Reform of the Mental Health, Developmental Disabilities and Substance Abuse Service System

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Reform of the Mental Health, Developmental
Disabilities and Substance Abuse Service System

• February, 2005

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Federal Pressures for Reform

• Olmstead vs. LC (6/22/1999)
• Court found that Georgias refusal to provide
  community living opportunities for individuals
  with disabilities constituted discrimination
  under the Americans with Disabilities Act.
• Executive Order 13217 (6/18/2001)
• The Presidents New Freedom Commission on Mental
  Health (7/2003)
• SAMHSA Action Agenda

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State Pressures for Reform

• State Studies and Audits
• Statewide Government Performance Audit (1995)
• MGT America (1997) study of state psychiatric
  hospitals
• PCG for the Office of the State Auditor (1998)
  study of state psychiatric hospitals and overall
  structure of mh/dd/sa system
• All studies/audits cited over-reliance on old,
  costly institution too few community based
  alternatives fragmented system
• Consumer and Advocacy Concerns
• Local government officials concerns lack of
  accountability

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HB 381 - An Act to Phase In Implementation of
Mental Health System Reform (10/15/01)

• Addressed issues of State and local governance
• Increased accountability
• Emphasized community-based services that are
  consumer driven and best practice
• Shifted the role of local public MH/DD/SAS
  agencies from direct service providers to
  managing and coordinating services
• Five year phase in beginning July 1, 2002
  proposed completion by 2007

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DHHS Requirements

• Develop a State Business Plan to address
• Increased participation by consumers and families
• Identification and Implementation of Target
  Populations
• Utilization of State facilities
• Better access to service
• Reduce of area authorities to ensure economies
  of scale and scope minimum population base of
  200,000 goal of 20 programs
• Outline requirements for Local Business Plans
  (LBP), approve LBPs, increase oversight of
  Area/County Programs
• Reorganize Division of MHDDSA

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Local Requirements

• Area Programs to transition from being deliverer
  of services to Local Management Entity (LME)
• Each county must determine governance structure
  Area Authority, County Program, Interlocal
  agreement
• Prepare a Local Business Plan
• Input from consumers families, local
  governmental leaders, public agencies
• Assess gaps in service delivery
• Emphasis on Consumer choice
• Address Utilization of State facilities

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Accomplishments to Date - State

• Developed State Plan for MH/DD/SA services
  updated annually
• Identified Target Populations
• Outlined Local Business Plan requirements
• Reorganized Division
• Changed mechanism for funding local programs to
  reflect reformed system
• Developed performance-based contract between DHHS
  and each LME
• Created State Consumer and Family Advisory
  Committee (CFAC)
• Redesigned community service array
• Moved 402 consumers from state psychiatric
  hospitals to community and closed those beds

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Accomplishments to Date - Local

• Developed Local Business Plans
• LBPs have been approved for all programs except
  those working on mergers (Rockingham,
  Lee-Harnett, RiverStone, Tideland,
  Roanoke-Chowan, Edgecombe-Nash, Wilson-Greene)
• Established local CFACs
• Divesting of services, recruiting providers
• Developing 24/7/365 access and screening capacity
• Completed mergers to increase efficiency and
  economies of scale (Western Highlands,
  Eastpointe, Sandhills/Randolph)
• Implementing LME structure

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State Plan Principles

• Participant driven
• Community based
• Prevention focus
• Recovery outcome oriented
• Reflect best treatment/support practices
• Cost effective

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Service Philosophy

• Consumers may enter services through a uniform
  portal - no wrong door
• Consumers most in need (target populations and
  Medicaid based upon medical necessity) will
  receive Enhanced package
• Service descriptions and consumer eligibility are
  based on national models established through
  research.
• Primary provider responsible for crisis services

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Changes in the Service Array

• Revised services available to reflect
  evidence-based best practices and emerging best
  and promising practices paying for what works
• Evidence based best practices documented to be
  effective in at least three controlled clinical
  trials
• Examples of evidence-based best practices
• ACT Team, medication management, supported
  employment, multi-systemic therapy, functional
  family therapy
• MH/SA Services designed to expand use of the
  Medicaid Rehabilitation option and reflect a
  recovery approach to mental illness and substance
  abuse

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Enhanced Services

• Service descriptions and consumer eligibility are
  based on national models established through
  research.
• All services include trigger points at which
  utilization review occurs opportunity to assess
  effectiveness of treatment.
• Model fidelity key to EBPs right service in
  the right amount for the right person.
• All Enhanced Services approved through a Person
  Centered Plan

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Person Centered Plan

• Consumer chooses provider agency
• Planning involves consumer, family, and other
  important individuals in consumers life. For
  children, includes the Child and Family Team.
• Plan focuses on consumers strengths and
  weaknesses, goals and objectives prioritized by
  consumer and family, includes crisis emergency
  contingency plans.

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• PCP outlines the paid services necessary for the
  consumer, but also includes information on
  natural and community supports that will be
  combined with paid clinical and skill building
  interventions to achieve goals and objectives.
• PCPs approved by LMEs and reviewed at least
  annually.

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Implementation New Service Array

• Plan to implement new array and new waiver
  services for CAP/MRDD 7/1/2005
• Services that are not consistent with the state
  plan mission to support recovery and self
  determination or are duplicative or ineffective
  are eliminated.
• Other services are under study or revision to
  ensure that they reflect best practices and
  adhere to State Plan and consumer empowerment,
  recovery/outcome orientation

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Timeframe Rehab Option Services

• DHHS has walked through new MH/SA service array
  with variety of stakeholders consumers and
  families, providers, LMEs, members of childrens
  Collaboratives
• New service definitions have been thoroughly
  reviewed by the MH subcommittee of the Physicians
  Advisory Group (PAG).
• State Plan Amendment being developed for
  submission to CMS. DMA will post for 45 day
  public comment at time SPA submitted.
• DMA DMHDDSAS staff have worked with providers
  to assess adequacy of proposed rates. Rates
  modified accordingly.
• Target implementation date July 1, 2005

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CAP/MRDD Waiver

• State, consumers and families and providers have
  identified problems with current CAP/MRDD waiver
• Individual limitation on services - 86,058
  (hinders MRC downsizing efforts)
• Current definitions allow too much stacking of
  services
• No standardized utilization review procedures or
  protocols
• Annual cost limitations on vehicle and home
  modifications problematic
• Overly cumbersome and bureaucratic. DMH/DD/SAS
  has tried to address weaknesses in actual waiver
  through a very complicated CAP/MRDD Manual.

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Replacement Comprehensive Waiver

• New comprehensive 1915 (c) waiver has been
  submitted to CMS for approval
• Service definitions streamlined and simplified.
• Providers working with Division to write manual
• Finalized after significant input from parents,
  advocates, providers
• Providers have reviewed and commented upon rates
  and rates have been modified accordingly - Final
  rates will be published next week
• Target implementation date July 1, 2005

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Implementation - LME

• Change from Area Program as service provider to
  Local Management Entity
• LME functions
• General Administration Governance
• Business Management Accounting
• Billing
• Information Management Analysis
• Provider Relations Support
• Access Line, Screening, Triage, and Referral
• Service Management
• Consumer Affairs and Consumer Satisfaction
• Quality Improvement Outcomes Evaluation

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Provider Relations

• Recruitment of providers identifying gaps in
  existing provider community and soliciting
  providers.
• Provider contracting.
• Provider monitoring to ensure health and safety
  of consumers and model fidelity to services
  delivered.
• Endorsement of providers to enroll in Medicaid
  program.
• Process complaints/appeals from providers.
• On-going technical assistance to providers.

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LME Provider Monitoring and Quality Assurance

• SB 163 requires LMEs to monitor all MH/DD/SA
  providers in catchment area for health and safety
  of consumers.
• DMH/DD/SAS, DMA, and LMEs will develop provider
  quality measures. LMEs will produce provider
  report cards based upon these quality measures
  to compare providers and offer consumers
  informed choice of providers.

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LME Role in Provider Enrollment

• Independent Practitioners, hospitals and ICFs/MR
  may enroll directly with Medicaid without LME
  endorsement.
• All other providers of MH/DD/SA services
  (enhanced benefit providers, CAP/MRDD providers)
  will be endorsed by the LME in order to enroll
  in Medicaid program.
• Requirements for endorsement
• Standardized agreement with LME covering issues
  such as assurance of model fidelity, staffing
  requirements, continuity of care, cooperation
  with primary care providers, accreditation,
  licensure, credentialing processes, etc.
• Will enter into agreement with the LME in each
  catchment area in which provider offers services.
• Must receive endorsement for each physical
  location and each service provided.
• DMA participation agreement provides for
  cancellation of Medicaid enrollment if LME
  removes endorsement for cause.

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Access Line, Screening, Triage and Referral

• Access to services must be available 24/7/365
• Trained clinician who can assess situation to
  determine emergencies and routine requests.
• In other than emergencies, if screening indicates
  need for service, LME offers choice of provider,
  makes first appointment and authorizes care

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Service Management

• Review and approval of Person Centered Plans
• Utilization Review for all DMH/DD/SAS funded
  services and CAP/MRDD waiver services
• Utilization Review for Medicaid funded MH/DD/SA
  services upon demonstration of ability to conform
  to statewide requirements
• Community collaboration
• Care coordination

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LME Role in PCP

• LME reviews and ultimately approves PCP. Approved
  PCP becomes basis for authorizing services.
• Does plan reflect involvement of consumer, family
  and other significant individuals?
• Do services and supports included in plan make
  sense given consumers diagnosis and declared
  goals and objectives?
• Do quantity and frequency of paid services and
  supports appear reasonable?
• Is there evidence that consumer has been given a
  choice of provider for services not offered by
  primary provider?
• Have natural and community supports been included
  in plan?

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LMEs Role in UR

• LMEs responsible for all UR of DMH/DD/SAS funded
  services and CAP/MRDD waiver services.
• UR for Medicaid State Plan services requires
  statewide consistency.
• DMA, with input from DMH/DD/SAS, developed RFP
  for all State Plan MH/DD/SA services.
• DMA, DMH/DD/SAS and representatives of the NC
  Council of Community Programs will use RFP as
  basis to determine policies, procedures, and
  processes that LMEs must follow to be authorized
  to provide UR function for Medicaid services.
• DMA and DMH/DD/SAS will conduct readiness
  reviews of LMEs on an annual basis.
• LMEs deemed ready will be authorized to provide
  UR.

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Consumer Affairs

• Each LME must have designated Consumer Affairs
  staff
• Handle complaints
• Gauge consumer satisfaction with services
  rendered
• Guide consumers through the system
• Support CFAC

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Status of Psychiatric Hospital Downsizing

• DMH/DD/SAS planned for 486 beds to be closed from
  SFY 2001 to SFY 2004.
• As of June 30, 2004 we have actually closed 402
  beds.
• Over 7.7 million in Mental Health Trust Funds
  have been allocated to LMEs to build community
  capacity for psychiatric services before the
  closure of state hospital beds.
• Through SFY 2004, more than 15.3 million in
  recurring funds have been transferred from the
  state hospitals budgets to the LMEs to fund
  community mental health services.

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Status of Downsizing of State Mental Retardation
Centers

• Average Daily Census declined 5.28 from 2000 to
  2003 from 2,006 residents in 2000 to 1,900 in
  2003
• Downsizing efforts have not been very successful
  to-date.
• DMH/DD/SAS has issued a Request for Information
  to solicit ideas for how to accelerate downsizing
  efforts on a more regional basis.
• State has greater purchasing power, therefore,
  may solicit increased provider interest.
• Based upon information received, DMH/DD/SAS will
  connect interested providers with LMEs.

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Questions?