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

1. Reform of the Mental Health, Developmental Disabilities and Substance Abuse Service System February, 2005

2. Federal Pressures for Reform • Olmstead vs. LC (6/22/1999) • Court found that Georgia’s 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 President’s New Freedom Commission on Mental Health (7/2003) • SAMHSA “Action Agenda”

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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

9. State Plan Principles • Participant driven • Community based • Prevention focus • Recovery outcome oriented • Reflect best treatment/support practices • Cost effective

10. 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

11. 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

12. 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

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

14. 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.

15. 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

16. Timeframe – Rehab Option Services • DHHS has walked through new MH/SA service array with variety of stakeholders – consumers and families, providers, LMEs, members of children’s 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

17. 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.

18. 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

19. 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

20. 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.

21. 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 consumer’s informed choice of providers.

22. 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.

23. 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

24. 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

25. 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 consumer’s 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?

26. 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.

27. 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

28. 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.

29. 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.

30. Questions?