Campaign


Centers for Medicare & Medicaid Services (CMS) • Balancing Incentive Program (BIP) • Money Follows the Person Program (MFP) • Community First Choice• Medicaid Home and Community Based Waivers (HCBS)

• Person-centered planning under 2402(a)• State transition plans under the “settings rule”

• Financial Alignment Initiative


Still gathering information from:

• Health Resources Service Administration (HRSA)• Family-to-Family Health Information Centers (F2FHICs)

• Administration for Children and Families (ACF)• Birth to 5: Watch Me thrive!

• Centers for Disease Control (CDC)

• National Institutes of Health (NIH)

Title 2 Goes HereExamples of Initiatives and Best Practices

Research• Colorado Dual Diagnosis Gap Analysis Project (UCEDD)– statewide study to

identify and address gaps in delivery of services. http://www.ucdenver.edu/academics/colleges/medicalschool/programs/JFKPartners/projects/Pages/Dual-Diagnosis-gap-Analysis-Project.aspx.

Integrated Care Models (SAMHSA)• Monroe Meyer Institute (UCEDD)brings behavioral health providers

into primary care physician’s offices. http://www.unmc.edu/mmi/news/annual-rpts/MMI_Annual_Rpt_2014.pdf

Services• Kirsch Developmental Services Center -behavioral health interventions

for families

http://www.ucdenver.edu/academics/colleges/medicalschool/programs/JFKPartners/projects/Pages/Dual-Diagnosis-gap-Analysis-Project.aspx

http://www.ucdenver.edu/academics/colleges/medicalschool/programs/JFKPartners/projects/Pages/Dual-Diagnosis-gap-Analysis-Project.aspx

http://www.unmc.edu/mmi/news/annual-rpts/MMI_Annual_Rpt_2014.pdf

http://www.unmc.edu/mmi/news/annual-rpts/MMI_Annual_Rpt_2014.pdf

Title 2 Goes Here

Future Steps

Review and collaborate on research agenda

Need for Research:• To establish baseline of who we are talking about• To be more inclusive in research practices• To support research for establishing evidence based practices• To adapt evidence based practices to this population• Environmental scan of what states are doing

HHS research components include:• NIH• NIDILRR• ASPE

Vicki GottlichAdministration for Community Living

[email protected]

NADD Annual Meeting’s Pre Conference Workshop:

Policy Updates in Addressing Challenges in Health Care Reform for Individuals with Intellectual/Developmental Disabilities and Co-Occurring Behavioral Health

DisordersSubcommittee Three

November 18, 2015

David W. MillerThe National Association of State Mental

Health Directors (NASMHPD)

Represents the $39 Billion Public Mental Health System serving 7.1 million people annually in all 50 states, 4 territories, and the District of Columbia.

An affiliation with the approximately 207 State Psychiatric Hospitals: Serve 151,000 people per year and 40,600 people served at any point in time.

NASMHPD Divisions

• Children, Youth & Families• Financing and Medicaid• Forensic• Older Persons• Legal• Medical Directors Council• National Association of Consumer/Survivor

Mental Health Administrators (NAC/SMHA)

NASMHPD/NADD Collaboration• CYF Division Meeting, July 2014

o 33 States in attendanceo Effective Services for Children with IDD and co-

occurring BH issues One of the Top 5 Issues Workforce

• NADD Meeting, October 2014• NASMHPD/Georgetown Paper, Summer 2015

NASMHPDBACKGROUND

The Great Recession’s Impact on State Mental Health Authorities

Level of SMHA Budget Reductions

* Preliminary Results based on 41 SMHAs Reporting Winter 2011-2012

FY2009 to FY2012 Total $4.35 Billion in Cuts*

Year Average Total

FY 2009(39 states) $36,849,116 $1,216,020,843

FY 2010 (38 States) $29,123,575 $1,019,325,136

FY 2011 (36 states) $35,294,953 $1,270,618,291

FY 2012 (31 states) $28,074,541 $842,236,221

Closing State Psychiatric Hospitals & Hospital Beds (2009-2012)

SMHA Has Closed

SMHA is Considering

Closing

Total Closed or Considered for

ClosureState Psychiatric Hospitals

8 States9 State

Hospitals

4 States6 State

Hospitals

12 States15 State Hospitals

State Hospital Beds

29 States3,222 Beds

10 States1,249 Beds 4,471Beds*

* 4,471beds represents over 9% of State Psychiatric Hospital Bed Capacity

Preliminary Results based on 41 SMHAs Reporting Winter 2011-2012

Increased Demand for Mental Health Services During the RecessionPercentage of States Experiencing Increased Demand for Services

Preliminary Results based on 41 SMHAs Reporting

SMHA Responses to Cuts in Overall SMHA Budget Winter 2011-2012 (Percentage of States with Cuts)

Preliminary Results based on 41 SMHAs Reporting

The Top Issues Facing Children’s Mental Health Directors

Creating and Retaining a Trained Workforce

• “75% of our counties have declared a workforce shortage crisis – 175 counties are declared a MH workforce crisis. Salaries are too low and we can’t compete with the private sector. We train these folks and then they leave.”

• “Lack of licensed MH providers.”• “Once clinicians are licensed they leave public system.”• “We train, give resources to and license professionals,

but then they move on for better salaries.”

Creating and Retaining a Trained Workforce (Cont’d)

• “Our biggest challenge is workforce development, especially developing training needs to serve children across MH, SA, and DD. We especially lack professionals who can address the multiple needs – e.g. mental health, sub abuse, developmental disabilities – of our service population.”

• “We have a workforce double whammy in being in the public sector AND being in the child system.”

• “How can we address the adequate training of MH professionals and can Medicaid, our major funder, ever pay a competitive rate?”

• “We need better oversight of our professions.”

Strategies for Implementing Consistent, Effective, and Quality Services and Supports, Infusing a System of Care Approach, across

Multiple Managed Care Entities and Providers

• “Coordination and collaboration between multiple MCOs across the state is a huge issue for us. There is system upheaval navigating between these MCO, especially between the adult and child care services and systems. In addition, more than coordination, many of these MCOs fight with one another.”

• “We are in the process of rolling out wraparound to 13 coordinated organizations and need a set of benchmarks or a framework of what an effective SOC or BH system looks like to work between multiple managed care organizations statewide. We have 16 Care Coordination organizations at different stages of understanding child mental health, how do we allow opportunity for local innovation and still have standards and benchmark everyone has to abide by?”


Multiple Managed Care Entities and Providers (Cont’d)

• “How do we maintain the continuum of care for children and sustain our SOC services in the face of tumultuous change as we move to full managed care statewide?”

• “We have a lack of consistency or uniformity of services across our state, it looks different in different regions. What does a stellar system look like?”

• “More than half of our counties are going to managed care. With multiple managed care entities, multiple acronyms, different rules, definitions, and services components among multiple statewide Managed Care organizations, how do we assure quality service statewide?”

• “On the community side, we contract out all of our services out. We need to figure out trends and how to structure and word our contracts to ensure quality evidence based practices across all of our providers.”

• “We need to use data to measure outcomes and make decisions about resource expenditures to drive services.”


Multiple Managed Care Entities and Providers (Cont’d)

• “Our state is in a new managed care environment with 9 managed care entities in various stages of development and understanding of children’s services. How can we be relevant, value added, and positively influence the managed care organizations to maintain SOC? Their care coordinators having 1 to 80 ratios and poorly written contracts are also issues.”

• “How do we take SOC thinking and values to Managed Care?”• “As one of 3 states who still have State Operated Services, we

are in the process of becoming the state mental health authority and moving away from role of being a direct services provider. We need assistance on how to sustain SOC work as we make this transition from being a direct service provider.”

Gaining Support for Appropriate Uses for Residential Care Services

• “One of our largest problems is people, especially leadership, thinking residential treatment is the place for kids to be, when we need to get away from this service model. “

• “The Culture of Placement is a huge issue for us. Even advocacy groups promote residential services, incarceration, and hospitalization. Judges and leadership also are very invested in these services. How do we educate and build support for an intermediate step such as PRTFs?”

• “We are being pushed to add more congregate care. Kids are stuck in ERs and good data indicates these are not SOC kids, but our department gets the blame. This has fueled calls for greater institutionalizing and we are being pushed to add more residential services.”

Gaining Support for Appropriate Uses for Residential Care Services (Cont’d)

• “The ones getting left out are kids in the middle-need range, or the ones with high need with no place to go. No one wants to take responsibility, not even PRTFs.”

• “Our biggest issue is the lack of PRTFs. We have licensed residential treatment programs, but CMS is beginning to push back against their bundled rate and now declaring them as IMDs. We have very violent kids that no one will take and this is a fast-approaching crisis.”

• “We need to build PRTF capacity and educate our leadership on how/why to move away from residential services. Judges can court order the residential center and love residential treatment. The residential centers have staff at court who will drive the kids directly to the center from court. Schools also like residential and day treatment.”

Effective Services for Youth with Mental Health Needs and Developmental Disabilities, including Autism

• “Our biggest issue is treating youth with both MH and DD. There is financing dysfunction and very little collaboration across systems, it’s all about, ‘who is responsible and pays for the child.’”

• “We are facing a lawsuit to serve children with autism.”• “We have a gap group with kids with DD. Our MH SOC did not

meet their needs and we felt we were at risk for another lawsuit, so an expansion grant was developed for that target population. We have not handled autism kids in the past but now with this grant, we are being pushed to take care of them. Should be a blended situation with the responsibilities. The differences in definitions, funding streams (or streamlining multiple funding streams to define the population and service) make it very difficult to integrate our services.”

Achieving Cross Agency Support and Participation in Implementing a System of Care Approach

• “Still struggling with how to help sister and brother agencies, that all have direct ties to SOC, understand how this is a large umbrella and how they fall under it. Everyone only talks about their individual reforms.”

• “With multiple providers, we are still struggling with implementation of wraparound facilitation statewide.”

• “As the joint (Child welfare and mental health) agency, we have a wonderful arrangement to build relationships between multiple agencies. However, it’s hard to get them to focus on children – the system is adult skewed. They call children a specialty population. More federal guidance from block grant would help, such as national performance measures related to children to help incentivize, mandate or guide the MH authority to focus on children and youth.”

Achieving Cross Agency Support and Participation in Implementing a System of Care Approach (Cont’d)

• “Our children’s BH division is integrated in with child welfare, juvenile justice and early childhood. We understand each other well, but do not get along and the others do not understand many of our initiatives like SOC, so this causes system upheaval.”

• “We have five different statewide contracts that all provide Medicaid BH services. We provide services to kids unless they are in foster care. None of the contracts contain any language about SOC, trauma informed care, or children’s EBP’s.”

• “People talk the talk of collaboration, but continue to work in silos. The mantra is always ‘who’s gonna get the credit?’”

NASMHPD’s Collaboration with Georgetown’s National

Technical Assistance Center for Children’s Mental Health

Learning CommunitySupports Inter-Agency Planning for Youth with Co-occurring Intellectual/Developmental Disabilities and Mental Health Disorders

© 2014 NATIONAL TECHNICAL ASSISTANCE CENTER FOR CHILDREN’S MENTAL HEALTH, GEORGETOWN UNIVERSITY

• Children’s MH Directors survey• NADD Meeting October 2014• Georgetown’s ongoing SAMHSA-funded

work to improve services and supports for this population

• Ongoing partnership with NASMHPD and NADD

Rationale for Learning Community


State A: • No System of Care (SOC) infrastructure for any

population• poised to roll out a state-wide initiative

State B:• SOC infrastructure at both local and state levels but this population not included • limited connection between the two levels

State C:• Had a fully implemented SOC infrastructure for

children, which included the identified population

Three States


Broad Cross-Agency Participation

Behavioral HealthIDDChild WelfareEducationMedicaidEarly ChildhoodJuvenile JusticeDD CouncilSAMHSA System of Care Expansion Grant

Community MH Center(s)Local Provider AgenciesPublic UniversityUCEDD- University Centers for Excellence in Developmental DisabilitiesFederation of FamiliesOther family organizations


Activities

• Application process that included forming a cross-agency team

• Three webinars• Three one-hour coaching calls per state• Resources for strategic planning• On-site visit• Resource sharing among participants


Webinar Topics

Webinar #1: Defining Needs• Overview, prevalence, common challenges, public health

implications, impact of system barriers on children and families

Webinar #2: Best Practices and Workforce Strategies• Recommendations for assessment, supports, service array,

two models: Systems of Care, Center for START Services

Webinar #3: Financing• Cross-agency funding opportunities and resources (joint

bulletins from CMS, etc)


• Policy • State and local infrastructure • Services and supports, including workforce

preparation

Strategies Emerged Reflecting 3 Themes


• Review all funding streams for MH and IDD services and align them as best as possible.

• Review Medicaid policy for potential barriers to serving those with co-occurring disorders.

• Cross-walk clinical eligibility requirements for all funding potentially available for this population.

Examples of Strategies Developed


• Develop a multi-disciplinary team of providers and state officials (pediatricians, psychologists, dentists, physical therapists, occupational therapists, educators, etc.) to develop strategies for serving this population and to discuss policy barriers to service.

• Expand use of telehealth consultation to increase access to specialists for rural providers and families.

More Examples


More Examples

• Develop or modify educational materials, including provider manuals, best practice guides, and family handbooks, for families, providers, and the community on best practices, resources for this population, how to access the system.


1. Importance of broad cross-agency collaboration2. Not about two systems- many systems need to be

involved3. Not a separate population4. Leadership of states’ Children’s Directors critical5. Buy-in from leadership of all child-serving systems6. Painstaking examination and alignment of policies

and financing

Lessons Learned


7. Coordinated use of existing funding

8. Systematic analysis of service gaps

9. Best practices in comprehensive assessment

10.People unaware of resources in other systems

11.Creative workforce planning for multiple levels

12.Attention to trauma

Lessons Learned (continued)


13.Sharing information across traditionally segregated workforce

14.Ways to strengthen feedback loops15.Addressed communication with families16.Focus on “doable” change over one year and

within sphere of influence

Lessons Learned (continued)


• There is a huge need to support this population• It isn’t necessarily about finding new money but about

collaborating to serve this population through policy, infrastructure and service/support changes

• Cross-agency data collection is important to making decisions

• Collaborative work focused on this population would reduce states’ vulnerability to legal action

• Having an independent facilitator, not associated with state government, to assist with strategic planning was extremely important

Implications for the Field


Questions About Learning Community

Diane Jacobstein, [email protected]

Linda Henderson-Smith, PhD, [email protected]

mailto:[email protected]

Next Steps• NADD and NASMHPD plan to use this paper as a

Springboard for activity of the NADD Subcommittee on State Inter-System Coordination, along with NASDDDS.

• NASMHPD and Georgetown are hosting a special “Peer-to-Peer” call with the NASMHPD CYF Division on December 1, 2015 to engage Children’s Mental Health Directors in replicating the work of these 3 states.

• NASMHPD plans a webinar to Commissioners in 2016 to also highlight this paper and issue.

NADD US Policy Updates

Addressing Challenges in Health Care Reform for Individuals with I/DD and Co-occurring BH

DisordersSubcommittee Four

NADD 32nd Annual ConferenceNovember 18, 2015

Jeffrey [email protected]

508 628-6662

mailto:[email protected]

www.Advocates.org

101

Committee Charge

• Building on the NADD Public Policy Position Statement, develop specific recommendations for State MCO contract specifications and expectations on the provision of quality services for individuals with intellectual/developmental disabilities and co-occurring BH disorders

• Building on the NADD Public Policy Position Statement, develop specific recommendations for MCO requirements for their network of providers to ensure the provision of quality services for individuals with intellectual/developmental disabilities and co-occurring BH disorders

• Develop recommended outcome measures that can be used by states or MCOs

www.Advocates.org

102

Committee Members

• Eileen Elias, JBS International• Rob Fletcher, NADD• Jeffrey Keilson, Advocates, Massachusetts• Bob Putnam, May Institute, Massachusetts• Barbara Brent, NASDDDS• Donna McNelis, Drexel University• Jane Mullin, Jawonio, New York• Christina Carter, Smoky Mountain Center, North Carolina• Mark Deasy, Beacon Health Options• Lauren Falls, Beacon Health Options• Sue Gamache, Parent and member of NADD Family Issues Committee• Kathy Enerlich, Children’s System of Care, New Jersey• Terry McNelis, NHS Human Services, Pennsylvania• Melissa Tuttle, student, North Carolina• Merrill Friedman, Amerigroup• Maria Quintero-Conk, Tri-County Behavioral Healthcare, Texas• Cheryl Chan, Parent, Massachusetts

www.Advocates.org

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Additional Collaborators

• Centene/Cenpatico• United Health Care• Autistic Self-Advocacy Network• State Medicaid agency, Massachusetts and New Jersey• State children’s agency, New Jersey• Other suggestions ?

www.Advocates.org

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Committee Activities

• Acquire information on current state MCO contract specifications either specifically focused on people with I/DD or specifications that could be adapted for individuals with I/DD

• Acquire information on outcome measures focused on people with I/DD or measures that could be adapted for individuals with I/DD

• Identify current state/MCO contract issues or concerns• Identify effective/promising practices from the MCO, state, provider,

family, and individual perspectives • Identify lessons learned both from the MCO and state experiences• Assess how states or MCOs currently address (or not) the needs of

people with I/DD

www.Advocates.org

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Survey

• NADD State/MCO survey was developed as one way to gather information

• Survey is very comprehensive and can be completed online:– http://goo.gl/forms/XM9I6NCPFL

http://goo.gl/forms/XM9I6NCPFL

http://goo.gl/forms/XM9I6NCPFL

www.Advocates.org

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Some Key Areas

• Data to support NADD’s position with states, MCO/ACO– Diversion from emergency departments– Reductions of hospitalizations and re-hospitalizations, both medical and psychiatric– Reduction of length of hospital stay

• Effective care coordination provided by people/agencies who know the needs of people with I/DD is critical

• Investment in long term services and supports will impact physical health and behavioral health expenditures

• Integration of physical health, behavioral health and long term services and supports

• Pilot or local initiatives that work– Collaboration with primary care

www.Advocates.org

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Next Steps

• Expand involvement of interested people/organizations across the country

• Complete gathering information through survey and other methods• Finalize recommendations for states and MCOs• Distribute to key stakeholders

www.Advocates.org

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Power to Impact Change

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