Home and Community Based Service for Mental Illness Waiver: Colorado’s Experience

1. Home and Community Based Service for Mental Illness Waiver: Colorado’s Experience Chad Morris, Ph.D. Colorado Division of Mental Health Achieving the Promise: The Real Work of Transformation State Mental Health NFI/ Olmstead Coordinators 4th Annual Training Institute September 13-15, 2004

3. The Colorado Public Mental Health System N = 83,706 Unduplicated Clients FY 01-02 17 Community Mental Health Centers 8 Capitated Medicaid Service Providers 6 Specialty Clinics 50 Public and Private 27-10 Facilities 2 State Hospitals: 293 Civil Beds (FY 02-03) 278 Forensic Beds (FY 02-03) Nursing Facilities Alcohol and Drug Abuse Division Criminal Justice

4. Colorado Waivers • Children’s HCBS Waiver (Formerly Katie Beckett) • Children’s Extensive Support Waiver • Children’s Habilitation Residential Program Waiver • Brain Injury Waiver • Mentally Ill Waiver • Persons Living with AIDS Waiver • Elderly, Blind and Disabled Waiver • Supported Living Services Waiver • Developmentally Disabled Waiver

5. Historical Context • In response to a lawsuit • Individual in a nursing home with schizophrenia (only) who wanted to transition to the community • Legal Services became involved • Extended court battle that went to the Colorado Supreme Court • The Supreme Court found this was a protected class and needed equal services • Contacted CMS for letter to courts- Medicaid agreed to start the waiver • Remains only such waiver for adults • Health Care Policy and Financing recently assumed responsibility for the waiver

6. Legal Basis The Home and Community Based Services for persons with mental illness (HCBS-MI) program in Colorado is authorized by a waiver of the amount, duration, and scope of services requirements contained in Section 1902(a)(10)(B) of the Social Security Act. The waiver was granted by the United States Department of Health and Human Services, under Section 1915(c) of the Social Security Act. The HCBS-MI program is also authorized under state law at 26-4-671 through 26-4-676, C.R.S. (1999). The number of recipients served in the HCBS-MI program is limited to the number of recipients authorized in the waiver.

7. Creating the Waiver • 3-month turn-around time • Used the existing EBD waiver but changed eligibility to diagnostic categories from Colorado’s targeted list- PASARR diagnoses • ULTC 100.2 used to assess nursing home level of care • Initially a purely medical model – new categories added addressing psychiatric issues

8. Eligibility • Major mental illness, as such term is defined in the diagnostic and statistical manual of mental disorders used by the mental health profession, and includes schizophrenic, paranoid, major affective, and schizoaffective disorders, and atypical psychosis, but does not include dementia, including Alzheimer's disease or related disorders; • (b) In need of the level of care available in a nursing facility; • (c) Is categorically eligible for medical assistance, or whose gross income does not exceed three hundred percent of the current federal supplemental security income benefit level, and whose resources do not exceed the limit established for individuals receiving a mandatory minimum state supplementation of supplemental security income benefits or, in the case of a person who is married, do not exceed the amount authorized in section 26-4-506.

9. Waiver Services • HCBS-MI services provided as an alternative to nursing facility placement include: • Adult day services, and alternative care facility services, including • Homemaker and personal care services in a residential setting, • Electronic monitoring, • Home modification, • Homemaker services, • Non-medical transportation, • Personal care, • Respite care • Case management is not a service of the HCBS-MI program, but shall be provided as an administrative activity through case management agencies. • HCBS-MI clients are eligible for all other Medicaid State plan benefits.

10. Pros • Social services in EBD • Same providers and forms • Medical model has made improvements to behavioral health model in some areas • Electronic monitoring- electronic medication boxes- missed doses lead to rapid response- call and follow-up visit • Non-medical transport

11. Cons • Medical model targeting the frail and elderly • Same providers and forms • Providers do not have mental health treatment background and may not understand mental health issues • Mental health treatment is not in waiver-Attorney General could not require mental health treatment – this is voluntary • Potential increased dependence • Clinician and HCBS coordination-Since July 03- Single Point of Entry agencies perform case management- case workers no longer work for CMHCs

12. Numbers and Location • Legislature approved 2,319 slots for 2003-2004 • ~70% reside in Alternative Care Facilities- room and board and 24-hour on-site supervision (typically 20-100 bed units privately owned and operated) • Person pays room and board through SSI- and other services are paid through Medicaid

13. Lessons Learned • Waiver is not a way to get around the IMD exclusion for state hospitals • Nursing home criteria work because of the level of care match • May be easier to expand current EBD waivers to include mental illnesses • Cost shifting? • Regional differences? (first 3 years of the waiver are run from central office and are then moved to regional offices)

14. Resources Department of Health Care Policy and Financing http://www.chcpf.state.co.us/ Staff manual http://www.chcpf.state.co.us/HCPF/StateRules/index.asp Colorado General Assembly http://www.leg.state.co.us/ CO Revised Statutes