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Washington StateDepartment

of Social & Health Services Mental Health Transformation

Work Group Update

October 26, 2007

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Washington StateDepartment of Social

& Health Services

Agenda For Today

1. Background and brief overview of STI projects

2. Benefits Package Update

3. Housing Action Plan Update

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Washington StateDepartment of Social

& Health Services

BackgroundChallenges Facing the 2006 Legislature• Decreasing community psychiatric inpatient capacity

• State hospital waiting lists

• Court rulings in September 2005

No wait for transfer of 90/180 ITA patients

Failure to follow proper procedures for assessing “liquidated damages”

• Variable inpatient utilization and lengths of stay

Long lengths of stay in Washington’s state hospitals

Significant disparities in lengths of stay when comparing state hospitals

Significant disparities between RSNs in per capita inpatient utilization

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Washington StateDepartment of Social

& Health Services

Background (cont’d)

Challenges Facing the 2006 Legislature (cont’d)

• Other system challenges Lack of clarity regarding waiver benefits

Idiosyncrasies of Washington’s ITA statute

Observable lack of residential and housing capacity

Goal for standardization & best practice in utilization management

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Washington StateDepartment of Social

& Health Services

Background (cont’d)

DSHS Approach Incorporated in Budget and Legislative Initiatives• Clarified roles of State & RSNs related to community and

state hospital care

• Time limited investment in State Hospital capacity to deal with inpatient access issues

• Investment in enhanced community resources to reduce reliance on state hospitals

• PACT

• Funding for PALS Residents

• By January 2008, requires RSNs to pay for individuals at PALS

• Long term planning

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Washington StateDepartment of Social

& Health Services

Key Provisions (cont’d)

Community Based Care (cont’d)

• Funding for PACT & other Expanded Community Services

Development funds FY 07

Operational Funds FY 08

Contract for Training & TA- WIMIRT

• Long Term Planning – RFP for Consultant Contracts

Benefits Package/ Rates- TRI West

Involuntary Treatment Act- TRI West/ Advocates for Human Potential

Mental Health Housing Plan- Common Ground

External Utilization Review- University of Washington- Harborview

Employment Initiative- WIMIRT (added to STI by MHD)

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Washington StateDepartment of Social

& Health Services

STI Implementation Process• Consultants For Each Project Initiative

• Standing Representative Task Force 35-40 members from variety of interested parties Monthly meetings beginning in Oct 06

• Community Forums- approximately 150 people each November 06, January 07, May 07, and July 07

• Tribal Roundtable and focus groups- Feb - May 2007

• Focus Groups- by consultants as needed

• STI Web Site

• Product- Reports with consultant recommendations to DSHS/MHD for improvements

• Next Step- MHD prioritize recommendations for further development with the Governor and Legislature

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Washington StateDepartment of Social

& Health Services

Benefits Package Update

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Washington StateDepartment of Social

& Health Services

Benefits Package- Access To CareReport FindingsTo receive Medicaid services through an RSN, a person must:

• Have a covered diagnosis (there are two lists- List A & List B)

• Have a functional impairment measured by a standard functioning protocol (GAF for adults, CGAS for children/adolescents)

• If B diagnosis, have additional risk issues

Challenges• Barrier to early intervention for high-risk populations

• Dilutes emphasis on managing higher need cases (long-term case management, day support, residential services)

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Washington StateDepartment of Social

& Health Services

Benefits Package- Access To CareReport Recommendations Prioritized by MHD for Further Development• Conduct a full actuarial analysis of the financial impact of

revising GAF and CGAS minimums for routine outpatient care

• If financially feasible, raise the GAF and CGAS minimums to at least 70 for all covered diagnoses

• Develop statewide standards for continuing care and discharge in order to shift focus from front-end restrictions for all enrollees to proactive care management of services for enrollees with intensive, ongoing needs

Statewide medical necessity standards for all levels of care

Includes criteria for initial and ongoing reviews

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Washington StateDepartment of Social

& Health Services

Benefits Package- ServicesReport Findings• Analysis of Washington’s State Medicaid Plan compared to

AZ, CO, NM and PA WA’s State Plan is very flexible; able to promote wide range of practices CMS is increasingly strict RSNs choose EBPs and develop within current funds

• Major limitations applying EBPs / Promising Practices in “real world”- efficacy in studies does not equal effectiveness and efficiency in financial modeling, practice and cultural relevance

• It does not work to simply mandate Best Practices across the board- systematic promotion of limited EBPs without development of infrastructure (training, monitoring, rates, and time)

• “Centers of Excellence” generally tied to successful statewide promotion of specific services (ACT, Peer Support)

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Washington StateDepartment of Social

& Health Services

Benefits Package- ServicesReport Recommendations Prioritized by MHD

for Further Development• Do not propose any changes to CMS regarding the structure

of the State Plan for Rehabilitative Services • Prioritize the following 3 EBPs for Statewide Implementation

Peer support services provided directly by Consumer and Family Run Organizations

Integrated Dual Disorder Treatment for persons with co-occurring mental health and substance use disorders

Collaborative Care in Primary Care Settings for populations most effectively served by clinicians located in primary care settings (e.g. older adults)

Note- 2 EBPs recommended for children (MTFC & Wraparound) will be considered as part of input process for 1088

• For any EBPs promoted statewide and paid for under Medicaid, conduct a formal actuarial analysis prior to implementation and at the end of each year to determine if RSNs have developed the service

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Washington StateDepartment of Social

& Health Services

Benefits Package- ServicesReport Recommendations Prioritized by MHD

for Further Development (cont’d)

• Primary goals used to prioritize practices for statewide promotion:

Biggest clinical impact (with emphasis on appropriate inpatient utilization)

Promotion of recovery and resilience Promotion of culturally relevant practices and cultural

competence Promotion of consumer/family-driven care Distribution across age groups Widest and most immediate possible impact Potential cost offsets

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Washington StateDepartment of Social

& Health Services

Benefits Package- RecommendationsConsumer/Family Run Services• Washington’s Peer Support modality is very broad and

superior to those of most of the comparison states

• However, requirement that the service must be provided by a CMHA complicates the peer-nature of service delivery by requiring that it take place in a professional setting

• The 1915(b) waiver could allow delivery of this service in other defined consumer and family-run settings similar to those allowed under Arizona community support agency provider type

• While this adds to the administrative burden of provider oversight by the State and RSNs, it also allows delivery of these peer-run services by less costly providers

• Could also facilitate interventions such as drop-in centers, family psychoeducation, and other consumer / family supports

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Washington StateDepartment of Social

& Health Services

Benefits Package-RecommendationsIntegrated Dual Disorders Treatment

• IDDT provides mental health and substance abuse services through one practitioner or treatment team and co-locates all services in a single agency (or team)

• IDDT encompasses 14 components, each of which is evidence-based, including:

Screening and assessments that emphasize “no wrong door”

Stage-wise treatment that recognizes that different services are helpful at different stages of the recovery process

Motivational interviewing and treatment

• IDDT is effective at engaging people with both diagnoses in outpatient services, maintaining continuity of care, reducing hospitalization, decreasing substance abuse, and improving social functioning

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Washington StateDepartment of Social

& Health Services

Benefits Package- RecommendationsCollaborative Care• Collaborative Care is a model of integrating mental health and primary care services in primary care settings in order to:

treat the individual where he or she is most comfortable build on the established relationship of trust between a

doctor and consumer better coordinate mental health and medical care reduce the stigma associated with receiving mental

health services

• Two key principles form the basis of the model: Mental health case managers and professionals are

integrated into primary care settings Psychiatric and licensed clinical consultation and

supervision is available to provide additional mental health expertise where needed

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Washington StateDepartment of Social

& Health Services

Benefits Package- RecommendationsCollaborative Care (cont’d)• Key components include screening, consumer education and

self-management support, mental health specialty referrals as needed, and linkages with other community services

• Multiple studies have documented the effectiveness of collaborative care models to treat anxiety and panic disorders, depression in adults, and depression in older adults

• IMPACT (Improving Mood: Providing Access to Collaborative Treatment for Late Life Depression) is a multi-state Collaborative Care program with study sites in five states, including Washington

• Focus on older adults found 1)Higher satisfaction with depression treatment 2) Reduced prevalence and severity of symptoms, and 3) Complete remission as compared to usual primary care

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Washington StateDepartment of Social

& Health Services

Benefits Package-Other Report Recommendations

• Additional recommendations which MHD will continue to study:

Revise current RSN contract requirements for Statewideness and provide definitive guidance to RSNs on implementation

Develop encounter coding protocols to allow MHD and RSNs to track the provision of other best practices

Develop Centers of Excellence to support the implementation of those best practices prioritized for statewide implementation

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Washington StateDepartment of Social

& Health Services

Housing Plan Update

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Washington StateDepartment of Social

& Health Services

Housing Plan

Report Findings• All RSNs need a range of housing options

Licensed residential facilities Community based housing Crisis respite beds

• Permanent Supportive Housing (PSH) most appropriate for most MH consumers

All RSNs need additional PSH Estimated need for up to additional 5000 units in WA for

people served by the public mental health system Initial goal should be for development of 760 PSH units

for mental health consumers between 2007-2010

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Washington StateDepartment of Social

& Health Services

Housing Plan

Report Findings (cont’d)

• Key elements to successful PSH Implementation Capital financing for new units- approximately 60% of needed

dollars are committed and there are sufficient capital investment dollars available within current state and federal allocations if subsidies & direct care and support services are secured

Rental subsidies (Section VIII wait lists)- 65% of units can be funded through existing sources leaving a gap of 35% (260 units)

Operating subsidies (e.g. landlord incentives, risk mitigation funds)- for excess costs related to renting to mental health consumers based on $1200 per unit per year

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Washington StateDepartment of Social

& Health Services

Housing Plan

Report Findings (cont’d)

• Key elements to successful PSH Implementation Access to on site supportive services

– Case manager caseloads ranging from 1:8-1:20 depending on needs of consumers

– access to 24/7 crisis response from MH provider

– Estimate that 480 of 760 units can be supported by new PACT or programs created related to PALS community funds

– Remainder of services will need to come from either new funds or redirection of current RSN service dollars

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Washington StateDepartment of Social

& Health Services

Housing Plan

Report Recommendations Prioritized by MHD for Further Development• Secure rent subsidies funding for 35% of units that can’t be

funded through existing sources (260 units)

• Secure funding for operating subsidies (e.g. landlord incentives, risk mitigation funds)- for excess costs of renting to consumers

• Identify whether additional funding for PSH services can be met through current allocations or require any new funds

• Promote the creation of PSH at the RSN and local level by providing best practice information on models, partnerships, and financing and funding TA to build capacity

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Washington StateDepartment of Social

& Health Services

Housing Plan

Report Recommendations Prioritized by MHD for Further Development (cont’d)

• Ensure PIHP benefit design includes flexible modality for services in home settings with rate sufficient to cover costs

• Suggest standard to identify number of crisis respite beds needed and identify funding if needed

• Develop a closer working relationship with CTED and consider a joint PSH funding proposal for 2009

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Washington StateDepartment of Social

& Health Services

Housing PlanAdditional recommendations which MHD will

continue to study:• Explore the use of the Charitable, Educational, Penal, and

Reformatory Institutions Trust Fund to support PSH for mental health consumers

• Capitalize on the opportunities offered through the Governor’s Mental Health Transformation Grant to further design and delivery of the landlord incentive package and peer support for PSH

• Collect data at RSN/provider level and publish an annual statewide report on the housing status and tenure of all consumers served in the public mental health system

• Promote the development of an additional 1600 PSH units for mental health consumers between 2010 and 2015 including a plan for securing adequate capital, rental subsidies, operating subsidies, and services

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Washington StateDepartment of Social

& Health Services

Wrap Up

For further information on STI:

http://www1.dshs.wa.gov/Mentalhealth/STI.shtml

Andy ToulonDSHS Health and Recovery Services AdministrationMental Health Division(360) 902-0818touloan@dshs.wa.gov