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 Human Resources (DHR) Dept of Health & Mental Hygiene (DHMH) 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) Governor’s 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 • Participants develop person-centered recovery plans • They then create individual budgets allocating dollar amounts to achieve the plan’s goals • Staff called “brokers” are available to help people purchase services & goods named in their plans • 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/sdsamhsaconfsentver3.pdf)

7. How is SDC Cost Neutral? • People’s individual budgets are set at levels no higher than the system’s current expenditures for traditional outpatient services • Use an average (e.g., average annual outpatient expenditure) • Individualized amount based on cost of participant’s 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 model’s 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 (n=44), Services as Usual (n=33) Female 68% Caucasian 59% African American 25% High School/GED 67% Unmarried 85% Parents 68% Annual income < $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

23. 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 6% 1% 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 (median=$290, sd=154)

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)

27. Purchases Made by 1 Participant Over 4 Months PurchaseTotal 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 you’re 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%

29. SDC Participant Outcomes Living in own home or apartment 84% Working for pay 26% In school/taking a class 19% Psychiatric hospitalization 6% Physical health now vs. before SDC Worse 10% About the same 35% Better 55%

30. “Ownership of one’s life…is 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

31. Further Information about SDC SDC Fact Sheet http://www.cmhsrp.uic.edu/download/SDCResearchFactSheet.pdf Funding Options http://www.cmhsrp.uic.edu/download/sdsamhsaconfsentver3.pdf Planning Guide http://www.bazelon.org/issues/mentalhealth/publications/DriversSeat.pdf Managed Care & SDC http://www.magellanprovider.com/MHS/MGL/about/whats_new/providerfocus/new/archives/fall06/clinical/article1.asp For more information, see http://www.cmhsrp.uic.edu/nrtc/default.asp