Self-Directed Financing of Services for People in Mental Health

Recovery

Judith A. Cook, PhD

Professor & DirectorUniversity of Illinois at Chicago, Department of Psychiatry

Presented at NYAPRS 7th Annual Executive Seminar on Systems Transformation

April 27, 2011, Albany, NY

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

Dept of Health &

Mental Hygiene(DHMH)

Departmentof

Disabilities

DivisionOf Rehabilitation

Services(DORS)

Mental Hygiene Administration

(MHA)

Department of Labor,Licensing, and

Regulation(DLLR)

MD Higher Ed. Comm.UM SystemCommunity

CollegeSystem

Dept Of Human Resources

(DHR)

MD State Dept Of Education

(MSDE)

Governor’s WorkforceInvestment

Board

Local/StateColleges

& Universities Local

EducationAgency(LEA)

Local WorkforceInvestment

Boards/One-Stops

6DORS

Regions

4 Regional

DDA Offices

Dept. ofSocial

Services(DSS)

MAPS-MD

Can this System Be Reformed?Dept.Of

VeteranAffairs

DevelopmentalDisabilities

Administration(DDA)

Blind Industries & Services Of

Maryland(BISM)

Medicaid

Consumer

Community Rehab. Program

Core Servic

e Agenc

y(CSA)

Key Elements Missing From Current System

• Accountability

• Choice

• Free market economy (overregulation, lack of competition)

• Consumer sovereignty

• Personal responsibility

What is Self-Directed Care?

1. Participants develop person-centered recovery plans

2. They then create individual budgets allocating dollar amounts to achieve the plan’s goals

3. Staff called “brokers” are available to help people purchase services & goods named in their plans

4. Fiscal intermediary provides financial management services such as provider billing & payroll taxes

Funds ordinarily paid to service provider agencies are controlled by service recipients

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)

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

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

counterpartsBudget neutrality prevailed by end of 2nd yearConsumer satisfaction was significantly higher among

those served in SDCIncidences of fraudulent behavior were lowHiring (& firing) friends/family members not problematic

(Foster, Brown et al., Health Affairs, 2003)

Evidence for SDC in MH PopulationsSingle group Pre/Post Study of Florida SDC

Significant increases in # days in the communitySignificant 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)

Texas SDC Location & Host Organization

NorthSTAR Region

North Texas Behavioral Health Authority

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

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

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

Technology

Personnel

Provider Network

Purchasing ProgramOperations

TX SDC Community Advisory Board Subcommittees

(included consumers, providers, UIC, DSHS, state VR, managed care, NAMI, MHA, & other advocates)

Convened collaboratively via teleconference by UIC & DSHS

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

Texas SDC Website keeps participants, staff, funders, & public informed

http://www.texassdc.org/default.asp

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

Use of Braided Funding

MedicaidState general revenueMental health block grantLocal funds

The Challenge: State must be able to account for all expenditures separatelyat the back-end, while remaining seamless to the consumer at the front-end.

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

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

•Some Early Research Findings

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 yearsAverage household size (inclu. participant) 3

As of May 2010, Types of Traditional Clinical Purchases Authorized

Individual Therapy

Psychiatrist

Groups

Case Management

Medication Mgmt

Other

32%

44%

4%8%

10%

2%

As of May 2010, Types of Non-Traditional Purchases Authorized

Health/Fitness

Transportation

Communications/PC

Clothing/Furniture

Job/School

Allow Card

Emerency Rent/Utility

Documents

12%

30%

16%

1%

16%

10%

6%10%

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)

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 levelPrepare myself for a job

(Cook et al., Psychiatr Rehab J, 2010)

Purchases Made by 1 Participant Over 4 Months

Purchase Total cost of PurchaseIndividual Therapy $910.00 Psychiatrist $332.50 Initial MH Assessment $90.00 Physical Fitness $273.34Massage Therapy $300.00Tuition (12 hours) $265.00Books for School $250.38Debit 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)

TX SDC Participant Satisfaction Survey42 participants with 3+ month tenure; 31 completed

the survey for a 74% response rate with no refusalsHow 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%

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%

SDC Participant Outcomes

“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

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