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Strategies to Promote SelfDetermination

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Title: Strategies to Promote SelfDetermination


1
Strategies to Promote Self-Determination
  • NYAPRS Annual Conference
  • September 24, 2008
  • Richard Dougherty, DMA Health Strategies
  • Michael Hlebechuk, Oregon Dept of Human Services
  • Bonni Hopkins, Magellan Health Services
  • Harvey Rosenthal, NYAPRS
  • John Allen, NYS Office of Mental Health

2
Self-Directed Care Definitions
  • A system that is intended to allow informed
    consumers to assess their own needs . . .
    determine how and by whom these needs should be
    met, and monitor the quality of services they
    receive (Dougherty, SAMHSA, 2003).
  • A system in which funds that would ordinarily be
    paid to service provider agencies are transferred
    to consumers, using various formulas to account
    for direct, administrative, and other costs
    (Cook et al., 2004).
  • a method of delivering services that is based on
    giving each consumer control of an individual
    budget with which to purchase goods and services
    to meet his or her needs (Alakeson, HHS, 2007).

3
Essential Elements of Self-Directed Care Systems
  • Person-centered planning, which constitutes a
    comprehensive strategy for putting necessary
    services and supports in place to help people
    achieve their goals
  • Individual budgeting, which enables people
    needing assistance to have some control over how
    the funds used for their care are to be spent

4
Essential Elements of Self-Directed Care Systems
  • Financial management services, which encompass
    such activities as tracking and monitoring
    budgets, performing payroll services, and
    handling billing and documentation
  • Supports brokerage, which includes both education
    and operational assistance, and is intended to
    help participants design and manage their
    self-directed care plans.

5
Self-Direction is a Method for Promoting
Self-Determination
  • Self-determination is a philosophy designed to
    help persons build meaningful lives with
    effective opportunities to develop and reach
    valued life goals
  • It focuses on the degree to which human
    behaviors are volitional . . . that is, the
    extent to which people . . . engage in their
    actions with a full sense of choice (Cook et
    al., 2004).

6
5 Principles of Self-Determination (Nerney 2001)
  • Freedom to choose a meaningful life in the
    community
  • Authority over the funds needed for ones own
    care
  • Support for participants efforts to make the
    choices that are best for them
  • Responsibility for managing finances, choosing
    services, and handling the tasks of daily living,
    and for the appropriate use of public funds and
  • Confirmation or Participation, that is, the
    opportunity for service recipients to participate
    in decision making about the care delivery
    system.

7
Key Values
  • Freedom of choice
  • Control over ones own life
  • Personal responsibility
  • Access to services and support
  • Consumer satisfaction and service quality
  • Efficiency and effectiveness
  • Cost effectiveness Protection of civil liberties
  • Fairness
  • Freedom from coercion
  • Use of free market forces

8
Operational Elements of a Self-Directed System of
Care
  • Person-centered planning
  • Individual budgeting
  • Consumer and provider education
  • Advocacy and coaching
  • Expanded provider network
  • Financial management
  • Oversight/quality improvement
  • Funding sources

9
2007 HHS Report Overview
  • There are currently five states with
    self-directed care pilots or established programs
    for adults with serious mental illness Florida,
    Iowa, Maryland, Michigan and Oregon, with a pilot
    under development in Texas.
  • These programs are in the early stages of
    development and currently serve a very small
    number of consumers.

10
2007 HHS Report Overview
  • The most important difference between programs
    across states is the scope of self-direction
    permitted.
  • Major Variables
  • the extent to which consumers are able to direct
    services provided by the traditional mental
    health system as well as recovery support
    services and
  • the extent to which individual budgets are
    separate from Medicaid funding or whether
    consumers have control over the way in which
    Medicaid resources are used.

11
Funding Sources for State SDC Initiatives
12
2007 HHS Report OverviewChief Spending Categories
  • Florida District 8
  • medication (16)
  • transportation (13)
  • psychiatric services (12)
  • counseling (8)
  • Multnomah County, Oregon
  • household items (15)
  • alternative therapies (14)
  • IT supplies (12)
  • goods and services relating to personal
    appearance (10)

13
2007 HHS Report OverviewSDC Funds As Last
Resort
  • In all states, consumers are encouraged to
    maximize the value of the money they have at
    their disposal by drawing on resources from other
    pubic programs and from the community and only
    using their individual budget as a last resort.
  • For example, if an individual requires
    transportation and can receive a bus pass through
    vocational rehabilitation, his self-directed
    budget should not be used.
  • One of the important roles that counselors play
    is to knit together the disparate parts of the
    public system for consumers and help them access
    the full range of available resources.

14
The Traditional Mental Health System
  • Assumes that clients are not able to make choices
    that are in their own best interest much of the
    time.
  • Believes it is often necessary to make decisions
    for clients.
  • Stresses client safety far more than client
    choice.
  • This results in the client growing dependent on
    the system to make life decisions. (Decreased
    client choice means increased client dependence.)

15
A Transformed System that Promotes Recovery
Through Self-Determination
  • Believes that people can and do recover from
    mental illness.
  • Helps facilitate recovery by providing
    self-directed services and supports.
  • Treatment in this system is centered around the
    goals of the person what is important to the
    person.
  • Safety issues are addressed in a collaborative
    relationship between the individual and the
    provider of services and supports.
  • Individuals are allowed to make, and grow from,
    their own mistakes.

16
Products of the Transformed System
  • People move toward recovery and become
    increasingly self-reliant.
  • As people recover they use fewer services.
  • It is a win-win proposition. Service dollars are
    saved. Far more importantly, people move on with
    their lives.
  • Individuals gain far higher levels of dignity and
    self-respect greater self-esteem.

17
Empowerment Initiatives Brokerage Oregon (EIB)
  • A project of Oregons FY 2001 Real Choice Systems
    Change grant awarded to Oregon Department of
    Human Services by Centers for Medicare Medicaid
    Services.
  • MH consumer operated and controlled. All board
    and staff members are consumer/survivors.
  • Serving 25 individuals referred by 2 Portland MH
    agencies.
  • These individuals continue receiving services
    from referring agency.

18
Oregon FY 2001 Real Choice Self-Direction
Projects
  • Person Centered Planning demonstrations in 4
    Oregon counties
  • Employment for Life project
  • Empowerment Initiatives Brokerage

19
What Weve LearnedAbout Person Centered Planning
  • The person centered planning (PCP) approach was
    central to the success of the Employment for Life
    project and Empowerment Initiatives Brokerage.
  • The 4 PCP pilots were largely unsuccessful. In
    many cases, the plans were written by case
    managers with the assistance of the person,
    rather than the other way around. These plans
    reflected the case managers goals for the person
    more than what is important to the person.

20
Analysis
  • Employment for Life and Empowerment Initiatives
    operate from the self-determination and recovery
    perspective. The 4 PCP pilots used traditional
    case management services that do not operate from
    the self-determination and recovery perspective.
  • A culture change that embraces self-direction
    and recovery in mental health treatment is
    needed. The use of Person Centered Planning,
    in-of-itself, is not enough to bring this change
    about.

21
How the Oregon Brokerage Works
  • Using a person centered planning approach the
    customer and the broker write a goal attainment
    plan that will help the individuals goals be
    attained.
  • An individual customer account is established to
    purchase services and supports on behalf of the
    customer. EIB customers have a 3,000 account.
  • Donated and naturally existing resources,
    services and supports are brokered as much as
    possible.

22
Oregon Goal Attainment Plans
  • Written by customer and broker through a person
    centered planning process.
  • Brokered services and supports are obtained
    through the implementation of this plan using the
    individual customer account.
  • Two examples (next 2 slides)
  • 1) Goal obtaining employment
  • 2) Goal being discharged from state hospital
    with suitable services and supports.

23
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24
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25
What Empowerment Initiatives Customers are Saying
  • I think the brokerage is a great program. They
    have helped me get back to school (They)
    encourage me to find my place in the world. They
    also made me feel like I can have a real life.
  • Independence - I was able to purchase my own
    manufactured home in a very low space rent park
    in the country and I am so very happy out here.
  • Today I feel like have options to help me get
    back on my feet again.
  • I am beginning to do things I have always
    dreamed of. I have new perspective because of
    it.
  • Yes I was able to attend community college. I
    was able to end last semester with a 3.5 GPA.

26
Some Findings From EIB Pilot Study
  • EIB customers are moving toward employment in
    response to brokered self-directed services and
    supports.
  • Employment (competitive) increased to 300 of
    baseline.
  • Education leading to employment increased to 600
    of baseline.
  • None of the participants were hospitalized or
    otherwise incarcerated during the project.
  • Surveys indicate that EIB customers are more
    engaged in their recovery.

27
Savings in Clackamas County2007 HHS Report
Excerpt
  • It costs the county between 40,000 and 60,000 a
    year to house an individual with a serious mental
    health condition in a group home.
  • For 10,000 per person per year, EI has
    successfully helped 14 people since June 2006 to
    move into supported independent housing. This
    figure includes the value of the individual
    budget, the costs of a resource broker and the
    administrative costs of the program.
  • The housing itself is paid for by the individual
    and by rent subsidies but is not funded by mental
    health services.
  • Freeing up places in group homes has allowed the
    county to move people out of the state mental
    hospital, saving in the region of 70,000-80,000
    per person per year.

28
EIB Community Development Project
  • Contracted with State Addictions Mental Health
    to transition 13 individuals from structured
    group home settings to supported housing with
    self-directed wrap-around supports.
  • Project was successful, allowing 13 individuals
    to be discharged from Oregon State Hospital into
    the openings at group homes created by the
    individuals who transitioned to more integrated
    community settings.

29
Transformation V Transition
  • Incremental systemic transition tends to not
    bring about system transformation. Incremental
    change generally takes years and usually results
    in a modified version of what currently exists.
  • Successful system-wide transformation requires
    extensive planning, technical know-how,
    dedication, and sustained commitment.
  • Responsible transformation requires that the
    various elements that compose the desired
    transformed system have been demonstrated to be
    beneficial for the persons receiving MH services.

30
Demonstrations and PilotsThings to Consider
  • Until a a systemic transformation to a
    self-directed care service delivery system is
    embarked upon, working collaboratively with
    existing providers of case management services
    will help avoid an us against them climate. For
    example, EIBs customers were referred by
    provider agencies and continued to receive
    services from referring agencies.
  • Collect qualitative and quantitative evidence
    that captures changes in customer self-esteem,
    employment and education status, living
    situation, AD recovery, and service utilization.

31
Oregon Contact Information
  • Michael Hlebechuk
  • Department of Human Services
  • Addictions and Mental Health Division
  • 500 Summer St NE, E-86
  • Salem, Oregon 97301
  • Ph. 503.947.5536
  • Email. michael.hlebechuk_at_state.or.us

32
Floridas Self Directed Care Program
  • The FloridaSDC program gives each participant
    control of the public financial resources to
    access mental health services that are normally
    directly contracted to a public community mental
    health provider.
  • FloridaSDC participants can use their budgets
    to purchase Clinical Recovery Services, Recovery
    Support Services, and Recovery Enhancements.

33
Clinical Recovery Services
  • Clinical Recovery Services are traditional
    mental health services.
  • For individuals who receive Medicaid these
    services are paid for through that system.
  • Medicaid recipients receive only 52 of the SDC
    allotment. These funds can be used for
    non-Medicaid services and supports.

34
Recovery Support Services
  • Recovery Support Services are services that are
    alternatives to traditional mental health
    services but likely to produce the same outcomes.
  • Example Instead of attending a psychotherapy
    group for depression at a local mental health
    professionals office, an individual might choose
    to participate in a Weight Watchers meeting.
    The outcomes might be similar but the cost and
    experience are different.

35
Recovery Enhancements
  • Recovery enhancements are tangible items or
    services that relate to the individuals recovery
    as they work towards the goal of employment or
    other productive activity such as volunteer work,
    training or education.
  • Participants must take responsibility to see
    that other sources of funding are explored prior
    to requesting FloridaSDC funds for the purchase.

36
The Funds
  • Funding for District 8 Participants Annually
  • Indigent 3,700.00
  • Medicaid/VA Eligible 1,924.00
  • Medicare Eligible 2,811.00
  • Indigent participants must allocate 48 of the
    total amount awarded for the purchase of clinical
    recovery services. Medicare participants must
    allocate 31.58 of the total amount awarded for
    those same services.

37
Profile of Individuals Served and Program Cost
  • Approximately 60 of the people in the SDC
    program receive Medicaid, Medicare or VA
    benefits.
  • The total cost of a Self-Directed Care program
    serving 200 adults, as it is now operated, is
    approximately 930,000.

38
Who is Eligible for SDC?
  • An individual who is age 18 or older and who has
    a diagnosis or diagnostic impression of an Axis 1
    or Axis 2 mental disorder AND
  • Receives supplemental security income (SSI),
    social security disability income (SSDI),
    disabled veterans income or any other type of
    disability income. OR
  • Does not receive disability income, but has an
    application in process or has received such
    income within the last 5 years AND
  • Is legally competent to direct his or her own
    affairs AND
  • Lives in the departments district in which the
    program they participate in is located AND
  • Applies for Medicaid and other income support
    programs for which he or she may qualify.

39
Who is Eligible for SDC?
  • People at all levels of recovery are eligible
    for SDC.
  • The ability to complete a Life Analysis and
    develop a Life Action plan and budget, with the
    assistance of a Life Coach, is the primary
    qualification.

40
The Process
  • Eligibility
  • Orientation
  • Enrollment
  • Life Analysis
  • Life Action Plan
  • Budget
  • Receive Services Supports
  • New Life Action Plans Budgets Quarterly

41
The Life Analysis
  • The Life Analysis is a tool that helps an
    individual plan their life activities and to
    determine how to get where they want to be in
    life.
  • The Analysis is similar to an assessment that a
    mental health professional would do in
    traditional services.
  • In the Life Analysis, the person
  • Looks at their life.
  • Assesses the state of their personal health,
    recovery from mental illness and symptom
    management skills, substance use as they relate
    to their health, and at their level of meaningful
    activity, including work.
  • Identifies their goals.


42
The Life Action Plan
  • The Life Action Plan is where a persons goals
    are translated into a plan for specific actions
    related to achieving those goals.
  • In this way, expected expenditures can be
    related directly to the recovery goals identified
    in the Life Analysis. It is a requirement of the
    program that all such expenditures are targeted
    to address these goals.
  • The Life Action Plan is similar to a treatment
    plan that would be developed in partnership with
    a mental health professional in traditional
    services.
  • In Self-Directed Care the person is their own
    Case Manager.

43
The Life/Recovery Coaches
  • Life Coaches orient the individual to the
    process involved in the program, provide referral
    information, advocate for the participants and
    promote self-advocacy, and help them to explore
    their personal recovery goals and to prioritize
    and plan for the use of their budgets.
  • Life Coaches help broaden a persons world view.

44
Program Supervision
  • The SDC program is supervised by a Masters level
    mental health professional.
  • It is their responsibility to assure that each
    individuals budgeted expenses match up with the
    recovery goals identified in their Life Analysis
    and Action Plan and to approve each plan and
    budget.
  • The program supervisor takes responsibility for
    the day to day operations of the program.

45
Participant Expenditures District 8
  • Food 20
  • Auto Insurance 14
  • Arts Craft Supplies 14
  • Computer Supplies 13
  • Utilities 13
  • Social Club 12
  • Computer 10
  • Haircut 10
  • Phone 9
  • Furniture 9
  • Software 8
  • Medicine 181
  • Psychiatrist 121
  • Transportation 87
  • Dental 74
  • Counseling 72
  • Clothing 61
  • Rent 49
  • Vision 39
  • Health Club 32
  • Car repair 30
  • School 22

46
Evaluating Success
  • The Self-Directed Care program is evaluated on
    several levels. The purpose of the evaluation is
    to assess the performance of the SDC program for
    adults with severe and persistent mental illness,
    as compared to the performance of other
    outpatient mental health treatment programs in
    Floridas public mental health system.
  • A comprehensive evaluation was implemented in
    January, 2007 to compare these groups on the
    following outcome measures re-hospitalization
    rates, levels of satisfaction, service
    utilization rates, residential stability, and
    level of community integration.

47
Personal Outcome Measures
  • 13. Interact With Others in Community
  • 14.Perform Different Social Roles
  • 15. Have Friends
  • 16. Are Respected
  • 17. Choose Services
  • 18. Realize Personal Goals
  • 19. Are Connected to Natural Supports
  • 20. Are Safe
  • 21. Exercise Rights
  • 22. Are Treated Fairly
  • 23. Have Best Possible Health
  • 24. Are Free From Abuse Neglect
  • 25. Experience Continuity Security
  • 1. People Choose Personal Goals
  • 2. Choose Living Arrangements
  • 3. Choose Where They Work
  • 4. Have Intimate Relationships
  • 5. Are Satisfied With Services
  • 6. Are Satisfied With Life Situation
  • 7. Choose Their Daily Routine
  • 8. Have Privacy As Needed
  • 9. Decide To Share Information
  • 10. Decide When To Share Info.
  • 11. Live In Integrated Environments
  • 12. Participate in Life of Community

48
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49
Challenges for Future Expansion
  • 1. Cost reimbursement contracts versus unit
    based.
  • 2. Centralized fiscal agent versus community
    based.
  • 3. Mechanisms for disbursement of funds to
    participants.

50
The Florida Peer Network
  • 13301 Bruce B. Downs Blvd.
  • MHC 2505
  • Tampa, Florida 33612
  • 877 352-7337 813 974-2851
  • info_at_floridapeernetwork.org
  • www.floridapeernetwork.org
  • Patrick Hendry Executive Director

51
The Michigan Experience
  • Pamela C. Werner
  • Office of Consumer-Directed Home and Community
    Based Services
  • Bureau of Community Mental Health Services
  • Michigan Department of Community Health
  • (517) 335-4078
  • email wernerp_at_michigan.gov

52
Building the Foundation for Systems Change
  • 1996 Mental Health Code changes
  • Consumers and family members on CMH Boards
  • Person-Centered Planning Process Requirement
    Established statutory right for all individuals
    served through the public specialty service
    system to have their Individual Plan of Service
    developed thorough a person-centered planning
    process
  • 2003 Contract Requirements
  • All adults have the option to request a
    Self-Determined Arrangement

53
What is the Difference Between Person-Centered
Planning and Self-determination?
  • Person-Centered Planning is the process of how
    the plan of service is developed.
  • Self-determination is a method of using Medicaid
    funds you are eligible for.
  • It emphasizes freedom of choice, control over
    ones own life, personal responsibility and
    access to services and support that are listed in
    your person-centered plan.

54
SELF-DETERMINATION BEGINS WITH YOUR
PERSON-CENTERED PLAN
  • You talk about your dreams.
  • You decide who will help you reach your dreams
    and goals.
  • The family and friends you choose support your
    choices about where you want to live, work, and
    have fun.

55
Self-Determination Involves
  • Rethinking how money is spent
  • Letting go of the old ways of doing business
  • Supporting not controlling
  • Making a power shift to people with disabilities
  • Providing what people truly need
  • Funding people not providers
  • Unbundling services
  • Seeking better value for public dollars

56
How Do You Request A Self -Determined
Arrangement?
  • Tell your case manager/support coordinator that
    you are interested in developing an arrangement
  • Set a person-centered planning meeting to talk
    about your dreams and goals
  • Get information on how much each of the services
    and supports you are using costs.
  • Surround yourself with creative people to find
    ways to meet your goals that are different from
    what you are doing now.
  • Hire a peer to help

57
Kalamazoo County Results from SAMHSA Block Grant
Funding
  • 67 people have been offered the opportunity to
    view their cost budget and self-determine
    services.
  • Of those, 44 individuals have reviewed their cost
    budgets.
  • 5 individuals leased staff from the Center for
    Disability Services
  • 5 currently employ their own staff
  • 1 more anticipated next month

58
Model Consumer Budget for Kalamazoo County
Mental Health Services 2005 - 2006, Michigan
  • Service Yearly Cost ()
  • Pathways Clubhouse 3,416.88
  • Psychiatric outpatient evaluation 339.74
  • Interact RN service 248.88
  • Pathways supported employment 493.78
  • Interact support employment 1,887.00
  • Rent subsidy -- transitional 2,172.00
  • Interact medication review 135.00
  • Hope Network -- case management 272.67
  • Interact case management 2,999.37
  • Interact RN service 497.76
  • Annual total 12,463.08

59
Success Stories Jeff
  • Hired a micro-enterprise assistant
  • She gave feedback and advice, helped with pricing
    and finding venues to display his art
  • Experienced growth in both his art and sales
  • Had his artwork placed in a local institute
    showcasing his work.

60
Success StoriesElizabeth
  • Hired a wellness coach to work on health issues.
  • Hired a social coach to assist in exploring
    community options and resources for evenings and
    weekends

61
Success Stories Jake
  • Hired a coach to support him as he moved from
    an Adult Foster Care into an apartment.
  • Hired a supported employment coach to help him
    find and maintain his current job.

62
Lessons Learned in Michigan
  • Certified Peer Support Specialists will be needed
    in all areas of the state to assist peers with
    options for self-direction.
  • Using existing funding without adding additional
    dollars is beneficial for future stability.
  • Technical guidance is needed to reference the
    Balanced Budget Act and other frameworks for
    consumer choice and control without additional
    administrative costs.
  • Models and programs that offer staff leasing need
    to be expanded.
  • Unbundling of services and providing budget
    information is fundamental.
  • We need more information to support
    person-centered process and self-determination as
    evidenced based practice in mental health
  • You are never there as there is no there

63
For Further Information
  • Michigan Department of Community Health Website
  • http//www.michigan.gov/mdch
  • Medicaid Provider Manualhttp//www.michigan.gov/
    mdch/0,1607,7-132--87572--,00.html

64
HHS Report on Consumer SatisfactionSupport As
Well as the Budget
  • An important part of the support consumers felt
    they received came through the person-centered
    planning process. Counselors tend to work with
    consumers for several hours to identify goals and
    then develop a spending plan.
  • In the case of EI, for example, the planning
    process has three stages which require separate
    meetings and involve a consumer and his resource
    broker spending 6-8 hours together.
  • Furthermore, counselors in SDC are able to
    provide ongoing support to ensure that consumers
    make progress in achieving their goals.
  • Consumers commented that creating a
    person-centered plan was only a starting point
    and that plans were meaningless without good
    follow up.

65
HHS Report on Consumer SatisfactionPeer Support
  • In the majority of SDC programs, counselors are
    peers.
  • Peers bring additional value to the relationship
    between consumers and counselors.
  • First, consumers do not perceive the same
    imbalance of power between themselves and peers
    as they do with professionals. This facilitates a
    true partnership that underpins the success of
    self-direction.

66
HHS Report on Consumer SatisfactionPeer Support
  • Second, peers act as effective role models for
    consumers who are seeking to rebuild a life in
    the community.
  • They have unique knowledge that comes from their
    personal experience of living with a mental
    illness.
  • This allows them to act as expert guides and to
    work with consumers to knit together various
    recovery support services and resources.
  • Peers combine learned knowledge of how to access
    public support such as vocational rehabilitation
    and Ticket to Work programs with real life
    experience of finding housing, cheap haircuts and
    free food in the community.
  • Many facets of this knowledge are beyond the
    reach of professionals.

67
HHS Report on Consumer SatisfactionGreater
Flexibility Meeting Needs
  • Consumers valued the flexibility that SDC gave
    them to meet their individual needs. This is
    reflected in the diversity of goods and services
    purchased under self-direction.
  • Other types of flexibility were also important to
    consumers, for example, the ability to schedule
    services when they needed them rather than having
    to fit around providers.
  • With an individual budget, a consumer in Michigan
    has been able to hire an assistant to work with
    her on social skill development at times that
    meet the consumers need and not vice versa.
  • Overall, the flexibility of SDC comes from giving
    consumers control over all the dimensions of
    service provision -- the who, what, where and
    when.

68
HHS Report on Consumer SatisfactionRecovery
Orientation
  • Consumers identified two important ways in
    which they felt self-direction was
    recovery-focused.
  • First, it provided consistent support that helped
    them stay well and did not mimic the cyclical
    nature of the traditional system. Consumers
    reported that traditional services tended to step
    in at times of crisis and then withdraw once they
    were stable rather than being provided on an
    ongoing basis.
  • Second, they felt that SDC demanded a certain
    amount of responsibility and active participation
    from them and this was seen to be a positive
    aspect of the approach. They felt that the
    traditional system demanded little of them and
    made it difficult for them to be involved in
    their own care, in part reflecting a view that
    they were incapable of taking control.

69
HHS Report on Medicaid
  • The extent to which self-direction can be
    supported through Medicaid is highly significant
    for the expansion and sustainability of programs.
    Self-direction pushes at the limits of what
    Medicaid will support.
  • States have overcome this issue to date by
    relying on general revenue funding but general
    revenue funds face many competing priorities.
  • There is a need to develop a funding model for
    self-direction that will better ensure
    sustainability at the same time as maintaining
    the flexibility that consumers value.

70
HHS Report on Medicaid
  • The joint federal-state Medicaid program is the
    single largest source of funding for public
    mental health services and is expected to account
    for an increasing share of the resources that
    underwrite state administered mental health
    services.
  • Therefore, although there are other funding
    sources that can be used to develop
    self-direction, the extent to which this approach
    can be supported through Medicaid is highly
    significant for the future of SDC.

71
CMS 1915.j InitiativeState Medicaid Director
Letter
  • Under section 1915(j), States have the option to
    amend their State plan to provide self-directed
    PAS (personal assistance services) to
    beneficiaries, without regard to the Medicaid
    requirements of comparability or statewideness.
  • This legislation permits States the flexibility
    to amend their State plans to offer a more
    comprehensive self-directed PAS program than
    under the traditional personal care services
    option and also relieves States of the
    administrative burden of submitting a waiver or
    demonstration proposal.

72
CMS 1915.j InitiativeState Medicaid Director
Letter
  • The State may elect to permit individuals to
    choose to receive cash disbursements, on a
    prospective basis, with which to purchase the
    self-directed PAS identified in their
    self-directed service plan.
  • If this option is made available by the State,
    individuals selecting the cash option are not
    required to utilize a fiscal management entity.

73
CMS 1915.j InitiativeState Medicaid Director
Letter
  • Individuals must be given flexibility to
    determine the functions, if any, to be performed
    on their behalf by the fiscal management entity.
  • Also, the State may elect to permit individuals
    to use their funds to acquire items that increase
    independence or substitute for human assistance,
    to the extent that expenditures would otherwise
    be made for the human assistance.

74
CMS 1915.j InitiativeState Medicaid Director
Letter
  • States may limit the population eligible to
    self-direct and the number of individuals
    self-directing.

75
Consumer-Directed Care in Alabama
  • Alabama first state to make consumer directed
    (also known as self-directed) care for Medicaid
    home and community-based services a permanent
    part of its State Plan.
  • Alabama worked closely with Centers for Medicare
    and Medicaid Services to ensure successful
    completion of the application.

76
Alabama Program Value
  • Budget-neutral
  • Offers consumer satisfaction and enhanced quality
    of life
  • Reduces unmet care needs, and
  • Increases access to authorized services

77
Alabama Expected Consumer Outcomes
  • Increased access to paid personal care
  • Increased satisfaction with services
  • Increased overall quality of life
  • Positive health and safety outcomes
  • Decreased stress on families and informal
    caregivers

78
Expected Outcomes for Alabama
  • Making consumer-directed care a permanent part of
    the State Plan will relieve Alabama of the
    intensive and repeated waiver renewal process.
  • Potential cost reduction and quality improvements

79
HHS Report RecommendationBraided Funding
  • This kind of coordinated funding approach has
    been more successfully developed for children
    with serious emotional disturbance than it
    currently has for adults with SMI.
  • Wraparound Milwaukee pools funds through case
    rates paid by the child welfare and juvenile
    justice systems, receives a monthly capitation
    payment for each Medicaid child enrolled, and
    coordinates other insurance and SSI payments to
    form a type of insurance pool.
  • Blending or braiding different budgets together
    would increase the financial support available
    for SDC, while only using the most appropriate
    source to fund each particular service.

80
Key Resources
  • Free to Choose Transforming Behavioral Health
    Care to Self-Direction Richard Dougherty
  • Derived from SAMHSAs Consumer Direction
    Initiative Summit March 22-23, 2004 in in
    Washington, DC http//mentalhealth.samhsa.gov/publ
    ications/allpubs/SMA05-3982/FREE_TO_CHOOSE_CDI_Man
    ual.pdf
  • Bazelon Center for Mental Health Law Study
    October 17-18, 2006
  • The Contribution of Self-Direction to Improving
    the Quality of Mental Health Services, Vidhya
    Alakeson, HHS 2007
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