Self-Directed Financing of Services for People in Mental Health Recovery

1
Self-Directed Financing of Services for People
in Mental Health Recovery

• Judith A. Cook, PhD
• Professor Director
• University of Illinois at Chicago, Department of
  Psychiatry
• Presented at NYAPRS 7th Annual Executive Seminar
  on Systems Transformation
• April 27, 2011, Albany, NY

2
A Word of Thanks to our Funders

• U.S. Department of Education, National Institute
  on Disability Rehabilitation Research
• Substance Abuse Mental Health Services
  Administration, Center for Mental Health Services

3
Can this System Be Reformed?
MD Higher Ed. Comm. UM System Community
College System
Department of Disabilities
Dept. Of Veteran Affairs
Dept of Health Mental Hygiene (DHMH)
Dept Of Human Resources (DHR)
MD State Dept Of Education (MSDE)
Department of Labor, Licensing,
and Regulation (DLLR)
Blind Industries Services Of Maryland (BISM)
Mental Hygiene Administration (MHA)
Developmental Disabilities Administration (DDA)
Medicaid
Division Of Rehabilitation Services (DORS)
Governors Workforce Investment Board
MAPS-MD
Dept. of Social Services (DSS)
4 Regional DDA Offices
6 DORS Regions
Local/State Colleges Universities
Local Workforce Investment Boards/ One-Stops
Local Education Agency (LEA)
Core Service Agency (CSA)
Consumer Community Rehab. Program
4
Key Elements Missing From Current System

• Accountability
• Choice
• Free market economy (overregulation, lack of
  competition)
• Consumer sovereignty
• Personal responsibility

5
What is Self-Directed Care?
Funds ordinarily paid to service provider
agencies are controlled by service recipients

1. Participants develop person-centered recovery
   plans
2. They then create individual budgets allocating
   dollar amounts to achieve the plans goals
3. Staff called brokers are available to help
   people purchase services goods named in their
   plans
4. Fiscal intermediary provides financial management
   services such as provider billing payroll taxes

6
How are Mental Health SDC Programs Funded?

• State general revenue (for individuals not
  covered by Medicaid)
• State general revenue combined with Medicaid in
  some manner
• Add-on to Medicaid Medicaid beneficiaries
  receive additional funds for SDC through 1) state
  MH dollars, 2) CMS Real Choice System Change
  Grants, 3) CMS Community Reinvestment Funds
• Medicaid funding pooled with other funds such as
  1) state MH dollars, 2) MH Block Grant, 3) local
  funds
• (http//www.cmhsrp.uic.edu/download/sdsamhsaconfse
  ntver3.pdf)

7
How is SDC Cost Neutral?

• Peoples individual budgets are set at levels no
  higher than the systems current expenditures for
  traditional outpatient services
• Use an average (e.g., average annual outpatient
  expenditure)
• Individualized amount based on cost of
  participants recent outpatient tx
• Provide different amounts based on Medicaid
  beneficiary status

8
How Well Does SDC work for other populations?

• Randomized evaluation of Cash Counseling
  programs (developmental physical disabilities
  the elderly)
• Outcomes of SDC participants were as good or
  better than regular fee-for-service (FFS)
• SDC participants received more services than
  their FFS counterparts
• Budget neutrality prevailed by end of 2nd year
• Consumer satisfaction was significantly higher
  among those served in SDC
• Incidences of fraudulent behavior were low
• Hiring ( firing) friends/family members not
  problematic
• (Foster, Brown et al., Health Affairs, 2003)

9
Evidence for SDC in MH Populations

• Single group Pre/Post Study of Florida SDC
• Significant increases in days in the community
• Significant increases in global functioning
• Only 16 were hospitalized (5 involuntarily
  admitted)
• Outcomes 33 in paid employment, 19 job skills
  training, 16 volunteer activities, 10
  postsecondary education/GED
• Of direct expenditures by participants 47
  traditional psychiatric services, 13 service
  substitutions for traditional care, 29 tangible
  goods, 8 uncovered medical care, 3 on
  transportation.
• (Cook, Russell et al., Psychiatric Services,
  2008)

10
Texas SDC Location Host Organization
NorthSTAR Region
North Texas Behavioral Health Authority
11
How Texas SDC Works

• Regardless of Medicaid eligibility, participants
  have 4,000/year to purchase goods services,
  with up to 7,000/year available for individuals
  who need high levels of service
• People must be willing to leave their current
  services in order to begin SDC
• Brokers (called SDC Advisors) are available to
  assist with all SDC components
• SDC is available for 2 years as a pilot program
  only for those willing to participate in the
  program evaluation

12
Why the Dallas NorthSTAR Area?

• Managed care waiver already in place in the
  7-county NorthSTAR area
• Braided funding system in place for Medicaid and
  State general revenue funds
• ValueOptions managed care company already
  administering a network of diverse MH providers
• Local mental health authority is a conflict of
  interest-free willing partner

13
Creating a Climate of Change

• UIC DSHS mobilized educated the community
  brought together people in MH recovery,
  advocates, providers, academics, family members
• Motivated educated DSHS staff
• Created a set of multi-stakeholder subcommittees
  that worked collaboratively to design the program
• Included community providers to ensure that their
  needs were addressed

14
TX SDC Community Advisory Board
Subcommittees (included consumers, providers,
UIC, DSHS, state VR, managed care, NAMI, MHA,
other advocates)
Personnel
Technology
Provider Network
Purchasing
Program Operations
Convened collaboratively via teleconference by
UIC DSHS
15
Use of Technology

• Program designed by community advisory committees
  that met via teleconferencing listserv
• Participant purchases made with debit cards
• Participants communicate with each other via a
  Chat Room closed to outsiders
• Support brokers travel with laptops portable
  printers, with wireless capability

16
Texas SDC Website keeps participants, staff,
funders, public informed
http//www.texassdc.org/default.asp
17
Purchases through Debit Card

• Decreases stigma from using vouchers or checks
  with program name on them
• Increases participant familiarity with use of
  debit/credit cards
• Enables hiring of traditional MH providers who
  want to be paid directly
• Allows participant responsibility for funds
• Allows program to restrict purchases (no alcohol,
  guns, pornography, etc.)
• Allows program staff to monitor expenses

18
Use of Braided Funding

• Medicaid
• State general revenue
• Mental health block grant
• Local funds

The Challenge State must be able to account for
all expenditures separately at the back-end,
while remaining seamless to the consumer at the
front-end.
19
Use of Peer Support Services

• People in MH recovery involved in all aspects of
  planning the project
• Emphasis on including consumer-operated programs
  certified peer specialists in the provider
  network
• Employment of peers as program staff-50 of SDC
  Advisors are peers

20
Research Evaluation

• Randomized controlled trial
  study conducted by the UIC
  National RTC on
  Psychiatric Disability
• Focus on recovery outcomes, participant
  satisfaction, service use, service costs
• Goal - to conduct research with the rigor to
  inform public policy in the state, with potential
  to support models replication in other
  communities
• Involving participants other stakeholders in
  the research process from start to finish

21

• Some Early Research Findings

22
Characteristics of 1st 75 SDC Study Participants
SDC (n44), Services as Usual (n33)

• Female 68
• Caucasian 59
• African American 25
• High School/GED 67
• Unmarried 85
• Parents 68
• Annual income lt 10,000 44
• Treated overnight for MH 61
• Treated for substance use 52
• Physical condition/impairment 48
• Currently working 15
• See self holding job in next year 60
• Average age 40 years
• Average household size (inclu. participant) 3

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As of May 2010, Types of Traditional Clinical
Purchases Authorized
2
4
8
44
10
32
24
As of May 2010, Types of Non-Traditional
Purchases Authorized
1
6
10
30
10
12
16
16
25
Ratio of Traditional/Non-Trad. Purchases (among
those with approved budgets for 2 months)

• 58 of budget allocated to traditional/42
  non-traditional purchases (with an average of 40
  of total budgets allocated)
• Per participant, traditional range from 20-98
• Per participant, non-traditional range from
  2-80
• of participants adhering to 60/40 split 61
• Average monthly expenditure (est.) 302/person
  (median290, sd154)

26
Recovery Goals of One SDC Participant

• Find a prescribing psychiatrist with whom I feel
  comfortable
• Participate in supportive psychotherapy to
  enhance my ability to cope
• Improve my health physical fitness
• Better manage my feelings of depression
• Lower my stress level
• Prepare myself for a job

(Cook et al., Psychiatr Rehab J, 2010)
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Purchases Made by 1 Participant Over 4 Months

• Purchase Total cost of Purchase
• Individual Therapy 910.00
• Psychiatrist 332.50
• Initial MH Assessment 90.00
• Physical Fitness 273.34
• Massage Therapy 300.00
• Tuition (12 hours) 265.00
• Books for School 250.38
• Debit Card Fees 3.95
• Total Traditional Services  1,332.50 (55)
• Total Non-Traditional Goods/Services 1,092.67
  (45)
• Grand Total Purchases  2,425.17 (100)
• (Cook et al., Psychiatr Rehab J, 2010)

28
TX SDC Participant Satisfaction Survey

• 42 participants with 3 month tenure 31
  completed the survey for a 74 response rate with
  no refusals
• How would you rate the SDC program?
• Poor/Fair 10
• Good/Excellent 90
• How do the MH services youre buying now compare
  to those you got before SDC?
• Worse 7
• About the same 19
• Better 74
• Would you recommend the SDC program to a friend?
• Not sure 3
• Yes 97

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SDC Participant Outcomes
Living in own home or apartment 84 Working for
pay 26 In school/taking a class 19 Psychiat
ric hospitalization 6 Physical health now
vs. before SDC Worse 10 About the
same 35 Better 55
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Ownership of ones lifeis a physical, mental,
spiritual, and responsible connection or
reconnection to life for an individual who seeks
his or her own destiny.Nancy Fudge, Florida
SDC Participant
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Further Information about SDC

• SDC Fact Sheet
• http//www.cmhsrp.uic.edu/download/SDCResearchFac
  tSheet.pdf
• Funding Options
• http//www.cmhsrp.uic.edu/download/sdsamhsaconfse
  ntver3.pdf
• Planning Guide
• http//www.bazelon.org/issues/mentalhealth/public
  ations/DriversSeat.pdf
• Managed Care SDC
• http//www.magellanprovider.com/MHS/MGL/about/wha
  ts_new/providerfocus/new/archives/fall06/clinical/
  article1.asp
• For more information, see http//www.cmhsrp.uic.ed
  u/nrtc/default.asp