One of the misguided changes made to Idaho Medicaid benefits in order to cut the budget, is the refusal to allow a person who has both a psychiatric illness and a developmental disability (DD) from receiving both developmental skill building services and psychosocial rehabilitation. People who have both diagnoses are expected to give up treatment for one or the other. This makes no more sense than asking a person with both diabetes and heart disease to pick which one they want to receive treatment for.
There are about 600 Idahoans on Medicaid who have a developmental disability (such as autism, or intellectual disability) and also have a severe and persistent mental illness, or emotional disturbance. Dealing with both of these conditions at the same time can be very challenging. Idaho Medicaid covers both developmental services (like developmental therapy and residential habilitation) and mental health services (like psychosocial rehabilitation, and partial care). However, under a new rule recently enshrined in Idaho Code by H 260, Idaho Medicaid will cover only one of these services even if the person qualifies for both. The rationale for this approach is that since all of these services include teaching skills, any one of the services can accomplish the same goals. Unfortunately, the fact that the services all include some type of skill building is the only thing that they have in common. The Department of Health and Welfare’s (H&W) web site offers this one sentence justification: “A participant may obtain all of his specific skill training service needs through one program even when he has dual diagnoses”. But just saying something does not make it so.
The Department’s own rules do not allow Developmental Disability Agencies (DDA) to provide PSR, unless they are also a licensed Mental Health PSR provider. Their rules also require specific credentials and certification of the people who provide PSR which is not required of people who provide DDA services. [i] Agencies which provide developmental therapy and Intensive Behavioral Intervention must be licensed and meet and meet a host of requirements, not required of PSR agencies.[ii] People who provide developmental therapy must be supervised by people with specific credentials and experience in developmental disabilities. [iii] PSR providers are not. Although these services both include skill building, they require radically different capabilities, training, credentials and supervision. How is it that DDAs are qualified to provide PSR services to people with a dual diagnosis but not to other people with severe and persistent mental illness? Why should we believe that PSR workers are qualified to provide Intensive Behavioral Intervention to people with dual diagnosis but not to other people with developmental disabilities?
Most people with both diagnoses will choose to keep their DD services and abandon their PSR. This will happen because many of these people need the DD services for day to day maintenance. For many adults their living situation is tied to their DD services, as in Certified Family Homes or in Supported Living apartments. For these people, giving up DD services means being forced out of their homes. The overall effect of this policy will be a wholesale loss of PSR services for people with both a developmental disability and a severe and persistent mental illness. This will result, over time, in increased mental illness symptoms, emergency room admissions, involuntary hospitalizations, arrests and other costly consequences as well as unnecessary increased suffering. Some of these people are already experiencing these problems.
PSR providers are trained in psychiatric rehabilitation and must be credentialed by the USPRA. The service includes helping clients to recognize emerging symptoms, or changes in symptoms, helping people work through difficulties caused by delusional thinking, general self care for mental illness, monitoring symptoms and medications, insuring that clients participate in ongoing mental health care, maintaining housing and when appropriate employment, and problem solving for other life stressors. DDA staff simply is not generally qualified to do these things and are not expected to do them based on DDA rules.
PSR providers however are not trained in designing individual developmental plans, intensive behavioral intervention, behavior shaping, reinforcement schedules or many other components of developmental programs. Medicaid requires specific training and certification for DD service providers which are not required for PSR workers.
The idea that DDAs will provide the same mental health symptom management, mental health monitoring, and psychiatric rehabilitation that people with severe and persistent mental illness receive through a qualified and credentialed PSR provider; or that a PSR provider will provide the same intensive behavioral and developmental training that DDAs provide, is a convenient fiction to justify elimination of a service for purely budgetary reasons. When we make policy decisions based on convenient fictions there are always undesirable consequences.
This policy has been in effect since January 2011. It will take more time for the damage done by this policy to become evident or widespread. However, there are people who are already experiencing adverse effects such as suicide attempts, hospitalizations and arrests.