Blog Archives

A Strength-Based Approach Could Get Us Out of the "Twilight Zone"

1/30/2018

To the right is a clip from the old "Eye of the Beholder" episode from the Twilight Zone.
I think with ART one is generally making a point in very broad strokes. Even if the ART is a little more "nuanced" or a lot more "nuanced" than this --- STILL we're NOT getting into the down and dirty details for the most part of addressing say "DIVERSITY" in our society.
Maybe all we can do in a short episode of the "Twilight Zone" is recognize the PAIN and ABSURDITY in not appreciating and recognizing people for who they are. THAT'S A LOT.
This little clip on the oppressiveness of society to have people CONFORM is a lot more POWERFUL than much of what has been written on the topic.
BUT what are some of the other consequences of this "OPPRESSIVENESS" or "DISCRIMINATION"?
Well, according to studies discrimination can lead to physical and mental health problems.
AND certainly mental health problems can lead to more discrimination.
So there's a pretty SCARY positive feedback loop going on.
By the time one gets to the well-meaning mental health professional --- that has plenty of medications and motivational interviewing to bring about the desired CHANGE -- well, at that point one may very well feel like one is in the TWILIGHT ZONE.
Of course, ART points to and reflects reality -- It's not reality.
SO it's not so much that people who are different are "PERFECT" -- it's that they often have STRENGTHS that are NOT being:

Recognized,
Developed
Employed, or
Rewarded.

for any number of reasons, including because one is "DIFFERENT" -- others don't get it (just don't UNDERSTAND the person or the person's talents), the person may just be discriminated against because of race, ethnicity, sexual orientation, or "disability," etc.
By the time one attracts the attention of Institutional Players within the Society such as the Court System and/or the Mental Health Profession, etc.--these entities are often focused 100% on Addressing Weaknesses -- well, there is not going to be time for:

STRENGTHS DEVELOPMENT,
REAL RECOVERY, &
As well meaning as all this is, it has the very real potential to make things worse. Sometimes a lot worse.

AND if it gets worse, there's going to be MORE DISCRIMINATION and more and more INTENSE ATTEMPTS to FIX THE PERSON.

Well, at this point this is even scarier than THE TWILIGHT ZONE -- and you add to it a Mental Health Profession with an out-of-date DIAGNOSTIC MANUAL in the DSM 5 and that is pretty oblivious to the limits of its own knowledge base -- and one has the makings for the GROSS HUMAN RIGHTS VIOLATIONS we see in Colorado and across the Country on a daily basis.

Advocacy for Mental health can be the binder that brings together different groups that have experienced discrimination to form a majority to bring about the massive changes in:

Medicaid
Housing
Employment,
Education
Etc.

to comply with the LAW and to SAVE OURSELVES AND OTHERS.

Because what we have in common is that we are ALL DIFFERENT.

Positive Feedback Loop --Causal loop diagram that depicts the causes of a stampede as a positive feedback loop. --- Wikipedia

Dr. Saltz' General Rule: Time spent on addressing Mental Health Issues should be divided as follows:

80% of the time on Developing Strengths, and
20% of the time on Work-Arounds for Weaknesses

Racism & Mental Health

Creativity, Divergent Thinking, Entrepreneurship ---Just Some of the Common "Strengths" of Some "Disorders": What if we started treating them like the Profound Strengths They Are & Use Our "Creativity" to Find Work-Arounds for the Rest?

1/28/2018

The truth is people who are Neurally-Diverse are expected to make "accommodations" for "Neuro-Typicals" everyday -- whether it is a hardship or not.
So on the one hand, I think people who are Neurally-Diverse do understand that it can be hard to make accommodations day-in-and-day-out for people who are "different" than oneself.
Some of the people on the Orchid Facebook Page are chaffing at the the label of "disability," and arguing that it is really just "Difference." I agree.
But most of our laws and protections are tied to "disability." When you're a neuro-minority you need protections -- even if they are very hard to enforce.
Of course, being a neuro-minority is plenty to subject one to all kinds of discrimination.
You heap some other minority statuses on top of it -- say race or ethnicity --- AND well, you may be lucky to stay out of the Homeless Shelter or the Jail or Prison. Of course, there are plenty of white folks with mental illness in the same position.
I know I don't just want to be "accommodated" or "tolerated," I want to be able to use my strengths and be recognized for them. I'm NOT the only one.
Dr. Gail Saltz in her book "The Power of Different" advises that recovery efforts should be spent:

80% of the time on Developing Strengths, and
20% of the time on Work-Arounds for Weaknesses

Below is very abbreviated information from:

"The Power of Difference"
"Blue Zones"
And the Job Accommodation Network

I. People with ADHD, ADD & Attention Issues

A. Common Strengths -

Entrepreneurial

[See Canada's Rise Program that
provides support for people with
mental health or substance use issues in pursuing their entrepreneurial goals. Video below in this column.]

B. Common Work-Arounds

Self Care: Nutrition, Exercise, Sleep & appropriate Healthcare
Social Inclusion
Finding ways to express their

entrepreneurial abilities in their work

See Accommodations for Executive Functioning Deficits -- below right.

II. People with Depression, Dysthymia, & Dysphoria
A. Common Strengths
1. Empathy
2. Insight
3. Creativity
B. Common Work-Arounds
1. Self Care: Nutrition, Exercise, Sleep &
appropriate Healthcare
2. Social Inclusion
3. Finding ways to express their empathy,
insight, and creativity in their work
4.  See Accommodations for Mental Health
  Impairments -- below right.

III.  People with Bipolar Disorder
A. Common Strengths
1. Creative
2. Looking @ Systems in more
sophisticated
ways than neuro-typical people
B. Common Work-Arounds
1. Self-Care: Nutrition, Exercise, Sleep &
appropriate Healthcare
2. Social Inclusion
3. Finding ways to express their creativity in
their work.
4. See Accommodations for Mental Health
  Impairments -- below right.

IV. People with Schizoid Personality Disorder*, Schizopherenia, and Schizo-affective Disorder
A. Common Strengths
1. Divergent Thinking
B. Common Work-Arounds
1. Self Care: Nutrition, Exercise, Sleep &
  appropriate Healthcare
2. Social Inclusion
3. Finding ways to express their divergent thinking in their work.
4. See Accommodations for Mental Health
Impairments -- below right.

*We are NOT big fans of personality disorders and in fact find them unscientific -- see our page on personality disorders.

Orchid's Concerns Re: Personality Disorders

Dr. Harvey Reitman's Interview of Dr. Gail Saltz: "Discovering the Gifts of Different Brains"

Blue Zones & Social Inclusion

According to the Blue Zones research, Social Engagement [Social Inclusion] is an important factor for Health.

ADHD as an Entrepreneur's Superpower

The Number One Rule for Dealing with Depression @ Work

Bipolar Link to Creativity & Being Intelligent

Stanford Professor Tina Seelig on Divergent Thinking

UK Key Changes: Mental Health & Music

Entrepreneurship, Microfinance & Mental Health

Accommodations are evaluated on a case-by-case basis. We have compiled a non-inclusive list of limitations that result in common accommodation situations. In addition, you can find more information at JAN's A to Z Web page at: http://askjan.org/media/atoz.htm.

Please select the limitation that corresponds with the individual needing an accommodation below.

Employees with Executive Functioning Deficits

Job Accommodations for People with Depression

Employees with Mental Health Impairments

At Bottom It's Work: Reasonable Medical Necessity "Tools" for Assertive Community Treatment AND Could Someone Please Give the State of Colorado Some More BANDWIDTH

1/28/2018

There is so, so much work to be done in Medicaid Mental Health. It is NOT likely to get done and it's NOT being done if it is left to the Medicaid Directors to get it done.
There have to be sufficient staff with sufficient knowledge to whom Medicaid Directors can delegate the vast majority of this Mountain of Work.
Maybe a grant for Mental Health Transformation for Parity and Olmstead Compliance, and that could be broader than just Mental Health.
The Advocacy Community can do a lot research for the State [which the State is probably going to want to double-check and conduct their own research --- of course, that takes time].
BUT at some point the State has to do a fair amount of work, not just summarily declaring themselves in compliance with Olmstead and Parity -- which they are NOT.
I think we pretty much get that the big issue is money when it comes to complying with Disability Civil Rights Laws, even if ultimately they would save money -- where do you get the money in the first place?
There are a lot of ideas that we have already bandied about BUT the State has to have the BANDWIDTH to pursue them.

Flexible ACT

Minnesota Eligibility for ACT

Eligible Recipients Recipients eligible to receive ACT services must meet the following criteria as assessed by an ACT team:

• 18 years old or older (Individuals ages 16 and 17 may be eligible upon approval by the commissioner)
• Have a primary diagnosis of schizophrenia, schizoaffective disorder, major depressive disorder with psychotic features, other psychotic disorders or bipolar disorder
• Have a significant functional impairment demonstrated by at least one of the following:
• No indication that other available community-based services would be equally or more effective as evidenced by consistent and extensive efforts to treat the individual [or]
• Written opinion of a licensed mental health professional that the recipient has the need for mental health services that cannot be met with other available community based services, or is likely to experience a mental health crisis or require more restrictive setting if assertive community treatment is not provided

http://www.dhs.state.mn.us/main/idcplg?IdcService=GET_DYNAMIC_CONVERSION&RevisionSelectionMethod=LatestReleased&dDocName=ID_058151

Minnesota Eligibility for Youth ACT

Eligible Recipients To be eligible for Youth Act, MHCP recipients must be 16 – 20 years old and have:
• Diagnosis of serious mental illness or co-occurring mental illness and substance abuse addiction
• CASII level of care determination of level 4 or above
• Functional impairment and a history of difficulty in functioning safely and successfully in the community, school, home, or job
• Probable need for services from the adult mental health system within the next two years
• Have a current diagnostic assessment indicating the need for intensive nonresidential rehabilitative mental health services
http://www.dhs.state.mn.us/main/idcplg?IdcService=GET_DYNAMIC_CONVERSION&RevisionSelectionMethod=LatestReleased&dDocName=DHS16_181612#er

Pennsylvania ACT Standards and Guidelines

Consumer Eligibility: Following are the eligibility requirements for Assertive Community Treatment Services: Adults, 18 years of age or older, who have serious and persistent mental illness.

A person shall be considered to have a serious and persistent mental illness when all of the following criteria for diagnosis, treatment history, and functioning level are met.

A. Diagnosis: Primary diagnosis of schizophrenia or other psychotic disorders such as schizoaffective disorder, or bipolar disorder as defined in the Diagnostic and Statistical Manual of Mental Disorders (DSM IV-R or any subsequent revisions thereafter). Individuals with a primary diagnosis of a substance use disorder, mental retardation, or brain injury are not the intended consumer group; AND

B. Functioning level: Global Assessment of Functioning Scale (as specified in DSM IV-R or revisions thereafter) ratings of 40 or below; AND C. Consumers who meet at least two of the following criteria:

10 a. At least two psychiatric hospitalizations in the past 12 months or lengths of stay totaling over 30 days in the past 12 months that can include admissions to the psychiatric emergency services;

b. Intractable (i.e., persistent or very recurrent) severe major symptoms (e.g., affective, psychotic, suicidal);

c. Co-occurring mental illness and substance use disorders with more than six months duration at the time of contact;

d. High risk or recent history of criminal justice involvement which may include frequent contact with law enforcement personnel, incarcerations, parole or probation;

e. Literally homeless, imminent risk of being homeless, or residing in unsafe housing; f. Residing in an inpatient or supervised community residence, but clinically assessed to be able to live in a more independent living situation if intensive services are provided, or requiring a residential or institutional placement if more intensive services are not available; AND

D. Difficulty effectively utilizing traditional case management or office-based outpatient services, or evidence that they require a more assertive and frequent non-office based service to meet their clinical needs [This may be problematic from a Parity Standpoint in that it may require "FAIL FIRST," which is prohibited by the Mental Health Parity and Addiction Equity Act of 2008]

An individual who needs to receive ACT services, but who does not meet the requirements identified above may be eligible for ACT services upon written prior approval by the Behavioral Health Managed Care Organization or the County MH/MR Office, as applicable. In order to meet the DACTS fidelity standard related to admission criteria, at least 90% of the consumers admitted to the program shall meet the eligibility criteria outlined in the bulletin.

Reflections on Franz Kafka, Perfection, Imperfection and the Terrifying, Arbitrariness of Power

1/27/2018

I have to say my Father was very different than Franz Kafka's Father. Dad was a very caring, compassionate person who was also both extremely self-disciplined and not particularly into changing people.
Additionally, neither my Father or Mother were Social Climbers or Political Climbers, so they were always quite free to do what they thought was right.
I don't know how I became so obsessed with Social Reform---- It's just always seemed so incredibly interesting and important, really since elementary school.
But at that time, as a Child one thinks -- the KEY is to get rid of ALL the BAD people and put in the GOOD people. Of course, everything is very BLACK and WHITE, GOOD and EVIL -- and oneself as a person has not had time to make significant mistakes. That will change.
My brother, who I sometimes refer to as the most Conservative Person in International Development working today, observes that one has to do a lot of MENTAL GYMNASTICS to retain the ILLUSION that one is PERFECT.
Unlike Franz Kafka's Father, Dad was not exactly the prime, physical specimen -- but maybe that gave him a lot of insight. Ironically, our son is a Body Builder -- life turns out different than what you think -- Dad would have thought that was HILARIOUS.
Not ONE person in my family is perfect, including me. AND some members of my family and extended family have had to struggle much more than others. Further, I've never met a perfect person. When I was a child, I thought I was a perfect person or would be, and there were a lot of perfect people.
The Greek Gods were really a reflection of the fickleness, and arbitrariness of FATE. We try to clean that up by saying: Character is Destiny. The Criminal Justice System tries to do the same thing, aided and abetted by a less than scientific mental health profession.
The Truth is that:

Social Determinants of Health:
The Negative Physical and Mental Effects of Racial Discrimination as well as other forms of Discrimination, including Discrimination against People who are Neurologically Diverse;
The Failure to Adequately Comply with Civil Rights Laws, including Disability Civil Rights Laws such as the Americans with Disabilities Act, Olmstead and Parity

greatly impact the lives of others, especially poor people with disabilities, and such Factors implicate us all.

Themes of Terrifying, Arbitrary Power

In Chinese philosophy, yin and yang (陰陽 yīnyáng, lit. "dark-bright", "negative-positive") describe how seemingly opposite or contrary forces may actually be complementary, interconnected, and interdependent in the natural world, and how they may give rise to each other as they interrelate to one another. -- Wikipedia

Mary Anne Evans, known by her pen name George Eliot, was an English novelist, poet, journalist, translator and one of the leading writers of the Victorian era. Novalis was the pseudonym and pen name of Georg Philipp Friedrich Freiherr von Hardenberg, a poet, author, mystic, and philosopher of Early German Romanticism. -- Wikipedia

Flexible Assertive Community Treatment: Could It Help Speed Getting Colorado Out of the Mental Health Dark Ages

1/26/2018

Often when we think of a FACT Team, we're thinking of a "Forensic" Assertive Community Treatment Team working with a person who is involved with the Criminal Justice System.
Here, a FACT Team refers to "Flexible" Assertive Community Treatment that is in some ways less intense or more "flexible" in it's provision of services.
There is no question that some people may be better served by straight Assertive Community Treatment, and in fact the treatment was designed for people who need long term care to live in the Community.
Having said that, we have certainly recognized that NOT everyone needs Assertive Community Treatment, and even those who do need it and desire the provision of care, the care should still be Strength-Based, Person-Centered, and Person-Directed to the extent possible.
BUT as Flexible ACT recognizes, many people do NOT experience a constant need for intensive services and that need ebbs and flows, and may go away.
For many of the people we are aware of need Intense Case Management/Social Work Services far beyond what is available under Colorado's Intensive Case Management. Those services are desperately, desperately needed.
Of course we also have to have safe Housing to get people into. Most people don't want to live in a Drug Den whether they have mental illness or not.
So ACT or Flexible ACT is NOT going to work if we are not providing safe housing for people.
In the Netherlands, there are 35 ACT Teams and 300 Flexible ACT Teams. The Netherlands has a population of approximately 17 million, and Colorado has a population of about 5.5 million.
One of the challenges for Colorado and many states is that we have a higher percentage of people who are homeless and/or leaving incarceration than say the Netherlands or the Nordic Countries [Denmark, Finland, Iceland, Norway and Sweden].
Those higher levels of homelessness and incarceration are going to increase the need for Intensive Mental Health Services -- such as those needed by people who are homeless and/or leaving incarceration.
That's BECAUSE homelessness and incarceration amount to ABUSE and often of people who have been abused much of their lives.
We have to have SAFETY but it can be done much more humanely than what we are currently doing.
Flexible Assertive Community Treatment as well as Assertive Community Treatment where "REASONABLY MEDICALLY NECESSARY"--- might help Colorado comply with Parity and speed the process of Getting Colorado Mental Health out of the Dark Ages.

Canada.

For Dutch Mental Health Professionals

The CCAF: Certification Centre for ACT and Flexible ACT
https://ccaf.nl/international/

ACT and Flexible ACT in the Netherlands

"Both ACT and Flexible ACT teams operate in the Netherlands. The two models are outlined below. ACT for the most severely ill patients ACT provides multi-disciplinary care with shared caseloads for the 20% group of most severely ill patients with SMI.

When a patient under the care of an ACT team stabilizes, he or she proceeds to a lighter form of care such as case management, provided by ‘step-down’ teams.

There are now 35 ACT teams in the Netherlands. Flexible ACT for all SMI patients Flexible ACT provides multi-disciplinary care for the whole group (100%) of SMI patients in a particular region (50,000 inhabitants).

Continuity of care is provided for these patients. If necessary (in the event of an imminent crisis recurring psychosis, threat of readmission) a Flexible ACT team can provide full ACT care by switching to shared caseload and intensive outreach.

After the crisis a step-down procedure takes place within the same team, which ensures more continuity. Because the area covered is smaller, the team is better able to support social inclusion for these patients.

The teams collaborate extensively with social partners for that purpose. There are now about 300 Flexible ACT teams in the Netherlands.

Responsive Gov't for Poor People and People with Disabilities Requires Grievance Systems and Procedures that Can Get To Systemic Issues and Reforms

1/25/2018

Fritjof Capra is an Austrian-born American physicist, author and professor.

There are a whole lot of BARRIERS for poor people and people with disabilities to get their grievances adequately addressed by Colorado State Government and probably a lot of other State Governments, too.
There are A LOT of reasons for that. Two of the biggest reasons are:

State Government doesn't have the Capacity or Bandwidth to address the issues; and
Unconscious Bias

State officials may think that if they are polite and cordial -- that's enough -- without having to Substantively Address the issues. Of course, it is not enough.
And State officials don't have unlimited time either, BUT MOST OF THESE SYSTEMIC ISSUES could be classified under various categories:

Need for more training for state workers;
- How about just trying to get something scheduled for the next regular training on the topic needed.
Need for more access to more information on the part of the person or people;
- Putting stuff on State websites is EXTREMELY HELPFUL and it is generally not too labor intensive
Inadequate Compliance with the Law
-  If the State has a legitimate argument that it is complying with the law, that's fine.
- BUT The State Shouldn't Jerk People Around Just Because It Can, and especially not poor people with disabilities.
- What does that mean: It Means if the State isn't in compliance with the Law, it needs to get in compliance with the Law.
Need for more resources
- this obviously is the hardest category.
- It might start with the formation of a Stakeholder Group and Data Collection
- AND based on the Data formulate a proposal using Social Impact Bonds, State Funds, etc. to address the need.

Of course, Colorado is already doing a lot of this. BUT it doesn't seem to have the BANDWIDTH to do what's necessary and that includes complying with Federal Disability Civil Rights Laws such as Olmstead and Parity as well as substantively address the individual complex concerns of poor people with disabilities.

I don't think anybody likes adversarial proceedings and/or encounters, BUT when States don't provide an effective means to address legitimate concerns regarding compliance with the law or redress of complex issues --- It is hard to avoid that.

It's not such a horrible thing to have a Systemic Issue that needs to be addressed -- IT IS WHATEVER IT IS, it is not addressing the Systemic issue that is horrible. Stonewalling and other means of avoidance are perceived so negatively, no matter how politely or cordially such tactics are delivered.

Honestly trying to address the issue as well as being honest about political roadblocks, go a long way to building TRUST with people. There are generally ways around those roadblocks, but its hard to do if we're not working together.

"Examining the debate of a systemic vs symptomatic approach to healing. Much of medicine has become obsessed with alleviating symptoms, but at what expense?

"As more patients exhibit complex chronic conditions, a focus has to be on systemic healing over symptomatic relief."

https://innovativemedicine.com/systemic-vs-symptomatic/

unconscious bias

Interpreting the Code of Federal Regulations & CMS Guidance on Parity: We Think It Supports Parity for Assertive Community Treatment

1/24/2018

Make no mistake about it-- Mental Health Parity is complicated, and it is so for many political reasons.
BUT within this complexity, seem to be a lot of nuggets for the Parity Advocate.
So at first swipe, the State of Colorado is relying on 42 CFR 438.920 to support its lack of Parity for Assertive Community Treatment.
And the State's Argument runs like this:

"The goal of Parity is to ensure Medicaid members have similar access to mental health and substance use disorder benefits as they do to medical and surgical benefits. Assertive Community Treatment (ACT) delivered to Medicaid enrolled individuals is a service provided through contracts with the Behavioral Health Organizations (BHOs) and is available to members with a BHO covered diagnosis.

"Although, the final Parity rule does not require managed care entities to provide mental health and substance abuse services beyond the scope of its contract nor require managed care entities to cover any specific mental health or substance abuse benefit (42 CFR part 438.920), we continue to work with the Behavioral Health Organizations to ensure access to ACT when appropriate for the member."

BUT the State's Interpretation of 42 CFR 438.920 -- does NOT appear to be accurate and ignores:

42 CRF 438.920(c)(3) which provides:

(c) Scope. This subpart does not -

(3) Affect the terms and conditions relating to the amount, duration, or scope of mental health or substance use disorder benefits under the Medicaid MCO, PIHP, or PAHP contract except as specifically provided in §§ 438.905 and 438.910.

So the Code of Federal Regulations specifically exempt:

Parity Requirements for Aggregate Lifetime and Dollar Amounts as well as
Parity Requirements for Financial Requirments and Treatment Limitations

from the Rule that there is not going to be any contract modification.

Well, that's pretty important.

42 CFR 438.905 - Parity requirements for aggregate lifetime and annual dollar limits.
42 CFR 438.910 Parity requirements for financial requirements and treatment limitations.

From our perspective the State is NOT limiting itself to the 4 Classifications of Treatments allowed under Parity Law:

Impatient
Outpatient
Emergency Care
Prescription Drugs

The State seems to be retaining the OLD Medicaid Mental Health Alternative Service Classification that limits access to service to the Savings from the Medicaid Managed Care Plan for certain treatments.

THAT does NOT seem to be able to withstand Parity analysis and seems on its face horribly discriminatory since some of the most important Intensive Mental Health Treatments, such as Assertive Community Treatment, have historically been treated by the State as an Alternative Service and not available where "reasonably medically necessary."

42 CFR 438.920
(c) Scope. This subpart does not -

(1) Require a MCO, PIHP, or PAHP to provide any mental health benefits or substance use disorder benefits beyond what is specified in its contract, and the provision of benefits by a MCO, PIHP, or PAHP for one or more mental health conditions or substance use disorders does not require the MCO, PIHP or PAHP to provide benefits for any other mental health condition or substance use disorder;

(2) Require a MCO, PIHP, or PAHP that provides coverage for mental health or substance use disorder benefits only to the extent required under 1905(a)(4)(D) of the Act to provide additional mental health or substance use disorder benefits in any classification in accordance with this section; or

(3) Affect the terms and conditions relating to the amount, duration, or scope of mental health or substance use disorder benefits under the Medicaid MCO, PIHP, or PAHP contract except as specifically provided in §§ 438.905 and 438.910.

42 CFR 438.905 - Parity requirements for aggregate lifetime and annual dollar limits.
42 CFR 438.910 Parity requirements for financial requirements and treatment limitations.

Washington State Study: Medicaid Managed Care Leading to Incarceration of People with Mental Illness

See Below Page 36 of the CMS Parity Toolkit which addresses Assertive Community Treatment in the context of Non-Quanitative Treatment Limitations

Quoting From CMS Document Above:

Frequently Asked Questions: Mental Health and Substance Use Disorder Parity Final Rule for Medicaid and CHIP
October 11, 2017:

The final rule requires that all beneficiaries who receive services through managed care organizations, alternative benefit plans, or CHIP be provided access to mental health and substance use disorder benefits that comply with parity standards, regardless of whether these services are provided through the managed care organization or another service delivery system.

States are required to include contract provisions requiring compliance with parity standards in all applicable contracts for these Medicaid managed care arrangements that provide services to enrollees in managed care organizations, including prepaid inpatient health plans or prepaid ambulatory health plans.

In contrast to the proposed rule, this final rule also extends parity protections to apply to long term care services for mental health and substance use disorders in the same manner that they are applied to other services.

Key Provisions for Medicaid Managed Care Organizations Under the final rule, states that have contracts with managed care organizations are required to meet the parity requirements regarding financial and treatment limitations consistent with the regulation applicable to private insurers.

States will include the cost of providing additional services or removing treatment limitations in their capitation rate methodology for affected managed care plans.

By allowing changes to the managed care rate setting process, the rule also provides each state with flexibility to enable Medicaid managed care organizations to fully comply with the rule by including additional costs necessary to include extra services or remove treatment limits without changing the state’s non-alternative benefit plans and state plan.

In addition, the final rule requires managed care entities to make available upon request to beneficiaries and contracting providers the criteria for medical necessity determinations with respect to mental health and substance use disorder benefits.

The rule also directs managed care plans to make available to the enrollee the reason for any denial of reimbursement or payment for services with respect to mental health and substance use disorder benefits.

With the Circle Program, the Hickenlooper Administration is Turning A Critical Corner in Honestly Addressing the Staffing Problems @ CMHIP -- That NO State Administration Has Ever Done Before

1/23/2018

State officials are proposing re-opening the "Circle Program" in the Community outside of the Colorado Mental Health Institute @ Pueblo (CMHIP):

to access Medicaid dollars; and
to avoid the severe staffing shortages @ CMHIP.

We couldn't be happier to hear this news, and even though we're only talking 20 beds -- it marks a HUGE CHANGE in Colorado State Mental Health Policy that has for DECADES been in DENIAL about the SERIOUS STAFFING PROBLEMS in Pueblo.
From the Neiberger Case spearheaded by Attorney Kathleen Mullin, finding insufficient staffing @ CMHIP almost 2 DECADES ago -- to the present time -- Staffing Problems have gone up and down --- BUT they have NEVER gone away.
This is particularly important with respect to the Circle Program because Pueblo is intending to turn it's Old County Jail into a Drug Treatment Facility --- and that is just going to put more pressure on finding competent staff in the Pueblo area.
We don't have a problem with CMHIP in principle -- BUT the number of beds have to be directly correlated to what the State can adequately staff.
Right now the State is still down 100 staff people and has been for months. The ability to staff CMHIP IS WHAT IT IS -- NOT WHAT WE WISH IT TO BE.
We and some of the professionals on the Orchid Facebook Page are already concerned about the proposal to loosen staffing standards by opening up some direct care positions to EMTs (emergency medical technicians) and paramedics. We are unclear where that stands based on the Jan. 8, 2018 Pueblo Chieftain report below.
https://www.chieftain.com/news/politics/pueblo-lawmaker-colorado-state-mental-hospital-will-be-hiring-paramedics/article_4937e2a8-0da8-530d-8303-530fe9533e4b.html

Having said that, the State's Circle Program Proposal marks a SEA CHANGE in DECADES OF COLORADO MENTAL HEALTH POLICY by placing HONESTY AND THE WELFARE OF PATIENTS FIRST.

Pueblo Chieftain

State officials want to move the highly respected Circle Program out of the Colorado Mental Health Institute at Pueblo, saying that would protect it from the chronic staffing shortages at the state hospital.

Colorado Department of Human Services officials will ask the Legislature's Joint Budget Committee to approve that idea Wednesday.

Where Circle would end up, or even reopen, is uncertain.

The 20-bed program treats people suffering from both mental issues and addiction. It was abruptly closed last June 5 so CMHIP could shift its nursing staff to help fill nearly 100 vacant direct-care staff positions.

The hospital had just failed a staffing inspection and was in danger of losing federal Medicare funds.

In its budget request, DHS argues that it wants to move Circle "into the community" -- meaning some other provider would operate the program.

The plan says there are two advantages for moving out of the state hospital. One is that patients could use Medicaid funds to pay for the 90-day treatment. Located at the state hospital, Circle patients can't use Medicaid funds to pay for care there.

Secondly, the specialized treatment program would no longer be vulnerable to chronic staff shortages at CMHIP. Although the hospital passed a staffing inspection in October, it still has more than 100 vacancies in patient-care staff.

State Sen. Leroy Garcia, D-Pueblo, said he has strong concerns about the DHS plan.

"We haven't seen this proposal until now and what happens if there aren't providers in our community able to operate the program?" he said Monday.

Circle has been popular enough with state lawmakers they have funded it by name in the state budget. The budget for next year was $2.2 million but DHS is asking to move much of that funding into the CMHIP budget. It notes the Circle staff was shifted into the hospital's direct-care staff to fill vacancies there.

The program is respected enough that Colorado judges refer defendants to it by name. When it was closed in June, The Pueblo Chieftain received several calls from distraught families around the state who had sons and daughters waiting in jail for an opening in the program.

https://www.chieftain.com/news/pueblo/colorado-officials-eye-moving-circle-program-out-of-pueblo-mental/article_fe600b92-c88e-57dd-abcb-bad3be3133df.html

Trauma-Informed Care & Justice

1/22/2018

We greatly UNDER-ESTIMATE the time and energy it takes to sufficiently address human conflicts, and that is nowhere better seen than in the concerns of marginalized populations, especially those who have been so traumatized that their presentation is a PRIMAL SCREAM rather than a concise and clear presentation of facts, law, and argument.
BUT the TRUTH is without money or resources, even if they do present the facts, law and argument --- they maybe IGNORED.
Which only tends to FUEL the PRIMAL SCREAMS and HORRIBLY DAMAGING SENSE OF INJUSTICE that is pretty par for the course for a whole lot of poor people in our society, including a whole lot of people with "mental illness."
I think some of us may have "intuited" TRAUMA-INFORMED CARE for years however imperfectly, recognizing that the Client that seems so "OFF-THE-WALL" -- Hey, there's A LOT going on there. AND the more one digs into it, the more one UNDERSTANDS:

What's going on with the Client;
What's going on with the Situation;
What's going on with the Case;
AND What is it REALLY going to take to RESOLVE this conflict and ADDRESS the UNDERLYING ROOT CAUSES of the Problem(s) which are more often than not very COMPLICATED.

AND more often than not, one finds there is A LOT OF JUSTIFICATION for the CLIENT"S PRIMAL SCREAMS and SENSE OF INJUSTICE.
BUT how many hours did it take to get that UNDERSTANDING of someone who was poor, marginalized with a "mental illness"? Many, many hours.
The LONGER people are subjected to GROSS INJUSTICE the more their mental health is damaged by it -- AND the HARDER it will be to ultimately address.
People in PAIN perceive being IGNORED as a GROSS INJUSTICE and that's because it is. STATE ENGAGEMENT and SUBSTANTIVE ADDRESSING OF CONCERNS WITH poor, marginalized people who have been TRAUMATIZED is HUGELY IMPORTANT for the SENSE OF JUSTICE in our SOCIETY.
It is not easy -- it takes A LOT of TIME and ENERGY -- BUT it is much more effective than IGNORING PEOPLE AND FAILING TO PROVIDE INCLUSION, JUSTICE and ULTIMATELY HEALING.

The Surprising Truth About the Silent Treatment
https://www.heysigmund.com/the-silent-treatment/

"Dealing with Homeless, Fires and Lawsuits" -- A Modest Proposal

1/21/2018

With our Dark Humor, Colorado's situation of "Homeless, Fires, and Lawsuits," reminds us of the Plagues on ancient Egypt in the Bible.
Colorado's situation may not be as much Divine Intervention as the Chickens Coming Home To Roost -- of course, maybe it's the same thing.
In any case, we need NOT only to deal with the ROOT CAUSES of these problems --- BUT have the COURAGE & INTEGRITY to acknowledge the SCALE OF THE PROBLEMS.
On some level, Colorado is addressing the ROOT CAUSES of these problems -- BUT it hasn't really been wholly effective because STATE GOVERNMENT is afraid to acknowledge the SCALE of the Problems and their LEGAL RESPONSIBILITY to provide HOUSiNG & SERVICES for People with Disabilities or to Have a Plan to Bring Those Housing & Services to SCALE under the US Supreme Court's 1999 Olmstead Decision.
Why is that? Why are politicians afraid to do that?
I'm sure this is going to SHOCK everyone -- BUT the well recognized reason is that this isn't CHEAP -- in fact -- it's EXPENSIVE.
So when you have Governmental Entities not complying with various LAWS @ the State, County, or Municipal level --- LAWSUITS are pretty predictable.
Housing and Intensive Community Mental Health Treatment that many people who are Homeless need --- is EXPENSIVE.
There is not necessarily just one way to FUND that. One way that was pioneered by the City of Denver was the use of Social Impact Bonds.
We have said it before and we'll say it again -- one of the most SERIOUS & DANGEROUS problems Colorado State Government has is that it is woefully Under-Staffed.
As one professor said -- "You can't read 'War and Peace' while you're taking a shower."
You can't:

Make those applications for Social Impact Bonds;
Adequately Monitor Facilities
Sufficiently Engage with the Public on Innovative Ideas for a Pretty Broken Mental Health System
Etc.

If you don't have the Bandwidth to do it.

There is a HUGE NEED within the Colorado Dept. of Health Care Policy and Financing (HCPF) for MORE HUMAN RESOURCES to deal with the TRANSFORMATION that needs to take place in MEDICAID to ADDRESS the MENTAL HEALTH CRISIS that Colorado is experiencing and is seen in the rest of the Country as well.

Further, while we understand that the Office of Behavioral Health and HCPF are closely coordinating ---- we think these offices need to be fully integrated--- so that concerns relating to Institutional and Community Mental Health Care are seamlessly addressed.

Additionally, LET'S BE VERY CLEAR --- IT IS OFTEN CHEAPER FOR GOVERNMENTAL ENTITIES TO VIOLATE THE LAW AND PAY ATTORNEYS FEES FOR THE OCCASIONAL LAWSUIT THAN IT IS TO COMPLY WITH THE LAW THE WAY THE LAW IS CURRENTLY ENFORCED.

So if one's most important value is "saving taxpayer dollars" -- Colorado's got the Government for you.

BUT make no mistake about it, it comes with a lot of abuse and neglect of people with disabilities and inhumane treatment of people with mental illness on the streets and in jails and prisons.

If we work together, we can figure out a way to pay for Sufficient Housing & Services for People with Disabilities and make a Plan to bring those Housing and Services to SCALE.

Colorado Springs Gazette: Letter to the Editor

Dealing with homeless, fires, lawsuits

If you build it, more will come. We will never have enough space until the homeless get mental help to change their lifestyles.

I am referring to the hard core group (mainly singles) that refuse to obey any laws that don't suit their style of living.

I would also like to thank the ACLU for helping put fear in our community, especially legal residents of the Westside (Old Colorado City), by not allowing Colorado Springs to enforce it's laws for fear of being sued and wasting precious taxpayer dollars on legal fees.

Tom Gallivan
Colorado Springs

http://gazette.com/letters-dealing-with-the-homeless-fires-taxes-and-lawsuits/article/1619255

Colorado Abuse & Neglect Scandals Involving People with Disabilities

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