Blog Archives

Trying to Move Colorado Beyond Vague Assurances to Concrete & Reliable Olmstead Commitments -- There's A lot of resistence

5/29/2018

A comprehensive, effectively working {Olmstead] plan must do more than provide vague assurances of future integrated options or describe the entity’s general history of increased funding for community services and decreased institutional populations.

Instead, it must reflect an analysis of the extent to which the public entity is providing services in the most integrated setting and must contain concrete and reliable commitments to expand integrated opportunities.

The plan must have specific and reasonable timeframes and measurable goals for which the public entity may be held accountable, and there must be funding to support the plan,

----DOJ Guidance on Olmstead, Answer 12.

It takes a lot of integrity to comply with Federal Disability Civil Rights Laws because:

Public Enforcement is patchy;
Private Enforcement is expensive and often out of the reach of people with disabilities and their advocates.

We're looking for a break from the Status Quo that will prioritize Colorado Compliance with:

Olmstead
Parity, and
Medicaid Network Adequacy

We are continuing to work on our letter to CMS regarding our concerns.

We have requested information from the State -- and we have not heard back.

DOJ GUIDANCE ON OLMSTEAD

2. When is the ADA’s integration mandate implicated?

A: The ADA’s integration mandate is implicated where a public entity administers its programs in a manner that results in unjustified segregation of persons with disabilities.

More specifically, a public entity may violate the ADA’s integration mandate when it:

(1) directly or indirectly operates facilities and or/programs that segregate individuals with disabilities;

(2) finances the segregation of individuals with disabilities in private facilities; and/or

(3) through its planning, service system design, funding choices, or service implementation practices, promotes or relies upon the segregation of individuals with disabilities in private facilities or programs.

12. What is an Olmstead Plan?

. . . A public entity cannot rely on its Olmstead plan as part of its defense unless it can prove that its plan comprehensively and effectively addresses the needless segregation of the group at issue in the case.

Any plan should be evaluated in light of the length of time that has passed since the Supreme Court’s decision in Olmstead, including a fact-specific inquiry into what the public entity could have accomplished in the past and what it could accomplish in the future.

13. Can a public entity raise a viable fundamental alteration defense without having implemented an Olmstead plan?

A: The Department of Justice has interpreted the ADA and its implementing regulations to generally require an Olmstead plan as a prerequisite to raising a fundamental alteration defense, particularly in cases involving individuals currently in institutions or on waitlists for services in the community .

In order to raise a fundamental alteration defense, a public entity must first show that it has developed a comprehensive, effectively working Olmstead plan that meets the standards described above.

The public entity must also prove that it is implementing the plan in order to avail itself of the fundamental alteration defense.

A public entity that cannot show it has and is implementing a working plan will not be able to prove that it is already making sufficient progress in complying with the integration mandate and that the requested relief would so disrupt the implementation of the plan as to cause a fundamental alteration.

Anne Sexton was an American poet, known for her highly personal, confessional verse. She won the Pulitzer Prize for poetry in 1967 for her book Live or Die. ------Wikipedia

There are multitudes -- in fact Thousands of people with "INVISIBLE DISABILITIES,"primarily mental illness, brain injury, and developmental disabilities that need access to both housing and intensive services across a continuum.

Many of these people are homeless or incarcerated or in the homeless/incarceration cycle.

State Good Faith & Substantial Compliance with Federal Law are BIG ISSUES. "We're Improving" is NOT SUFFICIENT FOR GOOD FAITH or SUBSTANTIAL COMPLIANCE, according to the US Dept. of Justice.

GOD OF THE GAPS & Criminal Liability of the gaps

5/25/2018

Sir Nevill Francis Mott CH FRS was a British physicist who won the Nobel Prize for Physics in 1977 for his work on the electronic structure of magnetic and disordered systems--- Wikipedia

" 'God of the gaps' is a term used to describe observations of theological perspectives in which gaps in scientific knowledge are taken to be evidence or proof of God's existence. The "gaps" usage was made by Christian theologians not to discredit theism but rather to point out the fallacy of relying on teleological arguments for God's existence.

"Some use the phrase as a criticism of theological positions, to mean that God is used as a spurious explanation for anything not currently explained by science.

"The concept, although not the exact wording, goes back to Henry Drummond, a 19th-century evangelist lecturer, from his Lowell Lectures on The Ascent of Man.

"He chastises those Christians who point to the things that science can not yet explain—"gaps which they will fill up with God"—and urges them to embrace all nature as God's, as the work of "an immanent God, which is the God of Evolution, is infinitely grander than the occasional wonder-worker, who is the God of an old theology."

----Wikipedia

Devils, Demons, & Intent

Human "intent" as the element of many criminal offenses was a big step up and may even go back to Roman Law.
When we talk about whether something is progressive or regressive it really depends on what we're comparing it to.
If we are comparing a concept of "mens rea" [criminal intent] to maybe societies thousands of years ago or hundreds of years ago-- well, it looks pretty good.
But we're not in ancient Rome or William Blakestone writing Legal Commentaries in England of the 1700s -- we're in the 21st Century and a whole lot has happened in our understanding of the complexity of human behavior since those times.
In fairness, the "Insanity Defense" and "Incompetent to Proceed" are potentially available but Colorado imprisons thousands of people with mental illness and brain injury and to successfully divert those people is going to require enormous amounts of housing and services, including intensive services.
The problem is we still have a FUNDAMENTAL RESISTENCE to the REALITY that human beings are biological organisms, and the question of "INTENT" while not irrelevant -- raises many other questions regarding what is spurring the "bad intent."
If the answer is just "FREE WILL" or just "EVIL" -- that was the best we could do for thousands of years -- IT IS NOT A SUFFICIENT ANSWER TODAY -- even though some "acts" are evil.
So we know that a person's intent is influenced by:

Mental Illness
Brain Injury
Developmental Disability
Problems in Emotional Regulation
Etc.

But what happens when we find someone that we don't understand very well and the information from the major Research Institutions is incomplete -- well typically we put the burden on the indigent defendant for issues Billion Dollar Governmental Research Institutions are still trying to completely figure out.

We might grant that the person is NOT possessed by a Devil or a Demon. If the person is floridly psychotic we might recognize a "DEFENSE" of insanity, but we are very unlikely to recognize the Complex REALITY before us for a whole lot of reasons:

bureaucratic,
practical: lack of treatment resources and placements
moral hazard concerns
etc.

However, if our Justice System isn't focused on PUNISHMENT, we are IRONICALLY in a much better position not only to provide ameliorating treatments as knowledge allows [& we often don't currently have complete knowledge] , we're also in a much better position to protect the community.
And, oh BTW, it's much more honest to move beyond our reductionist views of human intent and "Criminal Liability of the Gaps."
In "Slaughterhouse Five," Kurt Vonnegut wrote in connection with the WWII Bombing of Dresden, "The Brothers Karamazov isn't good enough anymore."
What did he mean? He meant that the argument that God allows evil in the world because of HUMAN FREE WILL isn't good enough anymore.
For Vonnegut it was a spiritual crisis and for many people acts of evil prompt spiritual crises.
But many of us today, across various Faith Traditions and Paths, have incorporated Science into our Spiritual, Ethical, and/or Moral Beliefs.
Recognizing the complexity of what the Human Being is contending with:

millions of years of evolution
genetic determinants of health
social determinants of health
developmental disabilities
mental illnesses
brain injuries
the health effects of discrimination
Trauma
Inter-Generational Trauma
poor diet adversely affecting the microbiome, which can affect the immune system and ultimately the brain.
emotional and physical intensities or "over-excitabilities" with the potential to damage the immune system and ultimately the brain.
brain damage from substance use [such substance use is not uncommonly the result of a dual diagnosis of mental illness]
Sleep Apnea, including High Altitude Sleep Apnea & Substance-Induced Sleep Apnea -- leading to insufficient oxygen, damage to the immune system & ultimately damage to the brain.
ETC., ETC., ETC.

ACKNOWLEDGING THOSE COMPLICATED REALITIES OF HUMAN LIFE, HUMAN BEHAVIOR AND INTENT DOES NOT LEAD TO MORAL HAZARD BUT TO MORAL REDEMPTION & SCIENTIFIC REALITIES.

BIG THINK with Dr. Robert Sapolsky of Stanford

DR. ROBERT SAPOLSKY IS A PROFESSOR OF BIOLOGY, NEUROLOGY AND NEUROLOGICAL SCIENCES, AND NEUROSURGERY @ STANFORD UNIVERSITY: "You are never really going to understand what is going on if you get it into your head that you're going to be able to explain everything with this is--

the part of the brain
the childhood experience
the hormone
the gene
or the evolutionary mechanism

---That explains everything.

"It doesn't work that way. Instead any behavior is the result of biology that occurred a second ago, hours ago, days ago -- a million years ago."
. . . .

"O000h it's complicated. Well, that's very useful.

"How 'bout, 'OOOh it's complicated and you better be really careful and really cautious before you think you understand the causes of a behavior, especially if it's a behavior you judge harshly.' "
. ------Prof. Robert Sapolsky Stanford

Duke Law Journal [2003]

OVERCOMING THE MYTH OF FREE WILL IN CRIMINAL LAW: THE TRUE IMPACT OF THE GENETIC REVOLUTION

Divergent

While Free Will may have a lot of problems so does Determinism. This is a really ancient construct that is not serving us well and we need to step out of it and engage in some "divergent thinking."

Structure of Legal Revolutions

"Even A Dog Distinguishes between being stumbled over and being kicked"

New Science is Amazing -- AND it has huge moral implications --NOW

Coloradans with Sex Offending behaviors: The Moral Imperatives to prevent homelessNESS, Provide placements & Services & Protect the community

5/24/2018

We've been struggling with dangerous behavior for a long time -- thousands/millions of years and we've been trying to figure it out for a long time.
Our knowledge is still very, very incomplete. Who is bearing the burden of that incompleteness -- generally people charged with bad acts.
That is deeply unethical and immoral.
It is also deeply unethical and immoral not to fully protect the community from people who are at varying risks for committing dangerous acts.
Punishment doesn't make sense anymore -- but that doesn't mean that Safety doesn't make sense anymore.
Having said that, Safety has to be addressed by individualized risk assessments, person-centered, strength-based treatment plans, and appropriate placement.
By the end of century, people may be getting their "Bio-Updates" on a regular basis -- we're not there now.
We have some very difficult ethical and moral choices. We've built some systems to handle these challenges -- but for the most part they don't have the resources to successfully discharge the tasks of humane treatment and community protection.
I really do think a lot of these issues are going to get solved -- but they can be incredibly complicated involving genetics and so much more.
It's probably not going to be in time for thousands if not millions of people living right now.
Our moment of choice for reform is NOW -- making our State more humane & safe -- also makes it more productive & efficient & prosperous.
We have to have availability of supportive housing & other placements where appropriate for Coloradans who have sex offending behaviors. And that availability must match the need.

Potential Implications of Research on Genetic or Heritable Contributions to Pedophilia for the Objectives of Criminal Law

--Recent Advances in Gene Sequencing (2014)

Colorado Civil Rights Attorney Alison Ruttenberg Photo Credit: Westword

What You Think You Know About Sex Offenders Is Wrong, Attorney Says

http://www.westword.com/news/the-truth-about-sex-offenders-9449138

"[Federal Judge Matsch] concluded: 'The fear that pervades the public reaction to sex offenses — particularly as to children — generates reactions that are cruel and in disregard of any objective assessment of the individual’s actual proclivity to commit new sex offenses.

"The failure to make any individual assessment is a fundamental flaw in the system.' "

Fourth 'sexually violent predator' takes up residence at Boulder homeless shelter
http://www.dailycamera.com/news/boulder/ci_31263478/fourth-sexually-violent-predator-takes-up-residence-at

Homeless sex offender rates on the rise in Southern Colorado

http://www.koaa.com/story/38210650/homeless-sex-offender-rates-on-the-rise-in-southern-colorado

Colorado's Sex Offender Management Board

https://www.colorado.gov/pacific/dcj/sex-offender-management-board

Intelligent, gifted, sensitivE: Congratulations! You've got a higher risk of joining the mental health club

5/20/2018

When we think of sensitivity -- we think of emotional sensitivity.
But there are all kinds of sensitivity involving:

Taste
Sight
Hearing
Touch/Skin
Smell
Etc.

Further, the line between Developmental Disability and Mental Illness can be pretty thin.

   The National Institute of Mental Health is now expressing some mental illnesses as: Genes x Age x Environment = Mental Illness.

As Human Beings, we're always after a bigger, more complete picture of reality -- AND that means taking in stimuli both externally and internally.

But we don't have an unlimited capacity to do that -- and we can also be overwhelmed by the amount of stimuli such as in some cases of Autism.

But there are probably a lot of gradations when it comes to our wiring for taking in stimuli.

Under certain circumstances, a greater than average capacity to take in and be affected by stimuli -- looks like intelligence.

In fact "gifted" individuals -- and there are many more than we recognize or acknowledge -- are characterized by "emotional intensity" as well as "over excitabilities" which can involve the senses, psycho-motor abilities, intellect, imagination, and emotion.

Further, these "gifted" individuals may have "disabilities" [including learning disabilities] -- and they are often not recognized for their abilities or "gifts." This is often known as 2e or Twice Exceptionality.

Well, that intensity and "over excitability" -- is very much a double-edged sword.

Research has recognized that people identified as intelligent have a greater risk of mental illness due to these intensities and over-excitabilities -- the idea is that it may damage the immune system and ultimately the brain.

SENG: Support for the Emotional Needs of the Gifted -- is often talking about how many "gifted" people are "misdiagnosed" with mental illness.

I'm sure a lot of people are "misdiagnosed" because our science isn't where it needs to be, including the need for much greater use of biomarkers ---

Having said that, if it looks like a duck, walks like a duck, and quacks like a duck -- maybe it is a duck.

Having said that, there are a myriad of implications that the needs of "gifted," "2e," and highly sensitive people have for our integrated physical & mental health, person-centered, strength-based care system.

Hyper-sensitive Immune System

CO Medicaid "Alternative" Mental Health Services, Discrimination & Parity

5/16/2018

Medicaid "Alternative Services" are defined as "additional non-Medicaid Services" provided under the Medicaid Managed Care Plan provided in a quantity in relation to the amount of savings of the Managed Care Plan.

On its face -- this is a good thing, right? -- people are going to get some services that can't be covered by Medicaid -- it's not complete coverage but these are "additional non-Medicaid Services."

But what if:

these are services that could be covered by Medicaid, the Colorado Department of Health Care Policy and Financing just refuses to designate it an optional Medicaid service.
And what if -- these services that HCPF is refusing to designate as optional Mental Health Services are actually some of the MOST ESSENTIAL MEDICAID MENTAL HEALTH SERVICES FOR PEOPLE WITH MENTAL ILLNESS -
- Residential Services
- Assertive Community Treatment ["the gold standard in intensive community mental health treatment"]
- Intensive Case Management

Well, those are HUGE SYSTEMIC problems. But what can we do about it --those services are "OPTIONAL" Medicaid services, right?

HCPF is NOT the only Medicaid Program or for that matter insurance provider to systematically discriminate against people with Mental Illness -- often without intent, and oblivious to the damage their policies are causing.

So the Mental Health Parity & Addiction Equity Act of 2008 is meant to address these issues. It has only recently been applied to Medicaid, since Oct. 2017.

Our Position Regarding Medicaid Alternative Services

So for services that CANNOT be Medicaid Services under any circumstances --- the Alternative Service route is very appropriate.

Also, there are Medicaid optional services that would be good to have BUT may not be strictly necessary to avoid institutionalization or homelessness.

Then there are Medicaid optional services that are ESSENTIAL SERVICES for people with mental illness to avoid institutionalization or homelessness. Residential Services, Assertive Community Treatment, & Intensive Case Management fall into that category.

Part of the problem is that States including Colorado did not comply with the 1999 Olmstead decision -- we're coming up on 20 years of non-compliance.

So other initiatives have been passed or re-emphasized due to various failures, namely the Mental Health Parity & Addiction Equity Act and CMS' much more rigorous take on Medicaid Network Adequacy after some critical federal reports.

To deem Residential Services, Assertive Community Treatment & Intensive Case Management as Non-Medicaid Alternative Services is like saying heart surgery or intensive rehab are "Alternative non-Medicaid Services" -- it's ridiculous, it's offensive, and we believe violates not just the spirit but the substance of Parity.

These are restrictions to ESSENTIAL MENTAL HEALTH SERVICES that to our knowledge are just not seen for physical or surgical ESSENTIAL SERVICES.

States can and are playing a lot of games with access to ESSENTIAL SERVICES under Medicaid for people with mental illness.

Some of these services are mixed: that is some of the elements of a service can be fully covered by Medicaid and some can't -- our understanding is employment can't be covered as a Medicaid service.

So employment would be appropriate as Non-Medicaid Alternative Service.

Further, Minnesota obtains grant money so that it can offer employment as part of Assertive Community Treatment to all where reasonably necessary. Minnesota covers all the other elements of ACT as a Medicaid rehabilitative service.

So we are working on a draft letter to CMS [Centers for Medicare & Medicaid Services] Region 8 regarding these issues. We will post a copy of the Draft on Saturday.

Note: HCPF is the CO Executive Agency charged with administering Medicaid here. This is somewhat similar to the problems at Pueblo overseen by CDHS. CDHS needed the cooperation of the legislature to begin to address the staffing problems @ the Colorado Mental Health Institute @ Pueblo.

HCPF will need the cooperation of the legislature to address this problem in "Alternative Services."

There are likely a lot of people who would want to support HCPF in making Residential, ACT, and Intensive Case Management available to all Medicaid recipients where "reasonably medically necessary," -- including law enforcement.

Among many other things including Safety, we think it is a matter of PARITY.

CODE OF COLORADO REGULATIONS 10 CCR 2505-10 8.200

8.212.4.B. Alternative services of the Community Behavioral Health Services program are:

1. Vocational -- Services designed to help adult and adolescent clients who are ineligible for state vocational rehabilitation services to gain employment skills and employment.

Services are skill and support development interventions, educational services,
vocational assessment, and job coaching.

2. Assertive Community Treatment (ACT) – Comprehensive, locally-based, individualized
treatment for adults with serious behavioral health disorders, that is available 24 hours a
day, 365 days a year. Services include case management, initial and ongoing behavioral
health assessment, psychiatric services, employment and housing assistance, family
support and education, and substance use disorders services.

3. Intensive Case Management -- Community-based services averaging more than one hour per week, provided to adults with serious behavioral health disorders who are at risk of a more intensive 24 hour placement and who need extra support to live in the community.

Services are assessment, care plan development, multi-system referrals,
assistance with wraparound and supportive living services, monitoring and follow-up.
Intensive case management may be provided to children/youth under the Early Periodic
Screening, Diagnosis, and Treatment (EPSDT) program.

4. Clubhouse and drop-in center services – Peer support services for people who have
behavioral health disorders, provided in a Clubhouse or Drop-In Center setting.

Clubhouse participants may use their skills for clerical work, data input, meal preparation, providing resource information and outreach to clients. Drop-in Centers offer planned activities and opportunities for individuals to interact socially, promoting and supporting recovery.

5. Recovery Services – Community-based services that promote self-management of behavioral health symptoms, relapse prevention, treatment choices, mutual support, enrichment, rights protection, social supports. Services are peer counseling and support services, peer-run drop-in centers, peer-run employment services, peer mentoring, consumer and family support groups, warm lines, and advocacy services.

6. Residential Services – Twenty-four (24) hour care, excluding room and board, provided in a non-hospital, non-nursing home setting, appropriate for adults whose mental health issues and symptoms are severe enough to require a 24-hour structured program but do not require hospitalization.

Services are provided in the setting where the client is living, in real-time, with immediate interventions available as needed.

Clinical interventions are assessment and monitoring of mental and physical health status; assessment and monitoring of safety; assessment of/support for motivation for treatment; assessment of ability to provide for daily living needs; observation and assessment of group interactions;
individual , group and family therapy; medication management; and behavioral
interventions. Residential services may be provided to children/youth under EPSDT.

7. Prevention/Early Intervention Services – Proactive efforts to educate and empower
individuals to choose and maintain healthy life behaviors and lifestyles that promote
positive behavioral health. Services include behavioral health screenings; educational
programs promoting safe and stable families; senior workshops related to aging
disorders; and parenting skills classes.

8. Respite Care – Temporary or short-term care of a child, youth or adult client provided by adults other than the birth parents, foster/adoptive parents, family members or caregivers that the client normally resides with.

Respite is designed to give the caregivers some time. away from the client to allow them to emotionally recharge and become better prepared to handle normal day-to-day challenges.

Respite care providers are specially trained to
serve individuals with behavioral health issues.

The deep persistent problems in Medicaid Managed care

5/15/2018

First, the Mental Health Crisis has A LOT of causes. When trying to identify significant causes -- Medicaid Managed Care is right up there.

Not only is Medicaid complicated, but how this actually plays out is sometimes pretty complicated as well. In other respects, it's pretty obvious.

Let's start with the obvious, essential community intensive services that people need to avoid institutionalization or life on the Streets --tend to be more expensive than less intensive services.

The people who would be getting all this "government largesse " have historically not been favored by the public in general, and governments. That's changing --mainly because it is becoming painfully obvious the disastrous costs of NOT providing for people with intensive mental health needs. AND we have a long way to go.

So in this instance, the failure largely rests with the States in failing to adequately designate and fund ESSENTIAL SERVICES such as Adult Residential Services, Assertive Community Treatment, and Intensive Case Management as a Medicaid Entitlement Service.

But it is not just Medicaid mandatory services that States need to be concerned about-- it's Parity, Olmstead, and Medicaid Network Adequacy.

That's a HUGE problem -- but there's also the problem that Medicaid doesn't cover housing or some other "Social Determinants of Health." Under Olmstead, States should be providing housing for people with disabilities -- and they do -- just not near enough.

So legally, morally, ethically and practically we need BOTH Essential Intensive Community Mental Health Services available to all Medicaid recipients where reasonably medically necessary as well as housing.

Thursday we'll be looking @ CO Medicaid Mental Health "Alternative" Services under the lens of Parity.

"Alternative" in that CO Medicaid considers them "additional" services so that the "entitlement" allegedly does not attach.

The problem is Adult Residential, Assertive Community Treatment, & Intensive Case Management are ESSENTIAL SERVICES that should be offered as a matter of right.

This is a unconscionable systematic failure --that can be fixed and there are a lot of ways to do it. Also, not surprisingly we believe it violates the Law.

What Are Medicaid Behavioral Health Services?

"States establish and administer their own Medicaid programs and determine the type, amount, duration, and scope of services within broad federal guidelines.

Federal law requires states to provide certain “mandatory” benefits and allows states the choice of covering other “optional” benefits.

Mandatory benefits include services like inpatient and outpatient hospital services, physician services, laboratory and x-ray services, and home health services, among others.

Optional benefits include services like prescription drugs, case management, physical therapy, and occupational therapy. "

https://www.medicaid.gov/medicaid/benefits/index.html

1915 (b) Waiver Basics

States can also implement a managed care delivery system using waiver authority under 1915(b). There are four (4) 1915(b) waivers:

(b)(1) Freedom of Choice - restricts Medicaid enrollees from receiving services within the managed care network

(b)(2) Enrollment Broker - utilizes a "central broker"

(b)(3) Non-Medicaid Services Waiver - uses cost savings to provide additional services to beneficiaries.

(b)(4) Selective Contracting Waiver - restricts the provider from whom the Medicaid eligible may obtain services

The Centers for Medicare & Medicaid Services (CMS) has started the process of "modularizing" its current 1915(b) waiver application to separate the various statutory authorities.

First in this process is a streamlined application for States to selectively contract with providers under their fee-for-service delivery system. It simplifies the process for documenting the cost-effectiveness of the waiver but requires that States demonstrate maintenance of beneficiary access.

https://www.medicaid.gov/medicaid/managed-care/authorities/index.html

Medicaid is the single largest payer for mental health services in the United States and is increasingly playing a larger role in the reimbursement of substance use disorder services.

Individuals with a behavioral health disorder also utilize significant health care services—nearly 12 million visits made to U.S. hospital emergency departments in 2007 involved individuals with a mental disorder, substance abuse problem, or both.

Congress enacted several laws designed to improve access to mental health and substance use disorder services under health insurance or benefit plans that provide medical/surgical benefits.

The most recent law, the Mental Health Parity and Addiction Equity Act (MHPAEA), impacts the millions of Medicaid beneficiaries participating in Managed Care Organizations, State alternative benefit plans (as described in Section 1937 of the Social Security Act) and the Children’s Health Insurance Program.

This is Colorado's Waiver thru June 2017--p.10

c.  1915(b)(3) - (Applies to the Community Behavioral Health Services Program and the Special Connections Substance Abuse Treatment Program)

The State will share cost savings resulting from the use of more cost-effective medical care with enrollees by providing them with additional services.

The savings must be expended for the benefit of the Medicaid beneficiary enrolled in the waiver. Note: this can only be requested in conjunction with section 1915(b)(1) or (b)(4) authority.

https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/Downloads/CO_Community-Mental-Health-Services-Program_CO-03.pdf

List of Medicaid Benefits

The list below outlines mandatory Medicaid benefits, which states are required to provide under federal law, and optional benefits that states may cover if they choose.

Mandatory Benefits

Inpatient hospital services
Outpatient hospital services
EPSDT: Early and Periodic Screening, Diagnostic, and Treatment Services
Nursing Facility Services
Home health services
Physician services
Rural health clinic services
Federally qualified health center services
Laboratory and X-ray services
Family planning services
Nurse Midwife services
Certified Pediatric and Family Nurse Practitioner services
Freestanding Birth Center services (when licensed or otherwise recognized by the state)
Transportation to medical care
Tobacco cessation counseling for pregnant women

Optional Benefits

Prescription Drugs
Clinic services
Physical therapy
Occupational therapy
Speech, hearing and language disorder services
Respiratory care services
Other diagnostic, screening, preventive and rehabilitative services
Podiatry services
Optometry services
Dental Services
Dentures
Prosthetics
Eyeglasses
Chiropractic services
Other practitioner services

Private duty nursing services

Personal Care
Hospice
Case management
Services for Individuals Age 65 or Older in an Institution for Mental Disease (IMD)
Services in an intermediate care facility for Individuals with Intellectual Disability
State Plan Home and Community Based Services- 1915(i)
Self-Directed Personal Assistance Services- 1915(j)
Community First Choice Option- 1915(k)
TB Related Services
Inpatient psychiatric services for individuals under age 21

Other services approved by the Secretary*
Health Homes for Enrollees with Chronic Conditions – Section 1945

*This includes services furnished in a religious nonmedical health care institution, emergency hospital services by a non-Medicare certified hospital, and critical access hospital (CAH).

https://www.medicaid.gov/medicaid/benefits/list-of-benefits/index.html

Mother's Day, Mental Health, Stigma & Hope

5/13/2018

I chose Rosemary Clooney's rendition of "I'll Be Seeing You" as the Musical Selection for Mother's Day for a lot of reasons:

Rosemary Clooney had a reputation of being "the girl next door" with enormous talent;
She also became famous in some respects for an unfaithful husband she married twice;
She was the mother of 5 children
She's also well known for having mental health and substance use issues

My mother passed away 11 years ago -- and I am seeing her in all the familiar and not so familiar places -- not just today but all the time.
Like a lot of mother and daughters, we definitely had our conflicts.
My mother bore the brunt of caring for our Father who had Lewy Body Dementia for 11 years.
She died a year after my father.
I had my psychotic break two months before my father's death--- due to many, many emotional & physical factors -- but definitely the stress of my father's illness played a big role in my physical & mental health.
After the death of my father and my potentially dangerous psychotic break, I now had the stigma of mental illness and was a Mom with two elementary age children.
When people talk about the pain of STIGMA it can be seemingly overwhelming and unbearable. For me, it was the stigma of being a Mother with mental illness. I never considered suicide before or since-- but I did after this psychotic episode.
When one's mind fails one so seriously --it's a terrifying experience -- at least it was for me.
I could NOT let this ever happen again
Maybe people would be better off without me? How could I ever be authenticate again? Would I always be living a secret life?
I'm happy I had a chance to have the Mother I had [& the Father] and the chance to have a loving Stay-the-Course Husband and two sensitive and outrageously opinionated kids -- I wonder where they got that?

Findings

Families developed resilience through processes such as shared humour or regular family rituals and routines.

In some cases, open communication about mental illness enabled families to better cope when parents were unwell and to build a greater sense of family connectedness.

However, data suggest that parental mental illness potentially creates stress and confusion for families and there are multiple social and cultural barriers that make it difficult for families to acknowledge and speak openly about mental illness.

For participants, resilience tended to be about maintaining a balance between stress/distress and optimism and strength within their family.

COACT Colorado & High Fidelity wraparound services could serve as a Model for Medicaid Adult Mental Health Services

5/12/2018

We have a HUGE challenge: bringing Medicaid Intensive Mental Health Services to scale to meet the need.

CO Medicaid to our knowledge still has not changed their regulations regarding Assertive Community Treatment (ACT), Residential Services, and Intensive Case Management as Alternative Services -- not available to all where reasonably medically necessary.

We were told by HCPF that ACT would be available where reasonably medically necessary -- but it seems to still be listed as an "Alternative Service."

That "Alternative Service" designation doesn't pass Mental Health Parity Muster as far as we're concerned.

But an option available to the State is to create an array of INTENSIVE SERVICES such as High Fidelity Wraparound to reduce the need for Residential Services and ACT.

Also, I think HIGH FIDELITY WRAPAROUND is better than Intensive Case Management --because it doesn't burnout the caseworkers as quickly and the results are likely better.

The Colorado Department of Human Services (CDHS) is already using HIGH FIDELITY WRAPAROUND for youth with serious behavioral issues -- under COACT, albeit not statewide.

COACT looks like Youth Assertive Community Treatment (ACT) with some built-in protective concepts such as:

Family Voice & Choice
Use of Natural Supports
Community-based
Culturally Competent
Individualized
Strength-Based
Persistence
Outcome-Based

Words matter -- the focus on High Fidelity Wraparound as opposed to "Assertive Community Treatment" probably has a lot of advantages -- it doesn't sound coercive and it seems more description.

I think this is pretty much what the people in the Adult Arena want as well when it comes to Assertive Community Treatment--High Fidelity Wraparound with Individual Voice and Choice.

Now one of the things that characterizes ACT is 24/7 -- 7 days a week coverage. Now not everybody probably needs that -- BUT a whole lot of people need HIGH FIDELITY WRAPAROUND.

With graduated intensive services available where reasonably medically necessary and clear screening tools, our Medicaid Intensive Mental Health Services could become much more understandable and user-friendly for everyone.

Under Medicaid Network Adequacy, we need to have an understanding of how many Coloradans need to access various levels of intensive mental health services --- and what do we need to do to plan for that.

"COACT Colorado is a system of care for children and youth with behavioral health challenges and their families.

It uses an evidence-based and effective process called high-fidelity wraparound to manage care for families with complex needs who are involved in multiple systems.

"High-fidelity wraparound implements a collaborative plan for the child and the family, as well as service providers and professionals working with the family. The process utilizes the individual strengths, needs, and culture of the family to achieve desired goals.

"High-fidelity wraparound often makes case work easier and more efficient for providers and professionals while generating positive outcomes."

https://coactcolorado.org/for-providers

1. Family Voice and Choice
Family and youth perspectives and opinions are asked for often, and prioritized during all phases of the process. Planning is built on family members’ perspectives, and the team aims to build a plan that reflects a family’s values.

2. Team-based
The wraparound team consists of individuals providing services to the family as well as the family’s natural supports.

3. Natural supports
The team actively seeks out and encourages the full participation of team members drawn from family members’ own networks of interpersonal and community relationships.

The plan reflects activities and interventions that draw on these individuals as sources of natural support.

4. Collaboration
Team members work together and share responsibility for developing, implementing, monitoring and evaluating a single high-fidelity wraparound plan. The plan is a collaboration of all team members’ ideas, opinions and resources and guides each team member toward meeting the team’s goals.

5. Community-based
The team implements a plan that offers services and supports that take place in the most inclusive, responsive and accessible settings possible; and that safely promote child and family integration into home and community life.

6. Culturally competent
The process respects and builds on the values, preferences, beliefs, culture, and identity of the family, child, and their community.

7. Individualized
The team will develop and implement a customized set of strategies, supports, and services to achieve goals laid out in its plan.

8. Strengths-based
The high-fidelity wraparound process and plan identify, build on, and enhance the capabilities, knowledge, skills, and assets of the child and family, their community, and other team members.

9. Persistence
Challenges can and will come up throughout this process. However, the team will persist in working toward the goals laid out in the plan until the team reaches an agreement that the goals have been met and the formal process is no longer needed.

10. Outcome-based
The team ties the goals and strategies of the high-fidelity wraparound plan to measurable indicators of success and monitors progress by checking in on these indicators.

If something isn’t working, the team will revise the plan.

The Deep Structural Problems In Colorado Medicaid Mental Health Inpatient and Intensive Community Services & Some Ideas to Fix them

5/10/2018

Mental Health Services are expensive. It's not like Colorado and other states aren't spending anything -- they are spending quite a lot.
But even with that States are struggling a lot to provide coherent and adequately staffed services, especially on the intensive end of the spectrum.
We really need clear screening tools for:

Inpatient
Residential Services
Assertive Community Treatment, and
Intensive Case Management

We don't have enough:

Inpatient beds
Residential Services
Assertive Community Treatment, or
Intensive Case Management

How could the CO Medicaid Community Mental Health Supports Waiver be made more relevant to the long term care needs of the vast majority of people with long term mental health care needs. [SUGGESTION: Get rid of the requirement for assistance with Activities of Daily Living [ADLs] and include on the array of services -- Residential and ACT]

Network Adequacy is a huge problem in Colorado and around the country.

A lot of the Mental Health Court Liaison program is designed to rely on existing resources in the community.

Well there are resources -- but they are NOT adequate -- that's how all those people ended up in jail.

We are going to be concentrating on the resources available under Medicaid -- because the more Medicaid can competently handle intensive mental health needs, the less need for more expensive Institute beds.

So we're working on a:

Complaint to CMS, and
A pitch for a Legislative Audit of Medicaid Intensive Mental Health Services assessing adequate quality and quantity , namely:
- Inpatient
- Residential Services
- Assertive Community Treatment, and
- Intensive Case Management
A pitch for Community Support to re-vamp the CMHS waiver, including:
- Getting Rid of the Requirement for assistance with ADLs
- Including Residential Services
- Assertive Community Treatment
- Peer-Run Services

To the State & Anyone Else:

If you believe there are important facts we should know ---please let us know.
If you think we have made any factual errors, please let us know.

Re-modelers Chip & Joanna Gaines

What are we trying to say with this video? Well our Mental Health System(s) are in the process of being remodeled -- and it is messy and necessary even as we may be trying each other's patience. Additionally, we need some "insurance" that things are being done as legally required.

Home & Intensive Services: There are A LOT of Conflicting Policies & De Facto Realities in Colorado Medicaid:

Can't access assisted living under the Community Mental Health Supports waiver unless need help with activities of daily living [really just blatantly violates mental health parity]
Mental Health Residential Services have traditionally been an "alternative service" -- meaning there is NO ENTITLEMENT to them. We are unclear as to how CO Medicaid intends to handle Residential Services under Network Adequacy.
Assertive Community Treatment (ACT) has traditionally been an "alternative service" under CO Medicaid -- meaning there is NO ENTITLEMENT. HCPF says they will make ACT available where reasonably medically necessary --- which is great --- but it is unclear that the State has determined Network Adequacy for the service. Further, historically neither the State nor the Mental Health Centers have not been really hip on providing intensive mental health services because of the cost --- how do you think we got into this mental health crisis?

First up, we've sent a request to the Colorado Department of Health Care Policy & Financing for data and analysis on how has Colorado measured Network Adequacy for Intensive Mental Health Treatment like Residential Services, Assertive Community Treatment, Intensive Case Management?, etc.

Further If there is no data and analysis by service, we've requested whatever data and analysis the State does have to demonstrate "network adequacy" for intensive mental health needs.

42 CFR 438.88(c) Development of Medicaid Network Adequacy Standards

(c) Development of network adequacy standards.

(1) States developing network adequacy standards consistent with paragraph (b)(1) of this section must consider, at a minimum, the following elements:

(i) The anticipated Medicaid enrollment.

(ii) The expected utilization of services.

iii) The characteristics and health care needs of specific Medicaid populations covered in the MCO, PIHP, and PAHP contract.

(iv) The numbers and types (in terms of training, experience, and specialization) of network providers required to furnish the contracted Medicaid services.

(v) The numbers of network providers who are not accepting new Medicaid patients.

(vi) The geographic location of network providers and Medicaid enrollees, considering distance, travel time, the means of transportation ordinarily used by Medicaid enrollees.

(vii) The ability of network providers to communicate with limited English proficient enrollees in their preferred language.

(viii) The ability of network providers to ensure physical access, reasonable accommodations, culturally competent communications, and accessible equipment for Medicaid enrollees with physical or mental disabilities.

(ix) The availability of triage lines or screening systems, as well as the use of telemedicine, e-visits, and/or other evolving and innovative technological solutions.

psychiatric Medication is pretty darn controversial for a lot of reasons: failure to provide Genetic Testing and high Level Neuro-pharmacology are 2 of the reasons

5/5/2018

I always get concerned when clinicians go off on "Medication Adherence."
The reality is -- if you have great medications -- people are either going:

to want to take them, or
in the alternative be glad they did afterwards.

In fact, there are a number of people who fit in one or both of those categories.
But there is a significant group that don't fall into either of those categories.
So "Medication Adherence" comes off as an abusive and even brutal practice.
   With the "Anna Karenina Principle" regarding animal microbiomes -- essentially good microbiomes are more alike, while bad microbiomes are more erratic and varied from individual to individual --- we are once again faced with the importance of individualized medicine.
Medication can affect the microbiome.
So when we talk about psychiatric medication we need access to genetic testing and the ability to consult a neuropharmacologist
-- because the variability among people with mental health concerns is so great.
It is probably not going to be too long before treatment for mental health issues includes individualized probiota.

We are not Alone in Our Body:

Insights into the Involvement of Microbiota in the Etiopathogenesis and Pharmacology of Mental Illness

Current Drug Metabolism (Dec. 2017)
https://www.ncbi.nlm.nih.gov/pubmed/?term=We+are+not+Alone+in+Our+Body%3A++Insights+into+the+Involvement+of+Microbiota+in+the+Etiopathogenesis+and+Pharmacology+of+Mental+Illness%E2%80%8B

Abstract:

Background: The etiopathogenesis of psychiatric disorders is still not completely understood.

Growing evidence supports the hypothesis that mental illness and related disturbances in the brain neurobiology do not necessarily originate in the brain.

Inflammation has been suggested to play a central role in psychiatric disorders, and altered levels of peripheral cytokines have been reported in several studies.

Objective and methods: In this review, we present and discuss studies exploring the role of dysbiosis and products of the gut-microbiota in the pathogenesis of psychiatric disorders, as well as its potential involvement in mediating the effect of antidepressants, mood stabilizers, and antipsychotics.

Results: Recently, it has emerged that bacteria populating the human gut could modulate low-grade inflammation, as well as high-order brain functions, including mood and behavior.

These bacteria constitute the microbiota, a large population comprising 40,000 bacterial species and 1,800 phila involved in key processes important to maintain body homeostasis.

Conclusion: Altered composition and functioning of gut microbiota have been reported in psychiatric disorders, and recent findings suggest that gut bacteria could be involved in modulating the efficacy of psychotropic medications.

Use of Pharmacogenetic
Testing in Routine Clinical Practice Improves Outcomes for Psychiatry Patients

Journal of Psychiatry (2016)
https://www.omicsonline.org/open-access/use-of-pharmacogenetic-testing-in-routine-clinical-practice-improves-outcomes-for-psychiatry-patients-2378-5756-1000377.php?aid=76391

Genetic testing for CYP2D6 and CYP2C19 suggests improved outcome for antidepressant and antipsychotic medication.
----Psychiatry Research (March 2018)
https://www.ncbi.nlm.nih.gov/pubmed/29699889

TedMed Talk

John Cryan, a neuropharmacologist and microbiome expert from the University College Cork, shares surprising facts and insights about how our thoughts and emotions are connected to our guts.

Long Video:

"Toward Precision Medicine in Psychiatry:
Current implementation strategies for antidepressant and antipsychotic medications"

Daniel Mueller, MD, PhD
Associate Professor, Department of Psychiatry, University of Toronto, Toronto, Canada

The Precision Medicine Conference 2016
Pharmacogenomics: Research To Implementation
Institute of Personalized Medicine (PUMA - IPM)
University of Minnesota

<<Previous

Val's Blog

Trying to Move Colorado Beyond Vague Assurances to Concrete & Reliable Olmstead Commitments -- There's A lot of resistence

DOJ GUIDANCE ON OLMSTEAD

GOD OF THE GAPS & Criminal Liability of the gaps

BIG THINK with Dr. Robert Sapolsky of Stanford

Duke Law Journal [2003]

OVERCOMING THE MYTH OF FREE WILL IN CRIMINAL LAW: THE TRUE IMPACT OF THE GENETIC REVOLUTION

Coloradans with Sex Offending behaviors: The Moral Imperatives to prevent homelessNESS, Provide placements & Services & Protect the community

Intelligent, gifted, sensitivE: Congratulations! You've got a higher risk of joining the mental health club

CO Medicaid "Alternative" Mental Health Services, Discrimination & Parity

The deep persistent problems in Medicaid Managed care

Mother's Day, Mental Health, Stigma & Hope

COACT Colorado & High Fidelity wraparound services could serve as a Model for Medicaid Adult Mental Health Services

The Deep Structural Problems In Colorado Medicaid Mental Health Inpatient and Intensive Community Services & Some Ideas to Fix them

psychiatric Medication is pretty darn controversial for a lot of reasons: failure to provide Genetic Testing and high Level Neuro-pharmacology are 2 of the reasons

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Val's Blog

DOJ GUIDANCE ON OLMSTEAD

BIG THINK with Dr. Robert Sapolsky of Stanford

Duke Law Journal [2003] OVERCOMING THE MYTH OF FREE WILL IN CRIMINAL LAW: THE TRUE IMPACT OF THE GENETIC REVOLUTION

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Archives

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Duke Law Journal [2003]

OVERCOMING THE MYTH OF FREE WILL IN CRIMINAL LAW: THE TRUE IMPACT OF THE GENETIC REVOLUTION