Category:

OLMSTEAD & DISABILITY HOUSING

1/22/2021

AT LEAST TODAY -- OLMSTEAD GETS TO HOUSING WHERE PARITY & MEDICAID NETWORK ADEQUACY DON'T

A lot of people might ask --- isn't the timing off in trying to push Olmstead during a pandemic?

My response is this may be the BEST TIME --- since the financial pressure on a State may be less, in fact a lot less --- than it would normally be.

And that really allows States to focus on "THE BONES OF THE HOUSE" ---- "THE BONES OF OLMSTEAD."

In a lot of ways, "The Bones of Olmstead" are:

Measurable Goals
Reasonable Time Frames and
Funding to Support the Plan

To bring:

Supported Housing
Home & Community Based Service (HCBS) waivers
Crisis Services
Assertive Community Treatment (ACT) teams
Case Management
Respite
Personal Care Services
Peer Support Services, and
Supported Employment

TO SCALE TO MEET THE NEED.
Colorado and most states are providing pretty much all of the services listed above --- but far below scale and it's costing states a lot of money to provide what they are providing.

Olmstead provides a LEGALLY REQUIRED FRAMEWORK to deal with some difficult issues. Some very difficult issues.

Olmstead provides a level of accountability and breadth that is certainly beyond the Ad Hoc Stakeholder Group and because Olmstead gets to HOUSING -- it is beyond Parity and Medicaid Network Adequacy as well.

Statement of the Department of Justice on Enforcement of the Integration Mandate of Title II of the Americans with Disabilities Act and Olmstead v. L.C.
7. May the ADA and Olmstead require states to provide additional services, or services to additional individuals, than are provided for in their Medicaid programs?

A: A state’s obligations under the ADA are independent from the requirements of the Medicaid program.

Providing services beyond what a state currently provides under Medicaid may not cause a fundamental alteration, and the ADA may require states to provide those services, under certain circumstances.

For example, the fact that a state is permitted to “cap” the number of individuals it serves in a particular waiver program under the Medicaid Act does not exempt the state from serving additional people in the community to comply with the ADA or other laws.

15. What types of remedies address violations of the ADA’s integration mandate?

Olmstead remedies should include, depending on the population at issue: supported housing, Home and Community Based Services (“HCBS”) waivers,crisis services, Assertive Community Treatment (“ACT”) teams, case management, respite, personal care services, peer support services, and supported employment.
Our understanding is that Colorado State Government and the Behavioral Health Task Force are making an enhanced commitment to Parity.

When it comes to Olmstead, we would like to see Colorado put in "THE BONES of the HOUSE" for a Housing Olmstead Plan that gets to:

Supportive Housing, and
Accessible Housing

for People with Disabilities who are Institutionalized or at Great Risk of Institutionalization.

OLMSTEAD & THE HIGH END OF THE CONTINUUM OF CARE ---BEYOND CRISIS SERVICES

1/19/2021

WE'RE Focusing OUR 2021 COLORADO COGNITIVE DISABILITY Report on Olmstead

   We anticipate providing issue briefs on a Strength-Based Approach and Accommodations or Workarounds for Executive Functioning Issues later this year.
   It would appear that Colorado needs a lot more in Housing and Residential Services and Enhanced Services.
We need a system that is "RATIONAL" and "DATA-DRIVEN" and maintains "WAITLISTS MOVING AT A REASONABLE PACE."

   Some type of Crisis Services often are a part of many US Department of Justice Olmstead Settlement Agreements.

BUT they are HARDLY EVER the sole element of COMPLIANCE --- it's often also:

Housing
Assertive Community Treatment
Supportive Housing

States like Colorado often correctly say --- "Hey, we're doing that!" YEAH BUT ---- you need several thousand more slots.

Orchid's 2021 Colorado Cognitive Disability Report

Decoupling Intensive Community Treatment from "Medication Adherence"

3/12/2020

Psychiatric Medication is so controversial because it is very complicated and we have very simplistic views coming out of:

the Mental Health Profession
the Criminal Justice System, and
the Mental Health Advocacy Community

    Much of Intensive Community Mental Health Treatment is to ensure "Medication Adherence."

    In many cases that strategy has been toweringly unsuccessful, and there are often medical reasons for that beyond the stubborn recalcitrance of the patient.

   On the other hand, just because the medication doesn't work doesn't mean the patient is fine.

So what is the Mental Health Strategy for patients:

with major mental illness,
meeting the criteria for gravely disabled, and
medication insufficiently controls symptoms

Maybe we should be looking at Transcranial Magnetic Stimulation (TMS) and other options. (See Video below -- MIT BRAIN/MIND SUMMIT 2019 -- failure of psychiatric medication seemed to predict success of TMS).

    But Failure of Psychiatric Medication in a significant percentage of cases is the CRUX/HORCRUX of the Financial and Human Rights Nightmare in Mental Health.

  Right now there are THOUSANDS of people in Colorado and HUNDREDS of THOUSANDS of people in the US who need significant one on one emotional support and practical assistance far beyond one hour a week.

  The Assertive Community Treatment Model which has numerous expensive professionals -- may not always be appropriate for the person in which medication is not particularly helpful.

   Maybe there is some broad psychiatric oversight -- but what is really needed is a Licensed Clinical Social Worker, Peer Support, and Supported Employment.

This proposal is largely less expensive than traditional ACT-- BUT we are talking about THOUSANDS of Disfavored and High Need Coloradans that the State has historically determined were too expensive to treat adequately and appropriately.

Image Credit: Care Australia

Assertive Community Treatment & Flexible ACT Index

Therapy Scene from the "Joker" (2019)

Link to YouTube Video - If Video Above Unavailable

What if our Basic Assumptions about Mental Illness were Wrong? MIT BrainMind Summit (2019)

Orchid Note: It is CRITICAL to understand that many of our current mental health paradigms are wrong. We are unlikely to get out of our Mental Health Crisis without major advances/reforms in diagnostics and treatment.

Amit Etkin, MD, PhD is an Associate Professor in the Department of Psychiatry and Behavioral Sciences at Stanford, a member of the Stanford Neurosciences Institute, and an Investigator at the Palo Alto VA. He has received multiple awards, most notably the NIH Director’s Pioneer Award in 2017, for groundbreaking work in clinical psychiatry and neuroscience.

CO Medicaid's Challenge to "Uncover" & Meet the True Need for Assertive Community Treatment Under Parity -- NOW

3/12/2018

So what is the "Cover-Up" we're railing against now?
We're focused on the Insufficiency & Lack of Parity within Medicaid Mental Health Services generally and in Colorado specifically [although a lot of the criticisms could apply to other states as well].
First of all -- WE ALL WANT TO LOOK GOOD -- the State wants to look good, I want to look good, everybody I know wants to look good.
When people, or organizations, or governmental sub-divisions -- start not exactly telling the truth about something -- well, it's pretty easy to get into CROSS EXAMINATION MODE (especially in our society) -- to ferret out, uncover, reveal THE TRUTH.
IDEALLY, we make it safe enough that people can tell the TRUTH.
This becomes exceedingly problematic where safety is concerned.
AND Safety gets implicated A LOT where the Criminal Justice System is concerned -- whether its judges, prosecutors, defense attorneys, individuals, service providers, State actors responsible for ensuring adequate:

bed space
housing;
and services, often intensive services.

So Orchid Advocacy is pretty much focused on the State actors but of course they are inter-connected to all the other players, actors, individuals. What we want the State Actors to do in bringing:

Bed Space;
Housing
Services, often intensive services

TO SCALE or to have A COMPREHENSIVE, EFFECTIVELY WORKING PLAN TO BRING THE ABOVE TO SCALE to meet the needs of people with disabilities, often invisible disabilities, who are homeless, incarcerated or otherwise institutionalized is required by the LAW but it is also REALLY DIFFICULT -- that's why we're not doing it.
We do CRINGE when there is a significantly less than transparent and honest discussion and acknowledgement of the past and current difficulties to bring ACT to SCALE in Colorado.

Let's talk about Assertive Community Treatment in Colorado & Nationally:

Prior to "Federal Parity Legislation," the US Department of Justice relied on the Americans with Disabilities Act and the 1999 Olmstead Decision to FORCE States to provide more Assertive Community Treatment to people with disabilities who were institutionalized or at great risk of institutionalization.
In a New Hampshire Olmstead case, DOJ required the State of New Hampshire which is 1/3 the population of Colorado -- to provide significantly more Assertive Community Treatment as Colorado was providing at the time.
Colorado has historically considered ACT a "alternative service" under Medicaid in which there was no entitlement to the Service.
Further, a significant percentage of the ACT that Colorado does provide is not through Medicaid but through the Office of Behavioral Health. Well, why is that important -- Medicaid is an ENTITLEMENT [unless of course its an "alternative service in which case it's not an entitlement] so a lot of the rights that attach to most Medicaid Services have historically NOT attached to the provision of ACT in Colorado.
Additionally, the State of Colorado through the Dept. of Health Care Policy & Financing refused to respond to or answer a question we posed 2 & 1/2 years ago as to whether the state had an objection to a WAITLIST for ACT.
Currently, it appears --although we need to double-check-- that Colorado maybe now facially complying with Parity-- saying well, providers can seek reimbursement for ACT under the general "reasonable medical necessity" standard of Medicaid.
Why wouldn't that be enough? Well, the answer to that brings in not only:

*The Administrative & Economic Realities of ACT
*The HUGE historical resistance by Colorado State Gov't to provide full funding of this service--- we can't ignore HISTORICAL DISCRIMINATION.
*AND just the HUGE NEED to PLAN for what may be thousands of additional people with mental illness:
----who are in the Criminal Justice System
----nursing homes
----homeless
----in the Mental Health Institutes

Most States that have really been serious about this have included specific eligibility by Statute and/or regulation so that everyone is on the same page, and people who should be included aren't inadvertently left out due to vagueness.

Specifically such eligibility criteria often include along with a "mental Illness":

Criminal Justice Involvement
History of Hospitalization or Institutionalization; and
Homelessness

Colorado is moving in the right direction -- It needs to move much more to make ACT a SUBSTANTIVE REALITY FOR THE POTENTIALLY THOUSANDS OF ADDITIONAL PEOPLE WHO MAY MEET REASONABLE MEDICAL NECESSITY CRITERIA.

Examples of DOJ (US Department of Justice) Settlement Agreements that included ACT

DOJ Settlement Agreements that include ACT
U.S. v. New York – 13-cv-4165 – (E.D.N.Y. 2013)

Community-Based Mental Health Services

The Agreement will ensure that individuals with serious mental illness receive the array of services they need to successfully transition to, and remain in, community-based settings.

These services include ACT, mental health clinic services, personal care services, home health services, care coordination, and crisis services.

See Fact Sheet on the Agreement
http://www.ada.gov/olmstead/olmstead_cases_list2.htm#ny

U.S. v. North Carolina – No. 5:12-cv-557 – (E.D.N.C. 2012)
Following a nationally recognized fidelity model, the number of ACT teams throughout the State will expand to 50 ACT teams with the capacity to serve 5,000 individuals by July 1, 2019.

See Fact Sheet on the Agreement
http://www.ada.gov/olmstead/olmstead_cases_list2.htm#NC

Amanda D., et al. v. Hassan, et al.; United States v. New Hampshire, No. 1:12-CV-53 (SM)
-          Over the first three years of the Agreement, the State will expand ACT team service capacity so as to be able to serve at least 1,500 people in the target population {Of course, New Hampshire is only 1/3 the population of CO]; this expansion will provide ACT team services to hundreds of additional people in need.

-          The State will develop effective regional and statewide plans going forward to provide sufficient ACT services to ensure reasonable access by additional eligible individuals.

See Agreement Fact Sheet
http://www.ada.gov/olmstead/olmstead_cases_list2.htm#wood

Assertive Community Treatment: Mental Health Parity, Olmstead, Capitation, & CMS Quality of Care Requirements for States Contracting with Managed Care Organizations

2/12/2018

So here we have it: ALL kinds of reasons why people with mental illness should have access to the Mental Health Care at the the level that they need AND one of the BIG REASONS why they don't.
These challenges are NOT unique to Community Mental Health or in fact to Managed Care. We have had serious quality of healthcare problems:

in Nursing Homes,
Abuse problems in facilities for people with developmental disabilities
Serious Staffing Problems @ the Colorado Mental Health Institute @ Pueblo for DECADES -- maybe the State is finally trying to tackle that this legislative session. We would like to see more Emergency Action on this.
The Deaths and maiming of Colorado Inmates with mental illness in the shadow mental healthcare system of our prisons and jails.
This is true in public health and its true in private healthcare. It is very difficult for patients and their families to enforce quality of care standards.

We are struggling as a Society "To Do The Right Thing" and at the same time "CYAing" ourselves to the maximum extent possible.

IT IS NOT WORKING.

On paper -- in the Statute books, the US Supreme Court Reporters, Federal Reporters, Code of Federal Regulations, CMS [Centers for Medicare & Medicaid Services] Guidance, State Regulations --- WE SHOULD NOT HAVE A PROBLEM WITH ACCESS TO PERSON-CENTERED, INTENSIVE ASSERTIVE COMMUNITY TREATMENT, ETC.

BUT WE DO HAVE A PROBLEM WITH ADEQUATE ACCESS TO ASSERTIVE COMMUNITY TREATMENT & A LOT OF OTHER THINGS.

If one has low to medium needs with regard to mental health treatment -- Managed Care may work out pretty well.

BUT Colorado Medicaid Managed Care it is a FRICKIN' EPIC FAIL when it comes to people with the most intensive mental health needs and is just NOT UP TO SCALE.

The State of Colorado knows that it doesn't have adequate capacity, and it's one of many reasons they have so powerfully passively resisted Olmstead Compliance and Planning and bringing needed housing & services to scale.

They are not necessarily opposed to those things, BUT they don't want to be held ACCOUNTABLE for them either.

Which brings us back to our Society that "Wants To Do The Right Thing" and spends a whole lot of time "CYAing" itself.

People Tort Reform is NOT going to get us to the Solution to this problem, mainly because it doesn't get us to Solutions to the "Root Causes" of the original presenting problems.

A LOT of the FOUNDATION for Solutions to the Systemic Problems we find in Mental Health Managed Care has really already been LAID -- in Statute, Caselaw, Federal Agency Guidance and Requirements, State Regulations.

It's really analyzing what are the BARRIERS to realizing this in PRACTICE and NOT just THEORY.

CMS -- Overview of Quality of Care Information for Managed Care

CMS on State Responsibilties for Quality Assessment & Improvement in Managed Care

CMS on State Responsibilities to Conduct External Quality Review of Managed Care Organizations

Mental Health Parity & Assertive Community Treatment: CMS Guidance, Reasonable Medical Necessity, Quality & Quantity, CMS & SAMHSA, HCPF & OBH

2/9/2018

Mental Health financing in this Country is pretty convoluted and there are divided responsibilities -- BUT the BIG KAHUNA IS MEDICAID, health insurance, for funding of Community Mental Health Treatment.
Further, MEDICAID is an ENTITLEMENT and CMS has issued guidance on MENTAL HEALTH PARITY.
Even further page 36 of CMS' Mental Health Parity Toolkit references "Assertive Community Treatment" and "reasonable medical necessity" as the appropriate standard.
"Fidelity" to the Assertive Community Treatment Model is important and "Prioritizing" relevant populations is important -- BUT we gotta get REAL and move beyond "Prioritization" and make this an ENTITLEMENT under MEDICAID where "REASONABLY MEDICALLY NECESSARY"
Colorado's Department of Health Care Policy & Financing (HCPF) & Office of Behavioral Health (OBH) are in some senses a State reflection of the National division of the Centers for Medicare and Medicaid Services (CMS) and the Substance Abuse and Mental Health Services Administration (SAMHSA).
National advocacy groups such as the Mental Illness Policy Organization and the Treatment Advocacy Center have demonized SAMHSA we think quite unfairly, especially given the reality that it is CMS that funds most of the community mental health treatment in this country.
Well, Parity has the potential to address the INSANE CONSEQUENCES that D.J. Jaffe and the Mental Illness Policy Organization, the Treatment Advocacy Center, and the rest of us are so concerned about. BUT NOT through SAMHSA -- through MEDICAID.

Response From CO Medicaid Director Gretchen Hammer

The Behavioral Health Organizations are able to make a medical necessity determination for ACT, like all other BHO services. Their requirements for medical necessity determinations are in their contracts. The specific language is:

2.2.10. The Contractor may place appropriate limits on a service:
2.2.10.1. On the basis of criteria applied under the Medicaid State Plan, such as medical necessity.
2.2.10.1.1. All medical necessity determinations must utilize the medical necessity criteria defined in 10 CCR 2505-10 8.076.

The rule was recently updated by the Medical Services Board, the rule making authority for the Department. One can find the current rule on the Secretary of State website.

Orchid's Take: Most States employing a "reasonable medical necessity" determination for ACT specifically define it in Statute or regulation -- not under a general definition of reasonable medical necessity. That may be too vague and many providers likely need additional guidance.

What Colorado is really lacking is a definition for "reasonable medical necessity" for ACT.

AND How does that affect CAPITATION RATES?

There have been all kinds of "insane" incentives for Medicaid Community Mental Health to cost shift their neediest patients to the streets and the jails.
If those Community Mental Health Centers are not adequately reimbursed for Assertive Community Treatment -- one can be sure they are NOT going to be doing it.
Well, what does that mean: LOTS of People with Mental Illness in:

Prisons
Jails
the Streets
Nursing Homes, and
Mental Institutes

Honesty & Creativity in Complying with Mental Health Parity

2/8/2018

Coloradans with Mental Illness DON'T HAVE TO FAIL FIRST in:

incarceration
homelessness
placement in nursing homes, or
mental institutes

without adequate resource to ASSERTIVE COMMUNITY TREATMENT or FLEXIBLE ASSERTIVE COMMUNITY TREATMENT where reasonably medically necessary.

Assertive Community Treatment & Flexible Assertive Community Treatment in Norway and the Need for Colorado to Comply with Parity and Ultimately Olmstead

2/7/2018

Assertive Community Treatment is often a component of US Department of Justice Olmstead Settlement Agreements addressing Mental Health.

Colorado has some Assertive Community Treatment and they've been working to increase it.

Despite these efforts, Assertive Community Treatment is STILL not available to all where "reasonably medically necessary."

Well Colorado's failure to provide ACT where "reasonably medically necessary" is a BIG PROBLEM for A LOT of reasons:

It violates mental health parity under the Mental Health Parity & Addiction Equity Act of 2008 and subsequent CMS (Centers for Medicare & Medicaid Services) Guidance;
Failure to provide or plan to provide adequate Community Mental Health Services for those at great risk of institutionalization or homeless violates the 1999 US Supreme Court Olmstead decision, subsequent caselaw, and US Department of Justice Guidance on Olmstead and Title II of the Americans with Disabilities Act.
Failure to provide adequate intensive Community Mental Health Services including ACT is HORRIBLE Policy and Short-Sighted, leading to more homelessness and incarceration of people with mental illness. The World Health Organization has specifically called out such short-sightedness when it comes to mental health policy.

NOT EVERYBODY NEEDS ASSERTIVE COMMUNITY TREATMENT, BUT ACCESS TO THAT TREATMENT HAS TO BE BASED ON "REASONABLE MEDICAL NECESSITY."

Both the US and Europe have suffered under what Europeans have termed "incompetent" mental health policy after de-institutionalization.

Well, we are decades out from de-institutionalization @ this point. Further, the US went WAY FURTHER than most European Countries in criminalizing mental illness.

The West has had incompetent mental health policies and that includes the US and the State of Colorado.

The Hickenlooper Administration, MIXED BAG that it is, has done great work so long as its their idea --- BUT ask them to comply with the LAW -- say PARITY or OLMSTEAD, and there is PASSIVE RESISTANCE like nobody's business.

Maybe we could just say it's the Hickenlooper Administration's idea to offer Assertive Community Treatment where "reasonably medically necessary" -- AND they might do it.

We certainly wouldn't have a problem giving them a lot of credit for it, AND they would DESERVE IT.

Congressional Research Service: Jan. 19, 2018: Prevalence of Mental Illness in the US

Additional analyses of NSC-R data were conducted to determine the 12-month prevalence of mental illness at three levels of severity: serious,19 moderate,20 or mild.21

Among the 26.2% of adults identified with a mental disorder in the analysis, serious disorders (22.3% among adults with a disorder) were less common than moderate disorders (37.3%) or mild disorders (40.4%).

The estimated 12-month prevalence of serious mental illness among all adults was 5.8%.

https://fas.org/sgp/crs/misc/R43047.pdf

ACT and Flexible ACT 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.

Prevalence of Severe Mental Illness & Co-Occurring Substance Abuse in Europe

A European survey estimated the annual prevalence of severe mental illness in two European catchment areas found that approximately 2 in 1000 persons suffered severe mental illness (Ruggeri, Leese et al. 2000).

The majority of people with severe mental illness have schizophrenia and many experience severely impaired functional disability. According to the World Health Organization’s (WHO) World Health Report “New understanding, new hope” from 2001, schizophrenia is the eighth leading cause of disability-adjusted life years (DALYs) worldwide for people between 15-44 years.

DALY is a measure of overall disease burden describing the impact of a health problem as measured by financial cost, mortality, morbidity, or other indicator.

DALYs are the number of years lost due to ill health, disability or early death. Many people with severe mental illness also suffer co-occurring substance use problems. The lifetime prevalence of alcohol abuse or dependence in the general adult population ranges from 13.5% to 22.7% (Regier, Farmer et al. 1990, Kringlen, Torgersen et al. 2001) while 3.4% to 6.1% of the adult population has a lifetime prevalence of drug abuse or dependence (Regier, Farmer et al. 1990, Kringlen, Torgersen et al. 2001).

Amongst persons with schizophrenia, the reported lifetime prevalence of any substance abuse or dependence, ranges from 47% to 60% (Regier, Farmer et al. 1990, Fioritti, Ferri et al. 1997, Fowler, Carr et al. 1998). Current prevalence ranges from 27% to 41% (Fowler, Carr et al. 1998, Ecker, Aubry et al. 2012).

p. 12
https://www.duo.uio.no/bitstream/handle/10852/58886/PhD-Hanne-K-Clausen-2017.pdf?sequence=5

Mental Health Parity: Finding the Line Between Prohibited "Fail First" Medicaid Provisions and Reasonable Medical Necessity

2/5/2018

The Mental Health Parity & Equity Addiction Act of 2008 prohibits so called "Fail First" provisions.
What does that mean? It means that people can't be required to "FAIL" @ a less expensive treatment, before receiving a more expensive, likely more intensive treatment.
Well, okay --- but not everyone needs the most expensive, intensive treatment.
How are we going to determine who needs which treatments?
Well, we can't do it the old crazy way that has been rife within Colorado Medicaid for years and probably many other State Medicaid Programs:
Colorado Medicaid historically only covered intensive treatments such as Assertive Community Treatment as long as the money didn't run out from the Savings of the Medicaid Managed Care Program.
Well it is these kinds of HORRIFIC policies that Mental Health Parity is designed to get rid of.
That still doesn't mean that everyone needs Assertive Community Treatment --- What we do need are coherent criteria for "reasonable medical necessity" and eligibility for various treatments across the spectrum for example Flexible ACT, etc.

The State has invited me to speak about these issues to the Regional Accountable Entities -- which I very much appreciate.

Ultimately, it's the
State's responsibility to comply with Mental Health Parity Law. Colorado isn't doing that right now.

The State indicates it will have some requirements for "network adequacy" --- Sounds good, but we don't know what it actually means.

Further it does strike us that the State is trying to side-step responsibility for Parity and put it on the Regional Accountable Entities.

The invitation from the State to speak to Regional Accountable Entities is great ---- but it is not sufficient.

We need "reasonable medical necessity" criteria for ACT or a process to get it by the end of this week, or I'm going to CMS Region 8.

The State of Colorado Could Give Lucy A Run for Her Money in Parity Bait & Switch Routines

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.

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