Blog

IDVR has Exciting Programs for Transition Age Students

Idaho Division of Vocational Rehabilitation offers services and programs especially designed for transition-age students (between 15-21 years old and attending high school or post-secondary education) with disabilities.  Click on the links below for more information.

IDVR Pre-Employment Transition Services –

idvr-pre-employment-transition-services-10-2016

PREP Academy 2017 –  A summer transition program for students with disabilities interested in attending college. Students participate in a five day, five night on-campus college experience.

idvr-bsu-prep-academy-2017

The McCall Outdoor Science School Program –   Five day residence camp to learn scientific and ecological principles and job skills that lead to successful employment.

idvr-mccall-outdoor-program-10-2016

Judge rules in favor of DRI in lawsuit by Ada County Coroner

Disability Rights Idaho received congratulations from the National Disability Rights Network in obtaining a strong opinion and court order from a U.S. District  Court requiring the Ada County Coroner’s office to release records to the P&A as part of an investigation into a suicide death at a psychiatric hospital.  To read the complete account of the case, please click here Coroner lawsuit

OPE Evaluated the Optum Medicaid Behavioral Health Contract, but Not the Outcomes for People with Mental Illness

Idaho’s Office of Performance Evaluation (OPE) just released its report on the Idaho Medicaid managed care contract with Optum Idaho, the Idaho Behavioral Health Plan. (to view full report click here). The report examines some important issues and makes some worthwhile points, but it completely fails to answer the questions that are most important to Idahoans with mental illness and their families. We were hoping that the report would focus on access to treatment and impact on the lives of Idahoans with mental illness, but these outcomes were not addressed. However, if you read carefully, the report contains some serious findings which deserve everyone’s attention.

Optum Radically Reduced Psychiatric Rehabilitation

The most salient finding of the report is the reduction in Psychiatric Rehabilitation (called Community Based Rehabilitation Services or CBRS by Optum, and very similar to Psycho-social Rehabilitation or PSR). For more information on Psychiatric Rehabilitation in Idaho, see previous articles on this site. (For 1st article click here. For 2nd article click here). The summary of the OPE report features a graph of expenditures on PSR/CBRS trending steeply upward until the Optum contract is implemented when the trend is abruptly reversed. Optum has cut community mental health services overall by about $28,000,000 per year in spite of increases totaling about $1,000,000/year in family counseling and psychotherapy. Almost all of this reduction was in CBRS.

What Happens to the “Savings”?

Under the terms of the contract, Optum is allowed to keep the first 15% of total reductions in expenditures as an “administrative” fee. This creates a potent incentive for Optum to cut services without realizing any savings to the State of Idaho or the taxpayers. If Optum cuts services beyond the 15%, federal rules require them to reinvest the savings in additional Medicaid services. So far, there has been very little reinvestment of the annualized $28,000,000 in savings. At this point, no one has benefitted from the CBRS reductions except Optum. There has been no savings for the state, few service improvements for Medicaid recipients, big losses for providers, and a lot of mental health crises for people with mental illness. To be fair, some improvements are in the works. Peer Supports and Family Supports (evidence based practices using people in recovery and parents of children with mental illness) are becoming available in some areas. They are still far from full implementation, and not able to fill the void created by the CBRS cuts. Other enhancements to the service array, like partial hospitalization, Medicaid covered Assertive Community Treatment (ACT teams), or intensive home based services for children, are not even on the horizon. From the participant’s perspective, the greatest failure of the contract is the intense emphasis on immediately reducing CBRS without even having a plan for replacing it with other community services. The report claims that “Investment of savings has proved more difficult than the department originally anticipated because of the restrictive nature of federal regulations.” It does not elaborate on what federal regulations have prevented the Department or Optum from developing Medicaid approved services like those mentioned above.

The Report Says Nothing About the Effect of the Plan on People with Mental Illness

OPE evaluators report at length on the effect of this reduction on providers (and the Department’s failures in communication and planning for this effect), but nothing is said about the outcomes for participants’ mental health. At page 15, the report says “We cannot comment on the appropriateness of Optum’s criteria for clinical review…” From our perspective, this is the biggest issue with the OPE report. Idaho Medicaid covers treatment for mental health and substance use disorders, in order to prevent the suffering and death they cause and the huge social costs associated with these illnesses. The point of “Managed Care” is to increase effective treatments and practices which improve health outcomes. The Idaho Behavioral Health Plan is sadly deficient in measuring the mental health outcomes for participants. Reducing payments for CBRS is only beneficial if the mental health needs of Idahoans are still met, and the devastating consequences of mental illness are avoided at least as much as they were before. There is a lot of piecemeal and anecdotal evidence suggesting that the reduction of CBRS, without introducing replacement services, has had terrible results for people with mental illness and their families and has created greater burdens on counties, hospitals, law enforcement, jails and juvenile justice systems. However, there is no comprehensive source of reliable data to measure the relationship between the Behavioral Health Plan and these outcomes.

What is the Goal of the Behavioral Health Plan?

It would appear from the report that the Department’s primary goal for the Optum contract was to reduce the amount of CBRS paid for by Medicaid. “Overreliance on or misuse of psychosocial rehabilitation (PSR) was a major concern of the department and a strong influence on the department’s decision to incorporate managed care into its behavioral health system.” (Report, p. 6). It was apparently more important to them than reducing hospitalization. “The department explained that the primary reason it excluded inpatient services was because it worried that managed care contractors might choose the standard approach of focusing on the hospital [inpatient services] rather than on the issues with PSR.” This single minded focus on cutting CBRS led to a contract that did not emphasize good mental health outcomes, or effective preventive and community based services, or even prevention of hospitalization. In fact, the report suggests that two years into the three year contract, neither the Department nor the contractor knows how to incorporate more effective services to replace the lost CBRS. “The Governor’s work group envisioned 20 services that would comprise the core of its continuum of care—to be available to anyone who needs it regardless of their geographic location or enrollment in Medicaid. Only 9 of the 20 services were part of the state’s Medicaid plan.” (Report, p. 33) But they are only now developing a plan to achieve this. “The Department and Optum are working together to create a plan to spend savings within the limitations of federal regulations,” (Report p. 37).

Meanwhile the Department Has Not Measured The Effect on Participants’ Mental Health.

The Department acknowledges that one reason that PSR/CBRS was heavily used was that it was often the only tool in the tool box. With only nine of twenty recommended services covered by Medicaid, people used PSR as a substitute for unavailable services. A person who needed ACT, or Partial Hospitalization, intensive in-home services, or even community supports, often had to make do with PSR/CBRS. It is no surprise that, cutting off PSR/CBRS before more appropriate services are available, is causing increased mental health crises and all of the suffering and expense that entails. However, it seems that neither the Department nor Optum is tasked with monitoring the actual mental well being of the participants. No one is keeping track of the actual results of the plan in terms of mental health outcomes for people. The tools for tracking mental health outcomes have been available all along. This is not even a new idea. In 1998 the American Academy of Child and Adolescent Psychiatry (AACAP) published a Guide for tracking outcomes in Medicaid managed care contracts (to view the full guide click here) Here is one of several sets of measurable indicators recommended by AACAP:

Performance Category EFFECTIVENESS

Domain Functional Status — Quality Indicator
* Percentage of children per year placed outside the home due to emotional or behavioral problems.
• Number of days per year spent in hospital or residential settings as a ratio over days in all services.
• Number of arrests/legal referrals per year in population compared with community rates.
• Number of children in restrictive school settings (including in-home tutoring) due to emotional or behavioral problems.
• Improvement of impairment scores for a sample of patients in the program population (See Appendix B for examples of currently available instruments).
• Number of days of school attended per year.
• Rates of graduation from middle and high school.
• Number of suicides and attempts per year compared with national and regional prevalence rates.
• Number of days in detention/incarceration per year.
• Number of child abuse reports and infanticides.
• Number of youth homicides.
• Number of teen pregnancies.

Clinical Symptoms
• Decrease in symptom level for a sample of patients in the population.

It isn’t hard to come up with an equivalent list of outcomes for adults such as substituting evictions and homelessness for “out of home” placements, and adding employment or job loss instead of school outcomes. You can’t manage what you don’t measure.

Currently, Optum is required to measure very little other than money spent on claims, number of grievances and appeals, and some provider satisfaction surveys. The Department relies almost entirely on Medicaid claims data to evaluate the system. The OPE report acknowledges that they did not have adequate data to measure whether costs were shifted to agencies other than the Department. “We did not complete a comprehensive investigation of every place a member could go if they were denied services under the Idaho Behavioral Health Plan and subsequently experienced a mental health crisis. However, we examined data provided by the Division of Medicaid and the Division of Behavioral Health which did not show unexplained increases above historical trends” (p. 32). In other words they did not look at arrests, jails, juvenile detentions, runaways, suicides, expulsions, evictions, job loss, out of home placements, symptom increases, etc. Optum does not collect this information, and neither does the Department.

Psychiatric Rehabilitation is an Important Component of a Mental Health Program

The report does not question the department’s assumption that PSR/CBRS is overused. Although it has sometimes been used as a substitute for other more appropriate services which are not available in Idaho, it is also often the right service for the person in question. Optum has reduced CBRS for children so drastically that is well on its way to eliminating the service. This policy ignores the treatment authority on which Optum relies for its clinical decisions, the AACAP. Since 1996 the AACAP has had standards for developing managed care contracts. For children with high level needs they conclude: “Criteria for access to the “high utilizer” track should be well-defined and based at least on functional impairment as influenced by support systems and risk factors. Such criteria should be independent of assigned diagnosis… Rehabilitative services are an integral component of this track, maximizing utilization of available educational and vocational services offered through public agencies, as well as other supplements dictated by the child’s and family’s needs. Such services should address practical daily living, employment, and social skills” (emphasis added). (To see the AACAP Managed Care Principles click here). Rather than trying to eliminate CBRS for children, the AACAP, evidence based guidelines suggest that all children with more severe conditions should have access to rehabilitative services. CBRS for adults is also included in American Psychiatric Association Guidelines.

Conclusion:

The OPE Report has valuable information, and it highlights serious mistakes in planning, and preparation. However, the report does not even consider whether the contract served people with serious mental illness well, or whether it has started an ongoing crisis in mental health. When it is read carefully, the report reveals that the department was so focused on cutting PSR/CBRS that they failed to plan for the services needed to replace it. So now we are sitting on money for services but we are not providing the services, and we are paying for it with people’s mental health and possibly with their lives.

Healthy Idaho Plan Position Paper

Idahoans with Disabilities in the Health Insurance Gap: The Healthy Idaho Plan

Contrary to popular opinion, not all Idahoans with disabilities, living in poverty, are eligible for Medicaid, Medicare or any other health insurance program. Many low income Idahoans with serious disabilities fall into the health insurance gap (for information on the gap, http://closethegapidaho.org).

Governor Otter’s work group on Medicaid Redesign* recommended that Idaho create our own solution to the health insurance gap by requesting a waiver of federal Medicaid rules. State and private stakeholders designed a plan which could solve the problem. It is called the “Healthy Idaho Plan”. The plan uses federal Medicaid funding to buy health coverage on the state insurance exchange for eligible families between 100% and 138% of the federal poverty level**, and extends Medicaid to eligible families below the poverty level. The plan would also extend Medicaid coverage to low income people with disabilities, and chronic health conditions, who are not currently covered. The Healthy Idaho Plan will be a great benefit to many Idahoans with disabilities.

Two large groups of people with disabilities are currently excluded from coverage. Of the roughly 41,000 Idahoans who have a serious and persistent mental illness (SPMI), only about 10,000 are currently eligible for Medicaid. About 12,000 more get some level of treatment each year from the Department of Health and Welfare, but only if their illness becomes so severe that that they pose a serious risk to themselves or others, or if services are ordered by a court. This group (SPMI) includes only people whose mental illness is disabling and recurring. The Healthy Idaho Plan would cover almost all of these people. The plan would provide federal funding for the care they need and relieve the burden on county indigent funds, and state general funds for catastrophic health care, and the Division of Behavioral Health programs. Currently, most Idahoans with SPMI have no coverage for mental health treatment, or for the expensive prescription drugs needed to control their symptoms.

People, who acquire disabilities after a period of employment, and are unable to work, often qualify for Social Security Disability benefits. Federal law, however, prevents these people from obtaining Medicare coverage for two years after the onset of their disability. If their Social Security benefits exceed $734/month, they are also excluded from Medicaid coverage, unless they are in need of nursing home care. There are always thousands of Idahoans with disabilities in this waiting period. A recent study of a random sample of county indigent program claims conducted by Dr. Douglas Dammrose revealed that 42% of the claimants are in this category***.

There are other people with disabilities, including many veterans, who are in this coverage gap due to individual circumstances. All of them need affordable health care coverage. People with SPMI need a robust benefits package to get adequate care and to maximize savings from state general fund programs. Many people in the Medicare waiting period may need long term in-home supports and services to keep them out of expensive nursing home placements. Idaho must insure that people with particular health care issues caused by disabilities, have access to regular Medicaid coverage to meet their needs and prevent higher cost services.

Conclusion:
The Healthy Idaho Plan would provide health care coverage for tens of thousands of low income Idahoans with disabilities. This would replace state and county tax dollars being spent in county indigent and state catastrophic health care and state mental health programs, with 90% federal Medicaid funds. This saves Idaho taxpayers tens of millions per year. It would provide access to mental health care and prescription drugs for people with serious and persistent mental illness. It would provide ongoing medical care for people with disabilities who are waiting for Medicare coverage. It would also make health care coverage affordable for the rest of the 78,000 Idahoans in the health care coverage gap.

* http://www.gov.idaho.gov/pdf/1204%20Medicaid%20Workgroup%20Report.pdf
** https://www.healthcare.gov/glossary/federal-poverty-level-FPL
*** http://www.healthandwelfare.idaho.gov/Portals/0/Medical/MoreInformation/08-14-2014%20Medicaid%20Redesign-Idaho%20Doug%20Dammrose.pdf

Idaho’s Mental Health System and the ADA “Integration Mandate”

DRI was asked to provide testimony to the Idaho Advisory Committee of the U.S. Commission on Civil Rights concerning Idaho’s mental health system and compliance with the U.S. Supreme Court Decision in Olmstead v. L.C. This is what I submitted.

Testimony of DisAbility Rights Idaho.

 

 

Idaho’s mental health services system is broken. Mental health crisis calls are stretching our law enforcement and emergency responders to the breaking point. Admissions to the state psychiatric hospitals are increasing and the prisons and jails have more inmates with serious mental illness than our hospitals do. Last but not least untreated or inadequately treated mental illness is causing enormous human suffering for people with mental illness and their families. Part of this crisis is the result of a lack of public funding for services, made worse by the significant cuts to state funded services and Medicaid since 2007. Part of the cause is a fragmented and disorganized collection of programs with conflicting priorities and inefficient parallel administrative structures. All of this was well documented in a 2008 study of Idaho’s mental health system commissioned by the legislature. The full text of that report is available on line, http://www.legislature.idaho.gov/sessioninfo/2008/interim/mentalhealth_WICHE.pdf(WICHE Report).

 

 

 

The WICHE report recommended that Idaho pool its resources for mental health and substance abuse treatment from all of its sources (Medicaid, Health and Welfare, Department of Corrections, federal block grants, counties, schools and private) and create  regional mental health authorities, with the power and authority to allocate the combined resources to meet local needs. The state mental health authority (Idaho Department of Health and Welfare, IDHW) would be the guarantor of services with the responsibility to insure that local agencies meet minimum standards and comply with state and federal requirements.

 

 

 

The report also condemned Idaho’s system for forcing people to reach some sort of crisis to get access to services. Access to mental health treatment for people who do not have Medicaid is available only to people who are involuntarily committed or who come into the system through the criminal courts, or who are at risk of harm to self or others. Since 2008, this situation has gotten much worse. A 40% cut to state funded services from 2007 to 2011 almost eliminated services for the 55% of Idahoans with serious and persistent mental illness who do not have Medicaid (unless their treatment is court ordered, or they pose a danger to themselves or others). Since 2008, some state level structural changes have been made. One Mental Health Crisis Center has been opened and one more approved. There has been a reduction in access to community services and Medicaid coverage of psychiatric rehabilitation services has been severely decreased.

 

 

 

Idaho’s History with Olmstead v. L.C. and Integrated Community Services

 

 

 

When the U.S. Supreme Court decided Olmstead v. L.C. 527 U.S. 581 (1999) (hereafter, Olmstead), it was concerned that, states with non-compliant systems would be swamped with individual suits and that litigious plaintiffs would move to the front of the waiting lists for services. The Court granted states protection from individual litigation if they developed a reasonable plan for compliance (Olmstead plan), and made consistent progress implementing it. Based on an Idaho Attorney General opinion, Idaho declared that the state was in full compliance with Olmstead, and that no plan was necessary. However, noting that there was widespread disagreement with this position, the Governor created a “Community Integration Committee” (CIC) to explore barriers to integrated services for people with disabilities, and to make non-binding recommendations to the state. The Committee consulted reports, evaluations, people with disabilities, and advocates.  The Committee’s last report was submitted in 2004 (attached). Idaho’s mental health system has deteriorated considerably since then.

 

 

 

Applying the ADA’s “Integration Mandate” to the State Mental Health System

 

 

 

Avoiding unnecessary institutional segregation requires a robust and flexible system of community services. The system must include access to mental health treatments like psychiatrists, medication management, psychotherapy, and counseling. For people at risk of institutionalization, it must also include rehabilitative services like psychoeducation, independent living skills, peer supports, and vocational services. Finally, the system must provide access to community supports such as affordable housing, medical care, case management and social services. Failure in any one of these areas can result in decompensation, relapse, re-hospitalization, arrest and incarceration, or suicide. The Olmsteaddecision, mandated the state system to be redesigned and even to include optional services like Home and Community Based Services (HCBS) waivers, in order to remove the institutional bias of the state’s Medicaid system. However, since the ADA applies to all state services, Idaho must remove institutional bias from the entire state operated mental health system. In other words, Idaho has an obligation to ensure that people with mental disabilities can get adequate mental health treatment and community supports without resorting to state hospitalization. Preventive treatment and supportive services are the key to avoiding unnecessary institutionalization, and segregation. While Olmstead addressed the needs of plaintiffs who were in the state hospital trying to get out, the principle also applies to people seeking mental health services to avoid institutional segregation. In this respect, Idaho’s mental health system falls short.

 

 

 

Idaho’s Department of Health and Welfare (IDHW) has two separate and very different systems which provide adult mental health services. Using national statistics, an estimated 75,000 Idahoans experience a serious mental illness each year.

 

41,000 of these have a serious and persistent serious mental illness (SPMI) that impairs their ability to function in society. About 19,000 of these Idahoans receive treatment through the Department of Health and Welfare for these illnesses each year. Only about 9,000 of them are covered by Medicaid; about 10,000 are not. Of the 21,000 people with SPMI who do not receive treatment from IDHW, some may be being treated privately, some are in jails or prisons, some get services from county indigent programs, some are receiving no treatment or services, some are homeless. We have no Idaho specific data on these subgroups.

 

 

 

The Division of Medicaid offers coverage for mental health services to people who qualify for Medicaid due to extremely low income combined with severe disability. Medicaid mental health services are covered under a managed care contract with Optum Health, Inc. People who have coverage from both Medicaid and Medicare also have the option of choosing a managed care plan offered by Blue Cross (True Blue).In the last three years, Optum has systematically reduced authorization for Community Based Rehabilitation Services (CBRS is the psychiatric rehabilitation service covered by the plan). They have increased authorization for clinical services like psychotherapy. However, community supports are often more important to preventing hospitalization than additional psychotherapy. For three years the amount of community based rehabilitation services authorized has declined significantly. Medicaid does not cover hospitalization for adults in psychiatric hospitals. So the financial burden of failed community supports is passed on to the Division of Behavioral health.

 

We do not have enough experience with the Blue Cross plan to know how they will deal with rehabilitation services

 

 

 

The Division of Behavioral Health (DBH) provides services to people with serious mental illness who do not qualify for Medicaid coverage or other insurance. Generally speaking, about 55% (about 9,000 per year) of the people receiving mental health services from IDHW receive only DBH services. DBH operates the two state psychiatric hospitals and provides some community services, such as therapy and Assertive Community Treatment (ACT) teams. Community services are mostly provided when ordered by a court for a criminal defendant, or when people are in crisis and pose a serious risk of harm to self or others.

 

 

 

Community Based Mental Health Services have declined and hospital admissions have increased since 2007.

 

 

 

In 2007, Idaho was spending just under $44 million on community Mental Health Services including ACT teams, and regional mental health centers. From SFY 2008 through SFY 2011 drastic cuts in state Community Mental Health (CMH) services were made. ACT teams were reduced and hundreds of people with severe and persistent mental illness lost ACT team support. IDHW closed many community mental health centers and cut services across the state. IDHW started this process before the recession and before the state legislature reduced budgets. The “budget cuts” (i.e. reduced appropriations) followed the service cuts and have never dropped as low as the state’s actual expenditures. Each year IDHW provided fewer services and requested less funding from the legislature. In 2011CMH expenditures had plummeted to just under $27 million, a 40% reduction from 2007. In 2014 it had rebounded slightly to about $30 million. During that time spending on state hospitals climbed from $27.8 million to $31.7 million.

 

 

 

Idaho Community Mental Health Funding 2007-2014

 

 

Source: Idaho Legislative Fiscal Reports

 

 

 

 

 

 

Source: Idaho Legislative Fiscal Reports

 

It is noteworthy that, starting in SFY2008, IDHW significantly cut services and expenditures well below the amounts appropriated by the legislature and continues to significantly underspend the appropriated amounts. During this time, many adults and children with mental illness have sought CMH services and been turned away by the Department. By 2010, the amount spent on community services was less than the amount spent on state hospitals and remains so to this day. However, the amount Idaho spends on services is not the ultimate issue in looking at Olmsteadcompliance. It is only relevant if the cuts in community services result in higher levels of institutional placements. Since 2007, state hospital admissions have steadily increased as the availability of community supports and services have declined.

 

 

 

Idaho State Hospital Admissions 2007-20014

 

 

 

 

Source: IDHW “Facts Figures and Trends” 2007-2014.  Note:  During 2008, SHS was required by the Joint Commission and the Centers for Medicaid and Medicare Services to reduce admissions due to a shortage of psychiatrists at the hospital.

 

 

 

CMH Expenditures vs.  State Hospital Admissions

 

 

Source: IDHW “Facts Figures and Trends” 2007-2014

 

 

 

When we map CMH expenditures over state hospital admission for the same time period we see a strong inverse correlation between CMH expenditures and state hospital admissions.

 

Another measure of the level of segregation of people with mental illness is the median length of stay (MLOS) at the state hospitals. Idaho’s MLOS statistics are not exceptional compared to other state hospitals and the yearly MLOS fluctuates without showing an overall trend since 2011.

 

 

 

These CMH figures apply only to the Division of Behavioral Health. We have no data which would tell us how many hospital admissions are DBH clients and how many are Medicaid patients. Although Optum has recently reduced access to Community Based Rehabilitation Services (CBRS), Medicaid patients in Idaho, generally have much better access to mental health treatment and community supports than DBH clients. People who have been diverted from the criminal justice system through a state mental health court, and receive services pursuant to the court’s order, may be exceptions to this rule.

 

 

 

Conclusion

 

 

 

Idaho is now dead last among all of the states in per capita expenditures on mental health services, http://kff.org/other/state-indicator/smha-expenditures-per-capita. Idaho is consistently in the top seven states for per capita suicide rates and the top five for juvenile suicide, http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6345a10.htm. In 2007, Idaho was investing in preventive and supportive community services at a much higher rate. For some reason, in SFY 2008, the Idaho Department of Health and Welfare decided to drastically reduce its commitment to community based services and began to rely increasingly on hospitalization for delivery of mental health services. Although there are no statewide data, many local hospitals and law enforcement agencies report increased utilization of county programs, law enforcement, jails and hospital emergency departments in handling mental health crises. 2014 and 2015 appropriations show an incremental reversal of this trend, but there is ample evidence of a continuing institutional bias in Idaho’s Mental health system. This raises legitimate questions about Idaho’s compliance with Olmstead’s “integration mandate”.

 

 

 

Submitted by: James R. Baugh, Executive Director, DisAbility Rights, Idaho

Psychosocial Rehabilitation and the Idaho Medicaid Managed Care Contract

Implementation of Idaho’s Medicaid Managed Mental Health Contract with Optum Health, Inc. has had a rocky start and has resulted in some major changes in the delivery of Medicaid covered mental health services in Idaho. There have been problems encountered by mental health service providers in processing and obtaining authorizations for services, but this article will not address those issues. I intend to focus on the problems being experienced by Idahoans with serious mental illness (SMI) and children with serious emotional disturbance (SED), in obtaining community based mental health services and supports. Most of the controversy revolves around authorization of Community Based Rehabilitation Services (CBRS).



Confusing Terminology

For many years, Idaho Medicaid provided a service called Psychosocial Rehabilitation (PSR). This service consisted of a mental health worker meeting with a person with SPMI, or SED and teaching them skills related to surviving in the real world while coping with a serious mental illness. PSR workers helped their clients recognize recurring symptoms of their illness, stick to their treatment plans, evaluate the effectiveness of their medications and their side effects, cope with stressors in their lives (family crises, evictions, expulsions, deaths of loved ones, encounters with the police, etc.), and build independent living skills (budgeting, shopping, getting or keeping a job, dealing with chronic health conditions, etc.). The strict rule definition of PSR limits it to skill building activities, but when a PSR worker found a client without food, behind in their rent, out of medications, afraid to leave the house to go to the doctor appointment (or whatever), they often just helped the person deal with the crisis. They might take them to the grocery store to get some staples, coach them through a call to the landlord about the rent, drive them to the doctor appointment, or help them understand their diabetes diet restrictions. If they find them in a crisis, they might take them to the emergency department of the hospital. Bureaucrats may argue about whether all of these activities fall under the definition of PSR, but they are all needed if we hope for people with SPMI/SED to survive in the community and stay out of hospitals, jails, prison, juvenile justice system, or homeless shelters.

Optum doesn’t use the term Psychosocial Rehabilitation. They offer an identical service called Community Based Rehabilitation Services (CBRS). The Psychiatric Rehabilitation Association (PRA) uses the term Psychiatric Rehabilitation to cover this type of service. The American Psychiatric Association includes Psychosocial services in a larger category of “Psychotherapeutic Interventions” which include Psychosocial rehabilitation, and in-home and community based services such as “Psychoeducational services” and others not named in the treatment guidelines (see e.g., APA Treatment Guide –Bipolar Disorder p. 52).

Services for children are equally confusing. In addition to the terms used above, there are a host of packaged services and approaches which may include some or all of the services described as PSR, or CBRS. “Wrap Around Services” and “Intensive In-home services” are two phrases used by the Substance Abuse and Mental Health Services Administration (SAMHSA) of the U. S. Department of Health and Human Services, to describe evidence based approaches which include services that Optum calls CBRS, along with other services. In addition, there is great overlap between other services such as Assertive Community Treatment teams (ACT teams) and CBRS even though it also includes some things that a CBRS client would not receive. While these words and phrases do not always describe exactly the same things, they have many common features and they significantly overlap each other. A person receiving any one of these services might not be able to tell the difference between one and another. In this article, I will use Optum’s term, Community Based Rehabilitation Services (CBRS), unless the context requires something else.
What is Optum doing?

Since the implementation of Optum’s contract some patterns have emerged.

  1. CBRS services to children have been significantly reduced.
  2. CBRS Services to people with both a mental illness and an intellectual disability have been significantly reduced.
  3. CBRS services have been reduced for people with diagnoses other than Schizophrenia (although Dr. Berlant has acknowledged that there is evidence that CBRS is effective for a range of diagnoses).
  4. CBRS services have been reduced in frequency and duration for many recipients and authorizations for CBRS are very short term.



In general the reason for reducing or denying CBRS is that it is not “medically necessary” according to the Optum care levels which are said to be based on the treatment guidelines of the American Psychiatric Association (APA) or the practice parameters of the American Academy of Child and Adolescent Psychiatry(AACAP), or SAMHSA. You will not find “CBRS” in these guides because CBRS is a term invented by Optum to describe psychosocial rehabilitation services (PSR). Due to the confusion over terminology described above, it is more difficult to nail down the evidence for the service.

Children’s Services

Optum medical directors have declared publicly that CBRS is not an evidence based practice for children. The American Academy of Child and Adolescent Psychiatry would seem to disagree.

American Academy of Child and Adolescent Psychiatry (AACAP) Practice Parameters – Schizophrenia:

Although further studies are needed, youth with EOS (Early Onset Schizophrenia) should benefit from adjunctive psychotherapies designed to remediate morbidity and promote treatment adherence. Strategies for the patient include psychoeducation regarding the illness and treatment options, social skills training, relapse prevention, basic life skills training, and problem solving skills or strategies. Psychoeducation for the family is also indicated to increase their understanding of the illness, treatment options, and prognosis and to develop strategies to cope with the patient’s symptoms.( Journal of the American Academy of Child & Adolescent Psychiatry, Volume 52, Number 9- September 2013. p. 986, note: this parameter is being revised)

AACAP – Treatment Guidelines – Bipolar

Bipolar disorder significantly affects social, family, academic, and developmental functioning. Therefore, in addition to efforts directed at reducing further episodes, psychosocial interventions are needed to address the myriad of disruptions that emerge in the wake of the disorder. Efforts to enhance family and social relationships, including therapies directed at communication and problem-solving skills, are likely to be helpful.(p.120)
Therefore, a comprehensive, multimodal treatment approach that combines psychopharmacology with adjunctive psychosocial therapies is almost always indicated for early onset bipolar disorder. Although medications help with the core symptoms of the illness, they do not necessarily address the associated functional and developmental impairments and the frequent need for support and skills building.(p.120)

The Substance Abuse and Mental Health Services Administration (SAMHSA) and the Center for Medicaid Services (CMS) in the U.S. Department of Health and Human Services have issued a joint information bulletin with a list of evidence based psychosocial service models for children with SED. The bulletin concludes:

While the core benefit package for children and youth with significant mental health conditions offered by these two programs included traditional services, such as individual therapy, family therapy, and medication management, the experience of the CMHI and the PRTF demonstration showed that including a number of other home and community-based services significantly enhanced the positive outcomes for children and youth. These services include intensive care coordination (often called wraparound service planning/facilitation), family and youth peer support services, intensive in-home services, respite care, mobile crisis response and stabilization.

The only service in the Optum array which approaches or incorporates elements of these SAMHSA/CMS recommended services is CBRS.

The Psychiatric Rehabilitation Association (PRA) is the national group which Optum and Idaho Medicaid use to certify CBRS providers in Idaho. PRA offers a specialized certificate in Psychiatric Rehabilitation for Children (http://www.psychrehabassociation.org/practitioner-training-continuing-education/children%E2%80%99s-certificate-psychiatric-rehabilitation-courses ). It would seem clear that these recognized experts consider CBRS for children to be evidence based practice also. And if there is any lingering doubt that Children’s Psychosocial Rehabilitation as practiced under Idaho Medicaid is evidence based and provides an objective and measurable benefit, it has been dispelled by the research published in the peer reviewed journal article “Preliminary Evaluation of Children’s Psychosocial Rehabilitation for Youth With Serious Emotional Disturbance” Research on Social Work Practice, Vol. 19 No. 1, January 2009 p.5-18. A study conducted in Idaho by Nathaniel J. Williams. The study showed “Participants improved significantly in psychosocial functioning and psychological symptoms, with effect sizes ranging from large to small. Improvements were clinically significant for 78% of participants” (p.1) and “Of the participants, 78% exhibited clinically significant improvement in their overall functioning across an average treatment time of 13 months. Participants’ improvement on the CAFAS/PECFAS was statistically significant and reflected a large effect size. Reductions in the number of severe subscales were similarly robust. Finer grained analyses of the CAFAS/PECFAS subscales revealed that participants experienced statistically significant improvements in functioning and psychological symptoms.”


Mental Illness and Intellectual Disability

Mental Health diagnoses are often ignored in people who have an intellectual disability (ID, formerly called mental retardation, MR) and as a result they do not receive appropriate mental health services. Nevertheless, studies show that mental illness is very common in people with ID. This applies to both children and adults. The AACAP practice parameters say:

Mental disorders occur more commonly in persons with MR than in the general population. However, the disorders themselves are essentially the same. Clinical presentations can be modified by poor language skills and by life circumstances, so a diagnosis might hinge more heavily on observable behavioral symptoms. (p.1)… The principles of psychiatric treatment are the same as for persons without MR, but modification of techniques may be necessary according to the individual patient’s developmental level, especially communication skills. Medical, habilitative, and educational interventions should be coordinated within an overall treatment program.(p.8S)

Robert Lieberman in “Recovery from Disability: the Manual for Psychiatric Rehabilitation” explicitly includes Intellectual disabilities among those who will benefit from PSR/CBRS. (p.12). I have found nothing in the literature which says that CBRS is ineffective with people who have an intellectual disability. Many dually diagnosed Idahoans can attest to the benefits they received from PSR/CBRS and to the harm suffered when it was withdrawn too early. I have found many sources which say that PSR/CBRS providers need additional training and expertise to properly provide mental health services to people with ID, and sources which say that mental health systems improperly exclude people with ID from mental health services. However, such exclusion would be impermissible under the Americans with Disabilities Act and other anti-discrimination laws.

Diagnoses Other Than Schizophrenia

The APA guidelines for Bipolar Disorder say:

“When the functional impairments of bipolar disorder are severe and persistent, other services may be necessary, such as case management, assertive community treatment, psychosocial rehabilitation, and supported employment. These approaches, which have traditionally been studied in patients with schizophrenia, also show effectiveness for certain individuals with bipolar disorder…Nevertheless, the weight of the evidence suggests that patients with bipolar disorder are likely to gain some additional benefit during the maintenance phase from a concomitant psychosocial intervention”,(APA Treatment Guidelines, p.52)”

It is important to note that the APA does not have guidelines for all major mental illness diagnoses. Therefore, it would be wrong to assume that the APA has any position on the appropriateness of CBRS for other diagnostic categories. Indeed, the guidelines themselves state:

These parameters of practice should be considered guidelines only. Adherence to them will not ensure a successful outcome for every individual, nor should they be interpreted as including all proper methods of care or excluding other acceptable methods of care aimed at the same results. The ultimate recommendation regarding a particular clinical procedure or treatment plan must be made by the psychiatrist in light of the clinical data, the psychiatric evaluation, and the diagnostic and treatment options available. (emphasis added, p.iv).

The Performance Standards for Psychiatric Rehabilitation of the Community Care Behavioral Health Organization , (2008 revision) use this standard:

General Description of Psychiatric Rehabilitation

Psychiatric Rehabilitation services are designed to address the needs of individuals with a history of severe mental illness as evidenced by a diagnosis of schizophrenia, major mood disorder, psychotic disorder not otherwise specified, schizoaffective disorder or borderline personality disorder of the DSM IV classification. The person receiving services must also have a moderate to severe functional impairment as a result of mental illness.(p.2)

Robert Paul Lieberman, M.D., Professor of Psychiatry UCLA Medical School (the founder of the field of evidence based psychiatric rehabilitation and the author of Recovery from Disability: the Manual for Psychiatric Rehabilitation) says:

The term “mental disability” is preferentially used to delineate the disorders afflicting patients who are appropriate recipients of rehabilitation… Psychiatric rehabilitation can benefit all those whose psychiatric disabilities endure beyond a relatively brief treatment of symptoms…Several terms have been used in the literature to delimit the population of the mentally disabled. The most frequent are terms such as “severely mentally ill”, “chronic mental patients”, and “seriously and persistently mentally ill”… A large number of individuals with disparate mental disorders listed here are often deemed disabled by the various criteria delineated above:

      • Schizophrenia
      • Bipolar disorder
      • Major Depression and disthymia
      • Obsessive-compulsive disorder
      • Social phobia
      • Panic and agoraphobia
      • Posttraumatic stress disorder
      • Some personality disorders such as borderline, schizotypal and schizoid
      • Developmental disorders such as pervasive developmental disorder or Down Syndrome (Recovery from Disability, p.9-11)

In my own search, I did not find any source which suggested that PSR/CBRS is only effective for people with schizophrenia. Dr. Berlant has acknowledged that CBRS may be appropriate for many people with Intellectual Disabilities depending on the nature and extent of the functional limitations involved. Optum spokespersons have publicly stated that there is no I.Q. cutoff for CBRS. In any case, the broad consensus is that psychiatric rehabilitation by whatever name, is generally indicated for anyone with a severe and persistent mental illness resulting in disability which persists beyond the period of acute treatment. CBRS is the only service in the Optum plan which can provide “psychosocial rehabilitation” or other ongoing psychosocial services. In fact, Optum does not offer any other psychosocial services which are evidence based such as, assertive community treatment, psycho-educational services, “wrap around” services or intensive in-home services. With the exception of case management, there is nothing to fill the gap between clinic services and hospitalization. For people who have severe and persistent mental illness, this is a serious shortcoming.

 

Proper use of Treatment Guides and Evidence Based practices

It is important to note that the APA practice guidelines do not cover all evidence based practices and are not properly used to refuse coverage for a treatment or service which is recommended by a treatment team for a particular person. The APA only has practice guidelines for 12 mental health diagnoses. They don’t include Shizoaffective, or Schizotypal disorders, for example. It would be wrong to assume that the lack of an APA guideline constitutes a basis for finding that CBRS is not evidence based for diagnoses which do not have guidelines. The APA says of the guidelines:

The guidelines linked on this page, excluding Major Depressive Disorder, are more than 5 years old and have not yet been updated to ensure that they reflect current knowledge and practice. In accordance with national standards, including those of the Agency for Healthcare Research and Quality’s National Guideline Clearinghouse, these guidelines can no longer be assumed to be current.

Since only one guideline is current, the failure of the guidelines to take PSR/CBRS into account should not be determinative of whether it is medically necessary or evidence based. Perhaps more importantly the APA says of each guideline:

The American Psychiatric Association (APA) Practice Guidelines are not intended to be construed or to serve as a standard of medical care. Standards of medical care are determined on the basis of all clinical data available for an individual patient and are subject to change as scientific knowledge and technology advance and practice patterns evolve. These parameters of practice should be considered guidelines only. Adherence to them will not ensure a successful outcome for every individual, nor should they be interpreted as including all proper methods of care or excluding other acceptable methods of care aimed at the same results. The ultimate judgment regarding a particular clinical procedure or treatment plan must be made by the psychiatrist in light of the clinical data presented by the patient and the diagnostic and treatment options available.

Similarly the AACAP declares:”These parameters are not intended to define the standard of care, nor should they be deemed inclusive of all proper methods of care or exclusive of other methods of care directed at obtaining the desired results.”

It is simply improper to use the guidelines as a basis to deny a treatment when the treatment is benefitting a patient based on the assessment of the treating psychiatrist and other treating clinicians.

Conclusion

Idaho has a long history of providing psychiatric rehabilitation services to children, people with intellectual disabilities, and people with a variety of psychiatric diagnoses. Although these services have occasionally been of poor quality, overall Idahoans have benefitted greatly from them and many have suffered from their loss. Close individual review of the actual benefits of CBRS to any individual and professional scrutiny of the value of the service are desirable and responsible. Categorical denial of services to individuals who benefit from the service and who will be harmed by the loss of the service, serves no purpose and can cause great harm.
Jim Baugh

Idaho Medicaid Redesign and People with Disabilities: “Option 3.5”

The Governor’s Work Group on Medicaid Redesign made a new recommendation on November 14th, 2014 to support a “hybrid” version of Medicaid expansion. They called this recommendation “Option 3.5”. It provides Medicaid eligibility for qualifying families below the Federal Poverty Level (FPL), and uses Medicaid funding to purchase coverage on the state insurance exchange for qualifying families between 100% and 138% of the FPL. Implementing this recommendation, or any other option for Medicaid expansion, will be of significant benefit to many Idahoans with disabilities.

Contrary to popular opinion, not all Idahoans with disabilities, who are living in poverty, are eligible for Medicaid. Two large groups are currently excluded. Of the roughly 41,000 Idahoans who have a serious and persistent mental illness (SPMI), only about 9,000 adults are currently eligible for Medicaid. About 10,000 more get treatment each year from the Department of Health and Welfare, but only if their illness becomes so severe that that they pose a serious risk to themselves or others, or if services are ordered by a court. This group (SPMI) includes only those people whose mental illness is disabling and recurring. Providing access to health care coverage for families up to 138% of FPL would include almost all of these people. Medicaid redesign would provide federal funding for the care and treatment they need and relieve the burden on county indigent funds and state general funds for both the Catastrophic Health Care Fund, and the Division of Behavioral Health programs. Currently, most Idahoans with SPMI have no coverage for mental health treatment, or for the very expensive prescription drugs needed to control their symptoms.

People who acquire disabilities after a period of employment, and are unable to work can qualify for Social Security Disability benefits. However, federal law prevents these people from obtaining Medicare coverage for two years after the onset of their disability. If their Social Security benefits exceed $734/month, they are also excluded from Medicaid coverage. At any given time, there are tens of thousands of Idahoans with disabilities in this waiting period. A recent study of Idaho county indigent program claims conducted by Dr. Douglas Dammrose, revealed that 42% of the claimants fell into this category (http://www.healthandwelfare.idaho.gov/Portals/0/Medical/MoreInformation/08-14-2014%20Medicaid%20Redesign-Idaho%20Doug%20Dammrose.pdf). 

There are other people with disabilities, including many veterans, who fall into this coverage gap due to individual circumstances. All of them would benefit from access to affordable health care coverage. Option 3.5” could have different effects depending on its implementation. Some plans on the exchange have very little coverage for mental health treatment. Some of the most effective treatments for many people with severe and persistent mental illness are not included in exchange based plans. People with SPMI need a robust benefits package to get adequate coverage and to maximize savings from state general fund programs. This can be provided through Medicaid or through “wrap around” coverage, but it is necessary to address the needs of people with SPMI. Many people in the Medicare waiting period may need long term in-home supports and services to keep them out of expensive nursing home placements. These services are typically covered under Medicaid but not under exchange policies. Idaho must insure that people with particular health care issues caused by disabilities, have access to regular Medicaid coverage or robust “wrap around” supplemental policies, to meet these needs and prevent higher cost services.

Conclusion:

Any Medicaid redesign option, which provides access to affordable health care for people in the “coverage gap”, will benefit Idahoans with disabilities and state and county budgets. Option 3.5 will be most effective for people with serious and persistent mental illness and other disabilities if it includes regular Medicaid coverage for those who need services that are not covered by state insurance exchange policies.

DRI Comments on Home and Community Based Services Transition Plan

 
Comments of DisAbility Rights Idaho
Idaho Medicaid Transition Plan for Compliance with CMS/HCBS Community Integration Regulations
 
 
Introduction
DisAbility Rights Idaho (DRI) is the Protection and Advocacy Agency for the State of Idaho under 42 USC §§ 15041-15045, 42 U.S.C.A. §§ 10801-10807, 10821-10827, and 29 USC § 794e. We are deeply concerned with the implementation of these Federal regulations and with the rights of people with disabilities generally.
Insuring that Idahoans with disabilities have full access to their communities, and control over their lives and homes, is a high priority for DRI. We believe that the approach to this transition should be much broader than the review of current state facility rules. Many Medicaid rules, practices and payment rates have a profound effect on whether people receiving HCBS services can achieve community integration and self determination within their own homes.
 
Recommendation 1.      The comment process being used by the Department of Health and Welfare (IDHW) is very technical and generally inaccessible to many consumers and stakeholders. The series of webinars have consisted of a recitation of the departments conclusions that certain rules either do or do not have provisions which relate to the new federal regulations. Without finding and reviewing the rules involved, commenters cannot determine whether they agree with the findings or not. The plan consists only of statements to address in some unspecified way the areas of current rules identified as “gaps”. Consumers, family members and even some providers cannot make meaningful comments on such a plan. DRI concurs with the recommendation of the Idaho Council on Developmental Disabilities (ICDD) on improving the comment process.
 
Recommendation 2.      The transition plan should contain more than a statement of identified gaps in Idaho Medicaid rules, and the process should include more than a review of the rules’ text. Determining whether Idaho Medicaid complies with the community integration mandate must explore actual conditions and experience of participants in HCBS settings. It must also review rate structures to determine whether they encourage or prevent integrated settings and practices, and how other factors such as cost sharing may impede access to community activities compared to people who are not HCBS recipients.
 
Recommendation 3.      CMS has not required states to submit a transition plan on how the state conducts “Person Centered Planning” (PCP). However, the PCP process is a key part of the community integration process and the new CMS regulations include changes to the language describing requirements for PCP. It will not be possible for Idaho to comply with the HCBS rules without proper implementation of changes to PCP processes. In order to be in compliance with the CMS regulations Idaho will need to change the person centered planning process in several HCBS programs. This issue is not addressed in the plan.
 
Recommendation 4.      Idaho Medicaid imposes limits on the cost of services for each individual in HCBS waivers and in Adult DD services under section 1915(i) of the Social Security Act. These limits are called individual budgets. The budgets set upper limits on the total cost of services for each individual. The budgets are determined differently in each waiver. However, in every case the budgets are set in a process which is prior to, and independent of, the person centered planning process. CMS rules address individual budgets only in the context of self directed services, but the budgets have the potential to affect each person’s ability to participate in community integrated activities. People whose budgets force them to access only center based or group services do not have the ability to choose individual or community integrated activities to the same degree as people who are not dependent on HCBS services. This issue is not addressed by the transition plan.
 
Recommendation 5.      Reimbursement rates for services can create unintended barriers to community integration.  “Blended rates” for Section 1915(i) services which pay the same rate for individual and group services creates a strong incentive to provide services in groups or in segregated centers. Center based and group services can have the effect of limiting individual choices and preventing participation in community integrated settings. For some individuals, the combination of individual budgets and rate incentives can effectively require them to spend all or most of their day in segregated, or disability group activities. The same effect can be seen in HCBS DD waiver models when individual budget limitations force a person to utilize mostly or only group based services. The transition plan does not address these issues.
 
Recommendation 6.      Medicaid Transportation can have a huge affect on a person’s ability to make personal choices about the services they receive. The current contract with AMR and its implementation restrict a participant’s choice of provider and the place where the service is received by limiting transportation to the closest Medicaid provider site to offer the service. This may pose another hidden barrier to participant choice and community integration, in violation of the CMS regulations. The issue is not addressed in the plan.
 
Recommendation 7.      Recent activities of the ICDD in surveying people receiving HCBS/DD services have revealed widespread practices by Medicaid providers which restrict individual choice and freedom. These include restrictions on access to food, and allowing participants to receive phone calls or respond to surveys. Even when current Medicaid rules might prohibit the restrictions, such practices persist and may be commonplace. The transition plan should include a plan to investigate the prevalence of such practices and the development of proper oversight and enforcement. (see also comments by ICDD)
 
Recommendation 8.      The CMS rules allow person centered planning processes to authorize exceptions to the new rules in settings which are provider owned or controlled, such as Certified Family Homes and Residential and Assisted Living facilities. The rules do not allow for a similar exception in non-provider owned settings such as Supported Living or My Voice My Choice. Idaho has made good use of these community integrated models for people with significant disabilities and significant behavioral issues. In Idaho’s system these HCBS models serve participants who could not be served well in congregate care settings. The success of these placements sometimes depends on the ability of the provider to restrict certain activities, and choices, when those choices pose a significant threat to the safety of the participant, their roommates, or members of the public. The effect of these CMS rules could be to force these participants into less integrated and less appropriate congregate care facilities. Idaho needs to explore the creation of one or more care models which can recreate the advantageous community integration of the current supported living model, while allowing for legitimate safety based concerns. These settings could include allowing provider leasing or ownership of a residence in a 2 or 3 bed community residence which can restrict unsafe activities, or application for a “Community Safety” waiver model under a non-HCBS authority such as section 1115 of the Social Security Act. Safeguards must be developed to insure that these models are not used to restrict the choices of people who do not pose a legitimate and significant safety risk.
 
Recommendation 9.      Cost sharing provisions of the HCBS/A&D waiver can also seriously impair the choices of participants as expressed in this comment we received from one of our clients:
Under current law the home that I live in and the lift equipped van I own are not considered a resource for Medicaid. The problem with Idaho’s personal needs allowance (PNA) is that it does not allow a participant to use his own income to repair, maintain, insure or even sometimes use the home or vehicle.

I live in my own home but do not drive and require a caregiver to drive me to church, the movies, my son’s band concert, and other activities in the greater community. I was told by a previous home healthcare provider that these type caregiver hours were not included in my UAI. I was required to private pay for these caregiver hours. I think I should have the same rights as a Medicaid participant living in a certified family home or a residential assisted living facility.

I don’t believe I’m allowed control over how my resources are spent to the same extent that a non-HCBS person living in the greater community has over their resources.

I feel like I am being institutionalized in my own home.

 
Some of these recommendations will also apply to non-residential settings and service design should consider both residential and non-residential services.
 
Submitted by DisAbility Rights Idaho
Contact: James R. Baugh, Executive Director
4477 Emerald St., Ste. B-100   Boise, ID 83706
Ph: 208-336-5353,  e-mail:  jbaugh@disabilityrightsidaho.org