KEY ISSUES UPDATE: Supports for PERSONS WITH DEVELOPMENTAL DISABILITIES

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KEY ISSUES UPDATESupports for PERSONS WITH
DEVELOPMENTAL DISABILITIES

• Arc Michigan State Conference
• June 19, 2009
• Michael J. Head, Director
• Mental Health Substance Abuse Administration
• Michigan Department of Community Health

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FY 09 Budget Executive Order

• Michigan is changing to a smaller, less wealthy
  state
• Estimated 2008 population (just over 10 million)
  46,000 less than 2007
• Michigans 2008 net migration to other states
  (1.1) was nations highest
• 850,000 jobs lost between June 2000 and December
  2009
• FY 10 GF/GP revenue expected to be about 2.85
  billion less than FY 2000
• Auto industry in crisis
• To help eliminate a shortfall in the 2009 state
  budget, the Governor issued an Executive Order
  May 5.
• Reduces spending by nearly 350 million
• 304 million in general fund savings
• There will be a shutdown of most state government
  operations for six days between now and Sept. 30

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FY 09 Budget Executive Order

• Total MDCH EO reductions 104.4 million
  effective in 4th quarter
• 4 Medicaid Provider Rate Reduction will save
  nearly 44.4 million
• Elimination of Select Optional Medicaid Services
  for Adults will save close to 9.5 M
• Community Mental Health non-Medicaid reduced by
  10 million
• Public health prevention programs will be cut by
  roughly 3.8 M
• Reduced funding to Michigans 45 local health
  departments to save 1.5 million
• Impact of 10 M GF cut in CMH Non-Medicaid
  funding
• Service capacity loss At average cost/case of
  4,800 results in over 2100 individuals not being
  served
• Affects those not eligible for Medicaid (i.e.
  Adults with MI)
• Reduces capacity for respite services for
  families with minor children
• If 10M is annualized to 40M reduction, this
  would represents the total combined annual
  funding of the 26 smallest CMHSPs.
• GF is 20 of all CMHSP system funding CMH
  Medicaid is as yet untouched

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FY 10 BudgetExecutive Recommendation

• Governors FY 10 Executive Budget proposes 670
  million in ongoing spending reductions across
  all departments
• DCH budget recommends total funding of 13
  billion, of which 2.8 billion is GF
• Proposes 106 million in general fund savings to
  help address Michigans structural deficit
• Mays Consensus Revenue Estimating Conference
  puts FY 10 general fund revenues at 6.95 billion
• Michigan is facing a 1.7 billion budget
  shortfall
• Central question Should there be revenue
  augmentation to reduce cuts?
• Senate Subcommittee action expands proposed 40 M
  GF (non-Medicaid) reduction to 62M (20 of
  current GF non-Medicaid funding)
• Proposes to send funds only to PIHPs requires
  equity funding
• Senate Subcommittee would make PIHPs at-risk for
  costs of Medicaid-paid anti-psychotic medications
• Medicaid funding left untouched
• Conference Committee action expected to be
  delayed

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CULTURE OF GENTLENESS

• Our goal Take action to induce and promote
  system-wide change of the public MH systems
  culture, so as to improve support for people with
  reputations to succeed as citizens
• Leadership orientation seminars - participation
  is encouraging
• Michigan Center for Positive Community Supports
• Change our culture From using force and
  containment to control those with problem
  behavior, to one which supports the person to
  heal and grow in safety and with affection
• It is clear We have so very far to go to
  achieve this
• Gentle teaching is a start
• So is a careful re-examination to evolve
  person-centered systems of support
• Individualized, tailored support models instead
  of group containment models
• Shifting power through methods involving consumer
  self-determination can and do work

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CULTURE OF GENTLENESS

• Additional overview sessions in August and
  September for
• providers, 3 CMH directors DHS licensing staff
• Arc members welcome
• More intensive sessions designed for CMHSPs and
  providers supporting MPC discharges are being
  scheduled regionally
• Michigan Center for Positive Living Supports

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Mt. Pleasant Center Closure

• Approximately 50 people left
• aim to transition at least 20 more out before
  facility closes
• Caro Center is developing ICF/MR units
• People moving to Caro will be aggressively
  supported for transition to community
• Gentle teaching base
• Central Michigan CMH has stepped up to offer
  opportunities in its service area.
• Some MPC staff are moving along with residents
• Continuous monitoring of transitioned individuals
  through DDI
• Tracking indicates mostly successful transition
  experiences
• Monitoring has resulted in provider changes in a
  few situations
• Enhanced waiver rate for MPC transitions
• Many CMHSPs skeptical they and their providers
  lack experience
• Safety Net plan

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Safety Net Plan

• Michigan Center for Positive Living Supports
• Operated through MORC
• Provides
• Intensive training
• Crisis Line (for triaging challenging situations)
• Mobile Crisis Response
• Crisis Assessment unit on temporary basis
• Over time, aim is to build provider capacity
• Already, some CMHSPs are availing themselves of
  training in Gentle Teaching through the Center
• More Centers? Depends on demand and budget
• Goal is to assure capacity in each PIHP area
• CMHSPs committed to idea change is slow

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CHANGING FROM FORCE AND CONTROL

• Technical Requirement for Behavior Treatment Plan
  Review Committees
• Contract requirement beginning in October 2008
• Bans physical management as part of a plan use
  is limited to crisis resolution
• Requires each incident where physical management
  used to be analyzed for quality improvement
  response
• Prohibits the use of prone restraint methods
• Department is having dialogs with Committees to
  assure they understand what kinds of
  interventions they should be promoting and those
  they should be denying
• Examining how to address over-medication issues

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ADDRESSING USE OF LARGE RESIDENTIAL SETTINGS

• MDCH Use of large residential settings is
  inappropriate for care of those with complex
  needs
• Little difference between a 12-bed ICF/MR state
  facility unit a 12-bed group home
• Local priority has been cost control ahead of
  life enhancement
• Initial steps Develop CMHSP awareness and
  establish data baseline
• Approximately 4 of individuals with DD served
  live in settings of 7 or more beds
• range across CMHSPs is 21 to 0 of DD service
  recipients living in large settings
• A little less than half of the CMHSPs are using
  very large facilities (more than 12 beds) for
  more than 10 of their people
• Action Plan
• MDCH will be following up with CMHSPs to find out
  why so many people are in these facilities, and
  what is the plan to move them out
• Monitor the appropriateness of care and the use
  of aversive, restrictive or intrusive
  interventions for control of behaviors
• Closer communication with DHS AFC licensing

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SELF-DETERMINATION

• Rekindling the expectations stated in the
  Self-Determination Policy Practice Guideline
• CMHSPs report approximately 3400 individuals who
  have an individual budget manage services
• Capacities and understandings vary widely
• TA will be developed based upon PPG responses
• CMHSP mentality is difficult to change
• Issued the Choice Voucher Technical Advisory
• Guidance for supporting consumers to directly
  hire their providers
• Technical assistance for finance and contract
  managers
• Aim is to expand consumer ally understanding
• Everything You Need To Know About
  Self-Determination
• Partners for Freedom
• Building into the 1915(b) Waiver renewal
• New covered service, Goods Services will
  allow option for redirection of savings in an
  individual budget to life-enhancing options
• Far to go

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APPLICATION FOR RENEWAL RECOMMITMENT

• The Application for Renewal Recommitment (ARR)
  was issued on February 9 to the 18 Prepaid
  Inpatient Health Plans (PIHPs)
• Responses received back by June 1
• Stakeholder involvement was expected to be
  central
• Responses should guide the PIHP in improving the
  quality of its programs and services in specified
  areas
• PPGs issued at the same time, to CMHSPs
• Overlap with several ARR focal areas
• Responses were provided in April
• PPG information developed by each CMHSP is needed
  for the PIHP to develop its ARR response
• Both documents are available via a link on the
  MDCH home page
• http//www.michigan.gov/mdch

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ARR

• The ARR asks PIHPs to assess the status of their
  performance outlined in the Concept Paper,
  Focusing a Partnership for Renewal
  Recommitment to Quality Community in the
  Michigan Public Mental Health System
• MDCH expects each PIHP to identify pathways for
  improving performance in each of the 11 Sections
• The ARR is grounded in continuous quality
  improvement
• it seeks performance improvement but does not aim
  for uniform compliance as such
• The quality improvement processes for each area
  must involve stakeholders, especially persons
  using services, their family members and local
  advocates

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ARR

• Completing the ARR involves specifying essential
  goals and determining methods to achieve them,
  starting with current reality in the PIHP system
• The ARR asks each PIHP to identify milestones
  of achievement that will mark performance
  improvement toward those goals
• Throughout, the PIHP process will be monitored
  and managed via a partnership between the PIHP
  and the Department

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ARR OVERVIEW

• Partnering with Stakeholders in the Design,
  Delivery, and Evaluation of the Public Mental
  Health System
• Improving the Culture of Systems of Care
• Assuring Active Engagement
• Supporting Maximum Consumer Choice and Control
• Expanding Opportunity for Integrated Employment
• Assuring Opportunity for Needed Treatment for
  People in the Criminal Justice System
• Assessing Needs and Managing Demand
• Coordinating and Managing Care
• Improving the Quality of Supports and Services
• Developing and Maintaining a Competent Workforce
• Achieving Administrative Efficiencies

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ARR PLANS

• Each topic area begins with an Environmental
  Scan
• Scan is expected to incorporate data, information
  and feedback from stakeholders based upon their
  experiences
• Plans specify milestones
• Milestones denote opportunities for improvement
  
• Achieving milestones is expected to be
  sequential, building upon previous work over a
  period of years
• Implementing plans
• MDCH expects that at least some steps toward
  accomplishing plans will commence June 1, 2009
• By October 1, 2009 all plans to be in
  implementation phase
• Each PIHP plan of improvement will be part of
  performance monitoring in FY10 beyond

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ARR STAKEHOLDER INVOLVEMENT

• Key to all of the ARR activity is the expectation
  that individuals who receive services, their
  families, and advocates will be significantly
  involved
• in environmental scans,
• In Quality Improvement Plan development
• In implementation activities
• In ongoing evaluation of accomplishment of
  improvement plans
• We also expect that PIHPs will invite providers
  and other community representatives to be
  involved in this effort
• Because it is so central to the philosophy
  underlying the ARR, the initial section
  specifically requires that the pathway to
  expanding the involvement of consumer, family
  and advocate stakeholders in design,
  implementation and evaluation of performance be
  itself a key area of performance improvement.